Childhood cancer in India: Progress achieved, persisting gaps, challenges, and the road ahead

Nearly 400,000 children and adolescents (0-19 years) are diagnosed with cancer worldwide annually, with nearly 90% of cases occurring in low- and middle-income countries (LMICs).¹ Based on the global estimates and local population data, approximately 76,805 children and adolescents in India were expected to develop cancer annually, according to the 2011 census.² Recent GLOBOCON data indicate that nearly 1.4 million new cancer cases are diagnosed annually in India, of which 3–5% occur in children.³ While survival rates exceed 80% in high-income countries (HICs), they remain lower in LMICs.¹ This survival gap is a major concern and underscores the need for sustained efforts toward equitable childhood cancer care.

Childhood cancer accounts for the highest disability-adjusted life years (DALYs) among all cancers in LMICs and ranks among the top six diseases contributing to DALYs in children, warranting focused attention.³ Survival outcomes for childhood cancer in India have improved over the past few decades, resulting in a growing population of survivors. It has been achieved through increased awareness among the physicians, early referral and diagnosis, appropriate staging and risk stratification, improved delivery of therapy, and increased availability of paediatric oncologists. Advances in surgical techniques, radiation therapy, and supportive care—including safe transfusion practices, effective antiemetics, and antimicrobial agents—have further contributed to improved outcomes.

Professional bodies and collaborative networks have played a central role in this progress. The Pediatric Hematology and Oncology Chapter of the Indian Academy of Pediatrics (IAP-PHO) and the Indian Pediatric Hematology Oncology Group (INPHOG) have strengthened education, training, guideline dissemination, and collaborative research nationwide. Similarly, the National Cancer Grid (NCG), comprising over 200 cancer centres and research institutions and delivering nearly 60% of India’s cancer care, has created a unified national framework through evidence-based guidelines, expert collaboration, and initiatives such as pooled procurement, thereby improving access to affordable, high-quality care for children.⁴

Financial support through government-funded schemes such as Ayushman Bharat, the Prime Minister’s fund, the Chief Minister’s fund, and other initiatives supported by the Ministry of Health and by central and state governments has also contributed significantly to improved outcomes. Support from non-profit organizations, including the Indian Cancer Society, CanKids–KidsCan, Cancer Patients Aid Association, IMPACCT Foundation, Sahayata, Tata Trusts, among others, has also enhanced equitable access to care. St. Jude India Child Care Centers, CanKids–KidsCan, and Access Life, additionally support underprivileged families by providing accommodation, transportation, nutritional assistance, and emotional support, thereby reducing treatment abandonment and improving adherence.

Ongoing research has played a crucial role in adapting international cancer treatment protocols to suit the Indian population. The Indian Council of Medical Research (ICMR) has been actively advancing childhood cancer research and has funded several collaborative, multicentre studies, particularly in acute lymphoblastic leukaemia (ALL), the most common childhood malignancy. A multicentric observational study conducted by the Indian Collaborative Childhood Leukaemia (ICiCLe) group demonstrated that risk-stratified, reduced-intensity, protocol-directed therapy, and collaborative care significantly reduced treatment-related mortality and relapse rates.⁵ This was followed by a prospective, randomised, multicentre, open-label, controlled therapeutic trial in newly diagnosed ALL (ICiCLe-ALL-14), which evaluated the impact of induction steroid administration (pulse versus continuous) and anthracycline randomization on overall and event-free survival (EFS).⁶ To further improve outcomes and reduce relapses, the ICiCLe group has initiated an ongoing randomized study, ICiCLe-ALL-24. In parallel, the ongoing ‘Improving survival in childhood acute lymphoblastic leukaemia in India’ (ISCALL) project aims to improve ALL outcomes by implementing the ICiCLe-ALL-14 protocol across centres in India using a hub-and-spoke model.

Burkitt lymphoma, another childhood malignancy with cure rates exceeding 90% in HICs, continues to have poor outcomes in LMICs, including India, with survival rates ranging from 20 to 70%. This disparity is primarily attributed to high treatment-related mortality. To address this, Radhakrishnan et al,⁷ conducted a single-centre clinical trial in which patients were treated with the Lymphome Malin de Burkitt (LMB)-89 protocol, with a 25% reduction in chemotherapy doses and the addition of rituximab. This approach resulted in improved outcomes, with a 4-year EFS rate of 88%.⁷

Relapsed/refractory Hodgkin lymphoma can be salvaged with chemotherapy; however, chemotherapy-only regimens are often associated with low remission rates and significant toxicity. Recently, novel agents such as nivolumab, a programmed cell death protein-1 (PD-1) inhibitor, alone or in combination with chemotherapy, have been used in heavily pretreated patients to improve outcomes. Srinivasan et al,⁸ demonstrated that a fixed low-dose combination of nivolumab (40 mg on days 1 and 15 of each cycle) and bendamustine achieved an 88% complete response rate, with a 1-year progression-free survival of 88%.⁸ Treatment protocols adapted for LMICs for acute myeloid leukaemia and autologous stem cell transplant for neuroblastoma have been published.^9,10

Despite these advances, major challenges persist. Several transformative therapies that are now standard of care globally, including dinutuximab for high-risk neuroblastoma and blinatumomab for relapsed or high-risk B-cell acute lymphoblastic leukaemia, remain largely inaccessible in India because of high cost and limited availability. The absence of affordable access to such drugs risks widening survival disparities as global standards of care evolve.

The availability of childhood cancer care services and trained personnel remains a major challenge. While paediatric oncologists were present in only a small proportion of centres in the late 1980s, recent surveys show that less than half of public and private hospitals have dedicated paediatric oncology services or trained staff, with comparatively better availability in NGO-managed institutions. Formal training in paediatric oncology and haematology-oncology is increasingly available in the country. However, the super specialty DM programme in Paediatric Haematology-Oncology, a standard course in HICs, has not yet been approved by the National Medical Commission. Paradoxically, many young specialists face challenges in securing employment after completing their training. Creating paediatric haematology-oncology units and faculty posts for paediatric haematologists-oncologists in the larger state medical colleges is the need of the hour.¹¹ It is encouraging that units for stem cell transplants are increasingly available, though they are disproportionately located in corporate hospitals. There is a pressing need to increase the number of beds for stem cell transplants in public hospitals. A stem cell transplant is essential for the cure of 50-60% children with acute myeloid leukaemia, and several patients with relapsed ALL, among other indications in paediatric oncology.

In conclusion, while India has made commendable progress in improving childhood cancer outcomes through strengthened clinical care, collaborative research, financial protection schemes, and supportive services, significant gaps remain. Addressing these challenges will require a coordinated national strategy that prioritizes the inclusion of essential paediatric oncology drugs in national formularies, the expansion of high-quality indigenous drug manufacturing, and price regulation to improve affordability. Strengthening human resource capacity through increased training positions, structured career pathways, and equitable workforce deployment is equally critical. Furthermore, scaling up hub-and-spoke models of care, integrating childhood cancer services into national non-communicable disease programs, and establishing robust national cancer registries will be key to reducing regional disparities. Sustained government commitment, multisectoral partnerships, and continued advocacy are essential to ensure that every child with cancer in India has equitable access to timely, high-quality curative care.