During a recent tweet chat with Sheena Mukkada, MD, MPH, an assistant member of St. Jude Children’s Research Hospital, joined Targeted Oncology to discuss how the COVID-19 pandemic has impacted pediatric cancer care.
The COVID-19 pandemic has created unique challenges for treating pediatric cancer patients. While COVID-19 infections in children are usually mild, patients with childhood cancer are more prone to serious illnesses
In a recent tweet chat, Sheena Mukkada, MD, MPH, an assistant member of St. Jude Children’s Research Hospital, and faculty in the Global Pediatric Medicine Department, Infectious Disease Department, at the St. Jude Graduate School of Biomedical Sciences discussed , new findings from a new study on outcomes in pediatric cancer patients infected with COVID-19.
The study enrolled 1,500 patients from 45 countries between April 2020 and February 2021. Data was submitted to the St. Jude Global and International Society of Peadiatric Oncology Global Registry of COVID-19 in Childhood Cancer, which is housed in an application developed by Vanderbilt University Medical Center in Nashville, Tennessee. The enrolled children had laboratory-confirmed COVID-19 infection and a concurrent or previous diagnosis of cancer or had undergone haematopoietic stem cell transplantation.1
“Children with cancer have their immune systems shut down because of a cancer diagnosis and then the treatment they received to treat it. So if the immune cells don’t have the ability to respond as they should to infections, we think they’re at risk for worse results, and that’s essentially what we were afraid to see, and the data seems to show in our study,” Mukkada said in an interview with Targeted OncologyTM.
Overall, severe or critical illness was seen in 19.9% of patients, according to the analysis. However, in low-income countries, serious illness was seen in 41.7%, compared to 16.5% in middle-income countries and 7.4% in high-income countries. Overall, COVID-19 infection caused changes in treatment in 55.8% of patients. In low-income countries, treatment adjustments were seen in 67.9% of patients, in middle-income countries in 48.1% and 63.9% of patients in high-income countries.
In cases where death occurred, COVID-19 was the cause in 60.2% of them. In low-income countries, COVID-19 was the cause of 60.6% of deaths, in middle-income countries it was the cause of 60.5% of deaths and in high-income countries it was the cause of 57.1% of deaths . Hospital admissions were most common in middle-income countries, with only 20% of patients not being hospitalized. In high-income countries 54.1% of patients were not hospitalized and in low-income countries 39.9% were not hospitalized.
Childhood cancer care during the COVID-19 pandemic
Given the impact of the pandemic on pediatric cancer care, adjustments were needed to continue providing care. According to a report published in the American Society of Clinical Oncology Education Book, the rapid spread of both information and misinformation posed a new kind of public health challenge.2
Within weeks of declaring a pandemic, the general recommendation was to continue standard care, diagnosis and treatment of pediatric cancer patients whenever possible. However, the report found that in a survey of 20 countries in Latin America, 36% of respondents reported that chemotherapy regimens needed to be adjusted due to a shortage of chemotherapy. In West Asia, North Africa and the Middle East, treatment interruptions were reported between 29% and 44% of institutions. In addition, 24% of those institutions limited the acceptance of new patients
“We know that interruptions in therapy can correlate with poorer disease control. But we’re not collecting the data within this study to say whether that actually correlated. We won’t find out until later. And because the registry is moving towards a particular We can’t say how long the treatment was interrupted or how many doses were really missed or whether that had an impact, but we know there are interruptions in the therapy, which is never a good thing,” says Mukkada.
In addition, the COVID-19 pandemic initially caused a sharp drop in clinical trial enrollment. However, recruitment in Europe and the United States has grown
An article published in September 2020 in Pediatric Blood Cancers raised concerns that the pandemic was causing the diagnosis of pediatric cancer to be missed. At the Dana-Farber Cancer Institute, there was a 25% increase in new patient diagnosis when comparing January-February in 2019 versus 2020. However, when comparing March to May in the same year, there was a 56% decrease in cases. While this partly reflects a gradual recovery, the paper authors say the decline is undoubtedly caused by both a decline in primary care visits and a reluctance on the part of parents to expose their children to the virus.3
COVID-19 results in pediatric cancer patients
Compared to children without cancer, children with cancer often have worse outcomes when infected with COVID-19. According to the report published by St. Jude, 4% of all pediatric cancer patients infected with COVID-19 died, compared to the 0.01-0.7% mortality seen in the general pediatric population. In addition, serious infections were more common in pediatric cancer patients than in the general population.
According to Mukkada, location and socioeconomic status also played an important role in the outcomes. Patients in low- and middle-income countries were more likely to develop serious infections than patients in high-income countries, highlighting the gap in care that exists worldwide.
“If you look at our analysis, perhaps the point that is most interesting to me is the fact that factors beyond biological, socioeconomic status of the country actually reporting the case are so correlated with the outcomes that cases living outside of low- and middle-income countries are almost six times more likely to have serious critical outcomes compared to those living and/or receiving treatment in high-income countries,” Mukkada said.
Currently, individuals 12 years of age and older are eligible for a COVID-19 vaccine.4-6 While a vaccine authorization is expected in the coming weeks for children between the ages of 5 and 12, none is available at the time of writing . This creates a unique challenge for younger patients.
The report published by St. Jude found that of the 1,301 COVID-19 cases evaluated, children ages 1 to 9 formed the largest sample, with 707 reported cases. Of those cases, 37.7% were symptomatic, 44.6% were mild or moderate, and 18.1% were severe
Children between the ages of 10 and 14 made up the second largest cohort, with 336 cases reported. Of those cases, 35.7% were asymptomatic, 44.6% were mild or moderate, and 19.6% were severe or critical.
According to Mukkada, a COVID-19 vaccine for this patient population can “only be positive”.
“If we get approval for it, the data for it will be good in terms of protective immunity against getting serious diseases, and hopefully reduce some of the transmission potential. So it can only be positive in terms of protecting everyone in the world.” the community, and certainly the vulnerable population from exposure to opportunities,” said Mukkada.
Until then, patients with weak immune systems should continue to wear a face mask, wash hands often, avoid crowds and maintain physical distance.
REFERENCES: 1. Mukkada S, Bhakta N, Chantada G, et al. Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort study. Lancet Oncol. 2021;22:1416-26 doi:10.1016/S1470-2045(21)00454-X2.Moreira D, Millen G, Sands S, et al. Caring for children with cancer during the COVID-19 pandemic. Am Soc Clin Oncol Educ Book. 2021;41:305-314. doi: 10.1200/EDBK_321497.3.O’Neill A, Wall C, Bornstein C, et al. Early diagnosis of childhood cancer: an unexpected victim of the COVID-19 wave. Pediatric blood cancer. 2020;22:e28729. doi: 10.1002/pbc.287294.Comirnaty and Pfizer-BioNTech COVID-19 vaccine. FDA. Accessed October 22, 2021. https://bit.ly/3C6nfPK5.Moderna COVID-19 Vaccine. FDA. Consulted on October 22, 2021. https://bit.ly/3b1e0Eu6.Janssen COVID-19 vaccine. FDA. Accessed on October 22, 2021. https://bit.ly/3E1Krz6