Late diagnosis of tumours in children collateral damage of COVID-19, doctors say

dr. Sheila Singh is used to explaining complex medical situations in simple terms. The pediatric neurosurgeon at McMaster Children’s Hospital in Hamilton says she’s been seeing too many oranges and grapefruits and fewer ping-pong balls lately.

That’s not good, and it could indicate that the COVID-19 pandemic has delayed the diagnosis of many childhood illnesses, sometimes with devastating results.

“You can imagine a tumor the size of a ping pong ball, it’s easier for me to work around it and remove it,” she said. “But when that ping-pong ball-sized tumor grows to the size of an orange or a grapefruit, the tumor has grown so large that it’s now much harder to deal with.”

Singh told Dr. Brian Goldman, host of White Coat Black Art, that she now sees two to three times more oranges and grapefruits than before the pandemic. In other words, the tumors have had to grow for much longer because of delays in diagnosis.

Singh says she believes the delays in diagnosis have been caused by patients staying away from hospitals because:

They are afraid of contracting COVID-19. There is a lack of personal visits with their GP. There is an anchor bias to look for COVID-19 symptoms at the expense of signaling other serious illnesses.

“There’s no doubt there will be collateral damage,” she said, “and some of it will be death and bad outcomes from diseases that could have had better outcomes.”

Singh says she remembered a recent patient, a young girl with a tumor that usually grows in one place in the brain. “This little girl came in and this tumor was actually in four places in her brain. And let me put it this way, two of those four places where I’d never seen this brain tumor before.” Instead of one operation, Singh had to perform several risky and difficult operations.

As a pediatrician, Singh says it was heartbreaking to see some children whose cancers have progressed far beyond the pre-pandemic norm. “I feel like I’ve been practicing in a third world country. I’ve seen a disease that has spread to the point where it’s almost like cases I’ve read about in rural India. It was quite difficult and alarming.”

Pediatric cancer specialists at CHEO, formerly the Children’s Hospital of Eastern Ontario, in Ottawa, also saw fewer patients come in the early days of the pandemic, when parents said they were afraid to go to the hospital.

26:30The consequences of COVID: tumors the size of oranges

dr. Sheila Singh, a pediatric neurosurgeon at McMaster Children’s Hospital, talks about the massive collateral damage caused by the pandemic. She now sees tumors the size of oranges and grapefruits, instead of ping pong balls. dr. Singh blames it for prioritizing COVID over everything else, telling people not to come to the hospital and relying too much on virtual health care – all lessons for the future. 26:30

Early Signs of Widespread Diagnosis Delays

Early research suggests that a later diagnosis of illness in children due to the pandemic could extend to other serious illnesses, not just cancer. In a study published earlier this year in the medical journal Pediatric Diabetes, researchers in Alberta found that more children are being treated for diabetic ketoacidosis, a serious and potentially fatal complication of diabetes.

The authors suggest that parents may have been reluctant to access medical services due to fears of COVID-19 and that “increased virtual visits resulted in decreased face-to-face contact with health care providers and may have contributed to the underrecognition of disease severity.”

Pediatric neurosurgeon Dr. Patrick McDonald says he wants lessons to be learned from what has been done right and wrong in providing adequate care during the COVID-19 pandemic. (Submitted by Dr. Patrick McDonald)

dr. Patrick McDonald says he remembers the challenges of the lockdowns. During much of the pandemic, McDonald headed the pediatric neurosurgery department at BC Children’s Hospital in Vancouver. In the early days of COVID-19: “I think we all struggled with the problem [of] how do we ensure that families know they still have access to care. It might be a little more challenging, and we might have to do it over the phone initially.”

He said that “it is a legitimate concern that people may not have access to care or not in a timely manner.”

Push for more personalized care

In October, the Ontario Ministry of Health and the College of Physicians and Surgeons of Ontario issued a letter encouraging doctors to resume clinical visits through virtual appointments.

“The standard of care is often difficult to achieve in a virtual care environment,” the letter states. “Personal care is essential for certain conditions and services or where physical assessments are needed to make an accurate diagnosis or treatment decision.”

Singh says it is imperative that children undergo a personal physical examination to receive an accurate diagnosis. (J.D. Howell)

This is especially true when examining a young patient, Singh emphasized. “There’s so much room to miss a diagnosis when you’re staring at a child on a screen.”

One of the most common symptoms of a brain tumor in a child is macrocephaly, a technical term for an enlarged head, which Singh says can be challenging to identify during a virtual visit.

“Depending on the angle you look at a child you may not even notice how big his head is or even startle you, whereas if that child walked into a room it would be the first thing you’d notice about them.”

McDonald says he believes it could be another year before the full impact of the delayed diagnosis due to COVID-19 is truly understood. When the data does come out, he stressed that we need to carefully examine what happened to understand why people may not have sought the care their children needed.

“There could be another pandemic, and we want to make sure we learn the right lessons for what we’ve done right and what we’ve done wrong in providing adequate care,” he said.

In the meantime, Singh gave two pieces of advice to parents. At first she said, “It’s safe to go to your hospital.” And second, “I would really encourage parents not to accept a virtual visit as a good way to diagnose your child.”

Singh stressed that when parents are concerned about their child, a personal physical examination is necessary to get a correct diagnosis.

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