Analysis of our treatment interventions demonstrated that the surgical local control rate in our study was high with a complete resection rate 64.8%. There was a 5% surgical refusal rate which is a cause for concern considering that half of those patients died of disease as a result. In a systematic review of factors influencing refusal of therapy in adult cancer patients, discomfort of treatment, fear of side effects and transportation difficulties were cited as the most important contributing to refusal of surgery (31).  In a recent study from Vietnam adherence to cancer treatment in children was found to be determined by prognosis whilst being associated with local perceptions of cancer and the economic status of affected families (32). It is possible that a more rigorous informed consent and assent process such as that proposed for a national treatment protocol may help to allay the fears associated with paediatric cancer treatment specifically with respect to the surgery which remains a cornerstone of care.