In a recent tweet conversation with Sheena Mukkada, MD, MPH, Associate Member of St. Jude Children’s Research Hospital, joined Targeted Oncology to discuss the impact of the COVID-19 pandemic on healthcare pediatric cancer.
The COVID-19 pandemic has created unique challenges for the treatment of pediatric cancer patients. While COVID-19 infections in children tend to be mild, pediatric cancer patients are more prone to serious illnesses.1
In a recent tweet conversation, Sheena Mukkada, MD, MPH, Associate Member of St. Jude Children’s Research Hospital and Professor of Global Pediatric Medicine Department, Infectious Disease Department, St. Jude Graduate School of Biomedical Sciences, discussed news results of a new study on outcomes in pediatric cancer patients infected with COVID-19.
During the study, 1,500 patients from 45 countries were included between April 2020 and February 2021. Data was submitted to the St. Jude Global and International Society of Peadiatric Oncology of COVID-19 in Childhood Cancer Global Registry. , which is hosted in an app. developed by Vanderbilt University Medical Center in Nashville, Tennessee. The children included had a laboratory-confirmed COVID-19 infection and a concomitant or previous diagnosis of cancer or had received a hematopoietic stem cell transplant.1
âChildren with cancer have weakened their immune systems because of the cancer diagnosis and then the treatment they received. So when immune cells don’t have the ability to respond to infections as they should, we think they may have worse outcomes. And that’s basically what we were afraid to see, and with the data seems to show in our study, âMukkada said in an interview with Targeted OncologyMT.
According to the analysis, severe or critical illness was observed in 19.9% ââof patients overall. However, in low-income countries, severe illness was observed in 41.7%, compared to 16.5% in middle-income countries and 7.4% in high-income countries. Overall, COVID-19 infection resulted in treatment changes in 55.8% of patients. In low-income countries, changes in treatment were observed in 67.9% of patients, in middle-income countries, 48.1% and 63.9% of patients in high-income countries.
In the cases of death, 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. Hospitalizations were most likely to occur 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.
Pediatric cancer care during the COVID-19 pandemic
Given the impact of the pandemic on pediatric cancer care, adaptations were necessary in order to continue providing care. According to a report published in the American Society of Clinical Oncology Education Book, the rapid spread of information and disinformation has presented a new type of public health challenge.2
In the weeks following the declaration of a pandemic, the general recommendation was to continue the standard care, diagnosis and treatment of pediatric cancer patients to the extent possible. However, the report found that in a survey of 20 Latin American countries, 36% of respondents said chemotherapy regimens need to be changed due to chemotherapy shortages. In West Asia, North Africa and the Middle East, treatment interruptions were reported between 29% and 44% of facilities. In addition, 24% of these establishments have restricted the acceptance of new patients.2
âWe know that therapy interruptions may be correlated with poorer disease control. But we’re not collecting the data in this study to be able to tell if this is actually correlated. We won’t find out until later. And because the registry is for a separate period of time, we can’t say how long the treatment was interrupted or how many doses were really missed, and if that had an impact. But we know there are interruptions in therapy, which is never a good thing, âMukkada said.
In addition, the COVID-19 pandemic initially caused a sharp drop in clinical trial registrations. However, recruitment in Europe and the United States has increased.2
An article published in Pediatric blood cancers in September 2020, expressed concern that the pandemic eluded the diagnosis of pediatric cancer. At the Dana-Farber Cancer Institute, there was a 25% increase in the number of new patient diagnoses comparing January-February in 2019 versus 2020. However, comparing March to May of the same year, there is had a 56% drop in cases. While part of this reflects a gradual recovery, the authors of the article say the decline is undoubtedly due to both a decrease in in-person 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 tend to perform worse when they are infected with COVID-19. According to the report published by St. Jude, 4% of all pediatric cancer patients infected with COVID-19 died, compared with 0.01-0.7% mortality observed 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 a major role in the results. Patients in low- and middle-income countries had a higher risk of serious infections than those in high-income countries, highlighting the care gap that exists globally.
âWhen you look at our analysis, what is perhaps the most interesting point for me is the fact that factors beyond the biological, the socio-economic status of the country that actually signals the case, correlate with results such that cases reported outside low- and middle-income countries are almost 6 times more likely to have severe critical outcomes than those living and / are treated in high-income countries, âsaid Mukkada.
Currently, people 12 years of age and older are eligible to receive a COVID-19 vaccine.4-6 However, while authorization for a vaccine is expected for children aged 5 to 12 in the coming weeks, none are available at the time of writing. This creates a unique challenge for younger patients.
The report released by St. Jude found that of the 1,301 cases of COVID-19 assessed, children aged 1 to 9 made up the largest sample, with 707 cases reported. Of these cases, 37.7% were symptomatic, 44.6% were mild or moderate, and 18.1% were severe.1
Children aged 10 to 14 were the second largest cohort, with 336 reported cases. Of these 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”.
âIf we are to get approval, the data will be good in terms of protective immunity against severe disease and hopefully reduce some of the potential for transmission. So this can only be positive in terms of protecting all members of the community, and certainly the vulnerable population from exposure opportunities, âMukkada said.
Until then, patients with weakened immune systems should continue to wear a face mask, wash their hands often, avoid crowds, and maintain a physical distance.