Serious Disruptions in Pediatric Cancer Care From COVID-19

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The COVID-19 pandemic has seriously disrupted pediatric cancer care around the world, a global survey has found. The most pronounced effects have been in low- and middle-income countries, although effects have also been seen in high-income countries.

“Access to quality care for children with cancer was inadequate before the COVID-19 pandemic in many countries,” Dylan Graetz, MD, St. Jude Children’s Research Hospital, Memphis, Tennessee, and colleagues observe.

“This study emphasises the urgency of an equitably distributed robust global response to support paediatric oncology care during this pandemic and future public health emergencies,” the investigators write.

The study was published online March 3 in the The Lancet Child and Adolescent Health.

Pediatric Oncology Providers

The survey was conducted by the St. Jude Global Alliance and International Society for Paediatric Oncology during the summer of 2020. Some 311 healthcare professionals from 213 institutions in 79 countries responded to the survey. The majority were from low- and middle-income countries.

Over 70% of respondents were pediatric hematologists-oncologists, but infectious disease specialists, other physicians, and nurses also replied to the survey’s questions.

The majority (78%) of the 213 responding institutions reported that the pandemic had affected their capacity to provide care for children with cancer. The most frequently cited negative effects were in regard to patient support, cancer-directed treatment, and availability of clinical staff.

The negative effects from the pandemic were independent of the number of COVID-19 cases at either an institutional or national level, the survey found.

The number of pediatric cancer patients who tested positive for COVID-19 ranged from 0 to 350, but there was only a median of two positive cases per institution, and 24% of institutions had no confirmed cases of SARS-CoV-2 infections among children with cancer, the authors point out.

Nevertheless, the impact that the pandemic has had on pediatric cancer care has been profound, they comment.

Seven percent of hospitals completely shut down their pediatric hematology-oncology services; the mean closure time was 10 days. The number of available pediatric oncology beds dropped in 19% of the institutions surveyed. Among centers that continued to evaluate new cases of suspected cancer in children, 43% reported a decrease in newly diagnosed pediatric cancer cases.

Over one third reported an increase in “treatment abandonment,” defined as failure to initiate cancer therapy or a delay in cancer care of 4 weeks or longer. Compounding the crisis, 66% of the surveyed institutions reported that they had fewer clinical staff to care for children with cancer, largely because staff had either contracted COVID-19 themselves or were in quarantine because of exposure to others who had tested positive for the virus.

“Multiple elements of paediatric cancer management were affected across institutions,” Graetz and colleagues note. Among institutions that reported changes to chemotherapy management, 69% reported a decrease in dose intensity; 49% reported a change in use from intravenous to oral treatment; and 21% reported a complete discontinuation of chemotherapy for patients.

Some 60% of all institutions surveyed reported that they had less access to blood products; some shortages were deemed critical.

“As many institutions in low-income and middle-income countries rely on family members for blood donation, visitor restrictions and stay-at-home orders might have reduced the number of donors and thus the supply of blood products,” the investigators note.

In addition, 72% of the institutions surveyed said that they had less access to surgical services, and 6% completely discontinued surgical procedures.

Of those centers in which radiotherapy had been provided prior to the pandemic, 10% reported that they had completely discontinued radiotherapy, and 20% said that they had only provided urgent radiotherapy.

“When assessing the overall effect of the pandemic, 25% of the institutions indicated that they believe a child had experienced a severe complication that would not have happened before the pandemic,” the authors note. Most of these complications occurred because of delays in patients coming to the hospital for care.

Respondents from a few centers indicated that they thought a patient had died as a result of the pandemic.

“The COVID-19 pandemic has considerably changed the care of children with cancer worldwide by creating barriers throughout the care continuum,” the authors conclude.

At least part of that impact can be attributed to the prioritization by hospitals for patients with COVID-19, but lockdowns and restricted access to public transportation also contributed to delayed cancer diagnoses, they note.

Worldwide, institutions have implemented new policies, created checklists, and redistributed resources and staff in an effort to mitigate the negative effects of the pandemic. These changes might lead to long-lasting improvements in childhood cancer care, Graetz and colleagues speculate.

Similar Findings

In an accompanying commentary on the findings, Soad Fuentes-Alabi, MD, National Children’s Hospital Benjamin Bloom, San Salvador, El Salvador, notes that a similar study conducted in Latin America, published in May, found that COVID-19 had negatively affected the prognosis of children with cancer across Latin America. In this study, providers reported delays in follow-up appointments, outpatient procedures, surgeries, radiotherapy treatments, stem-cell transplants, and palliative care.

For more than one third of pediatric cancer patients in this Latin American study, chemotherapy regimens were modified because of drug shortages. The majority of respondents reported a shortage of blood products. “During the COVID-19 outbreak, children with cancer have been particularly at risk of suffering the consequences of resource reallocations by having treatments delayed, interrupted, or substantially modified,” Fuentes-Alabi confirms.

“These studies [emphasize] the challenges of delivering childhood cancer treatment and care during the pandemic, especially in resource-constrained settings,” he states.

Graetz and Fuentes-Alabi have disclosed no relevant financial relationships.

Lancet Child Adolesc Health. Published online March 3, 2021. Full text, Comment

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