The care of children with cancer depends on appropriate evaluation and diagnosis, referral to specialized centers, multidisciplinary teams, coordinated multimodal therapy and access to supportive care. In most countries around the world, these elements do not exist consistently for children with cancer. Hence, the additional stress suffered by health systems and institutions worldwide as a result of the 2019 coronavirus disease (COVID-19) pandemic has negatively impacted services for this patient population. The disruption of health services and additional barriers for children with cancer pose a serious challenge to maintaining quality care around the world, but especially in low- and middle-income countries (LMICs).
In this issue of Cancer, Sharma et al1 conducted a quantitative study on the effects of the COVID-19 pandemic on the care of children with cancer in India. This work described a nearly 50% decrease in newly registered children with cancer after the implementation of a national lockdown and significant delays in all elements of multimodal cancer therapy. This article is an important contribution to a growing body of literature describing how the pandemic has affected various elements of pediatric cancer care. Worryingly, these data shed light on the magnitude of the effects of the COVID-19 pandemic and the mitigation strategies adopted for accessing diagnosis and treatment of children with cancer. In India, a lower-middle-income country, the pandemic has impacted the number of new childhood cancer cases, added barriers to cancer-targeted therapy and changed the practice of treatment centers. These indirect effects of the pandemic are undoubtedly greater than the effects of the virus itself on pediatric cancer patients.
Numerous reports have described a decrease in the number of newly diagnosed pediatric cancer cases with the pandemic.2,3 Sharma et al describe a temporal relationship between the implementation of the lockdown in India and an almost 50% decrease in new cancer cases. A sobering number, given that before the pandemic it was estimated that almost half of the world’s childhood cancer cases are never diagnosed.4 This correlation can be expected as travel restrictions limit access to medical facilities, including for the initial assessment of children suspected malignancies and subsequent referrals to specialized centers. This is further substantiated by the fact that this study points to a decrease in the number of new cancer patients having to travel greater distances to get to the pediatric cancer ward. Although telemedicine has been used to deliver care during the pandemic5, detecting cancer in children would be difficult given the vague symptoms often associated with malignancies and the inability to perform physical examinations. In addition, it is important to note that the frequency of treatment discontinuation has not been captured in this study, an additional element that may also be affected by the closure and the added travel barriers. Previously published reports have described an increase in treatment discontinuation during the pandemic, a phenomenon mainly seen in LMICs
In addition, several cross-cutting studies6-8 have sought to evaluate the effects of the COVID-19 pandemic on children’s access to cancer-targeted therapy. The work of Sharma et al. adds patient-level data from more than 1000 cases, a huge feat that increases the granularity of information not achieved before. This publication highlights the effects on the administration of chemotherapy, radiotherapy, stem cell transplantation and surgery, impacting 36% of admitted cases. This effect is consistent with previous studies of LMICs.
The COVID-19 pandemic has forced pediatric cancer departments to adapt their operations to reduce the risk of viral spread and continue cancer-targeted therapy. This study includes the description of the practice of pediatric cancer centers in India, describing the changes, or lack thereof, in the treatment of acute lymphoblastic leukemia, acute myeloid leukemia and sarcomas. For all three diseases, at least 70% of the evaluated centers in India continued with treatment without changes. This is relevant because professional associations involved in the care of children with cancer have published consensus statements to advise treatment providers during the pandemic.9, 10 These guidelines recommend continuation of standard care in the diagnosis, treatment and supportive care of children with cancer. This is the largest report documenting the level of compliance with these recommendations.
A new insight from this study that has not been reported in such detail during the pandemic is the role of non-governmental organizations working with pediatric cancer departments to provide support during cancer treatment. Nearly 80% of centers reported that they needed more support than usual, highlighting the key role these organizations play in pediatric cancer care, especially during these difficult times. This data highlights the role of these support organizations and the need to engage them as key stakeholders in the strategy to reduce the impact on pediatric cancer services during the pandemic and beyond.
While this study represents an important step forward, limitations still remain regarding the description of the ultimate effects of the pandemic. As stated by the authors, the effects of the added barriers to diagnosis and treatment on the outcome of children with cancer remain unknown. The additional obstacles to quality assurance can only mean one thing: poorer results. We’ll have to wait and see how much worse.
The survival rates of pediatric cancers are significantly lower in LMICs, as 2 in 3 children with cancer will die from their disease.11 This disparity is largely due to the capacity of the health system in the different countries of the world. This kind of work continues to prove that the impact of the COVID-19 pandemic on pediatric cancer care reflects the strength of health systems. This study highlights the urgency of a robust response to support pediatric oncology care during the pandemic as it continues to evolve with new viral variants and limited access to vaccines in most LMICs.
Sadly, the COVID-19 pandemic struck at a time of unprecedented dynamism for children with cancer with the launch of the World Health Organization’s Global Initiative for Childhood Cancer. We can only hope that this momentum can be used to define a strategy to continue caring for children during the pandemic and learn from the implemented strategies to optimize resources for cancer care after the current health crisis.
No specific funding has been disclosed.
Disclosure of Conflict of Interest
The author has made no disclosures.