Referral Patterns and Diagnostic Timeliness in Pediatric Cancer: A Hospital‐Based Study in Indonesia

BACKGROUND: Timely diagnosis and treatment are critical for improving survival among children with cancer. In low- and middle-income countries (LMICs), delays are common and may be influenced by fragmented referral pathways and diagnostic limitations. This study analyzed the diagnostic and treatment continuum among children with suspected cancer, including diagnostic and treatment intervals, referral pathways, and early clinical outcomes. METHODS: A retrospective cross-sectional study was conducted using Indonesian Pediatric Cancer Registry data at Dr. Hasan Sadikin Hospital from January 2020 to December 2022. Children aged <18 years with confirmed or suspected cancer were included. Time intervals were compared across diagnostic status, referral pathways, and early outcomes using Mann-Whitney U, Kruskal-Wallis, and Chi-square tests. RESULTS: Among 865 children, 764 (88.3%) had a confirmed diagnosis, while 101 (11.7%) remained without diagnostic confirmation. Early losses included death before diagnosis (9.7%), death before treatment (19.5%), and upfront abandonment (8.2%). Referral pathways differed significantly in diagnostic interval (p < 0.001). The primary-secondary-tertiary referral pathway had the longest diagnostic interval (median 88 days, IQR 34-186), whereas direct presentation to the tertiary hospital was associated with the shortest diagnostic interval (median 37 days, IQR 15-61) but the highest proportions of suspected diagnoses (32.1%), deaths before diagnosis (25.0%), and deaths before treatment initiation (32.1%). CONCLUSION: Substantial diagnostic and treatment interval burdens during pre-diagnosis and treatment losses were observed. Shorter referral intervals did not necessarily translate into favorable early outcomes, highlighting the need for coordinated referral systems with effective triage, early multidisciplinary involvement, and flexibility to initiate pre-emptive treatment.