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Table of Contents
EDITORIAL
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 281-283

Survival of children with cancers amidst COVID-19: A fight with two enemies


1 Sir HN Reliance Hospital and Research Centre, Mumbai, Maharashtra, India
2 Department of Pediatric Oncology, SPMC Children's Cancer Institute; Department of Global Pediatric Medicine, St. Jude Global Medicine, Davao, Philippines
3 Department of Pediatric Hematology, Oncology and Transplantation, Hue Central Hospital, Hue, Vietnam
4 Department of Medical Oncology, B P Koirala Memorial Cancer Hospital, Bharatpur, Chitwan, Bagmati Pradesh, Nepal

Date of Submission18-May-2020
Date of Decision19-May-2020
Date of Acceptance20-May-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Shweta Bansal
Sir HN Reliance Hospital and Research Centre, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_206_20

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How to cite this article:
Bansal S, Dolendo M, Hoa Nguyen TK, Sharma K. Survival of children with cancers amidst COVID-19: A fight with two enemies. Cancer Res Stat Treat 2020;3:281-3

How to cite this URL:
Bansal S, Dolendo M, Hoa Nguyen TK, Sharma K. Survival of children with cancers amidst COVID-19: A fight with two enemies. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 6];3:281-3. Available from: http://www.crstonline.com/text.asp?2020/3/2/281/287245



The world is facing an unprecedented challenge and a severe threat to survival because of the coronavirus disease 2019 (COVID-19) pandemic. The first case of COVID-19 was reported in December 2019 in Wuhan, China, and since then, it has rapidly spread across the globe.[1] The developing and developed countries both have been equally affected, and the health-care systems are bearing the brunt of the current crisis. During this pandemic, the health-care delivery systems for other diseases have been adversely affected because of various reasons, such as the nationwide lockdowns; infection among health-care workers; inaccessibility of hospitals and other health-care facilities; and shortage of hospital beds, staff, and drugs.

Before the pandemic, the low- and middle-income countries (LMIC) faced several issues in the management of children with cancers, including advanced disease at presentation, financial difficulties, lack of knowledge about the disease, and difficulty in accessing well-equipped and competent tertiary care centers. In 2018, the Word Health Organization launched the Global Initiative for Childhood Cancer with the aim of improving the survival rates of children with cancer. It is unfortunate that when pediatric oncology collectively was moving forward toward achieving this aim, we were struck by the COVID-19 pandemic.[2],[3]

The article, “COPING with CORONA: A developing country perspective on managing children with cancer during COVID-19 pandemic,” was insightful and pragmatic.[4] The COVID-19 pandemic has widened the gap in cancer care, which has been effectively highlighted in this article. There are several issues pertaining to the delivery of care to children with cancer amidst the pandemic, especially in the LMIC: (1) travel restrictions; (2) problems with new cases; (3) reduced staff strength; (4) postponement/cancellation of intensive curative treatments; (5) shortage of drug supply; (6) scarcity of blood products; (7) limited funding, advocacy, and participation of nongovernmental organizations (NGO); (8) difficulty in running clinical trials.[4],[5],[6]

The article provides guidelines for the management of cancer in pediatric patients with hematological malignancies and solid tumors. For hematological malignancies, it is advised to avoid intensive chemotherapy, prioritize the treatment of curable malignancies, rationalize the use of blood products, and defer the follow-up visits.[7] For solid tumors, it is advised to decrease the intensity of treatment in patients who are in remission; delay the local therapy, including surgery and radiation, and bridge the gap with chemotherapy; and limit the number of hospital visits with the liberal use of granulocyte colony-stimulating factor and by avoiding weekly doses of vincristine.[4],[8],[9]

Various international organizations, such as the International Society of Pediatric Oncology (SIOP), Children Oncology Group, SIOP Europe, SIOP Pediatric Oncology in Developing Countries, and St. Jude Global, as a rapid global response, have provided guidelines for the management of children with cancers during this pandemic. The guidelines are focused primarily on six conditions, namely acute lymphoblastic leukemia, retinoblastoma, Hodgkin's disease, Burkitt's lymphoma, Wilms' tumor, and low-grade glioma.[10],[11] We have similar guidelines, documents, and experiences reported from other parts of the world.[12],[13]

It is important to understand the issues faced by the LMIC and that they can differ from country to country and even from center to center in the same region.

The Philippine Pediatrics Society and the Pediatric Infectious Disease Society of the Philippines released guidelines for the diagnosis and management of COVID-19 in the pediatric age group.[14] The Southern Philippines Medical Center (SPMC), a public tertiary hospital in Davao City, was among the designated COVID-19 referral hospitals to facilitate and maximize government support. PhilHealth, the country's national insurance agency, also guaranteed health coverage for patients with COVID-19.[15] In the current situation, travel restrictions and overcoming the resultant hurdles in getting the patients to the hospital are among the toughest challenges faced in pediatric oncology. Cancer units, including those at SPMC, have limited the admissions and outpatient treatments to decrease the risk of contracting COVID-19 from the suspected patients.

Vietnam, another South Asian country, has been able to limit the vast spread of COVID-19, and its medical facilities are able to deliver cancer care, but with a few limitations. The major issue faced by the health-care system was the inability to continue treatment because of the imposed travel restrictions. As patients could not visit the hospitals, they were contacted by satellite hospitals in their vicinity to guide their treatment. Other challenges faced were a shortage of blood products; asking the medical staff, employees, and their relatives to donate blood products; and the need to defer transplantation.

In Nepal, the B.P. Koirala Memorial Cancer Hospital is the only national government cancer center, where both pediatric and adult cancer care are available. Each year, about 300 children with cancer come to this hospital for treatment. Since the imposition of a lockdown, patients are facing difficulties in traveling to the hospital for treatment. In addition, it is difficult to get admission and treatment because of the lack of personal protective equipment (PPE) for health-care workers. There is also a shortage of blood products, specific diagnostic tests, and chemotherapeutic agents. Moreover, patients who visit the hospital for care face the problems of unavailability of food and shelter.

The logistic issues are a major hurdle in the management of pediatric patients with cancer during this pandemic. Many centers have reported the shortage of blood products, medical staff, PPE, and hospital beds, and difficulties in getting the preliminary diagnostic tests, as most of these resources have been reassigned to the care of patients with COVID-19.

A few other important issues left unaddressed are (1) handling of asymptomatic children with COVID-19, (2) need for and frequency of testing for COVID-19 in asymptomatic children and their caregivers, (3) management of cancer simultaneously with COVID-19, and (4) facility and availability of isolation/negative pressure rooms.

There is a paucity of data regarding the course of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the pediatric population; however, a few studies have reported a milder course in children, except in those aged less than a year.[16],[17] It is noteworthy that not many centers have reported an increased rate of SARS-CoV-2 infection among pediatric oncology patients. In a study from New York, the rate of SARS-CoV-2 infection in pediatric patients with cancer was only 2.5% in those asymptomatic for COVID and 29.3% in symptomatic COVID-positive patients.[18] The morbidity and mortality associated with the infection were also low in these patients.[19] A systematic review on the impact of COVID-19 on immunosuppressed patients, including children, highlighted the better outcomes and decreased mortality in pediatric patients compared to the general population.[20]

This pandemic has certainly posed some unforeseen challenges to the pediatric oncology community. Most importantly, the health-care systems' attention and resources have been diverted to control and limit the spread of the pandemic, and treatment and care of patients with COVID-19 has taken priority over cancer care.

Hence, for the pediatric oncology community, the fight against cancer begins yet again with advocacy and awareness. We need coordinated participation from the NGOs and community at large to prevent and reduce the morbidity and mortality from childhood cancers.

Considering the findings of the above reports and the available data, it is imperative for the pediatric oncology community to think and rethink their strategy regarding the management of pediatric patients with cancers, who now have two enemies to fight against. It will be difficult to quantify the impact of COVID-19, but certainly a careful look at patient outcomes under these conditions should be a good area of study.



 
  References Top

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Novel Coronavirus (2019-nCoV) Situation Reports. World Health Organization. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/. [Last accessed on 2020 May 18].  Back to cited text no. 1
    
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Jalali R, Goda JS, Patil V. Coronavirus disease 2019 pandemic and its implications on triaging patients with brain tumors for surgery, radiotherapy, and chemotherapy. Cancer Res Stat Treat 2020;3 Suppl S1:49-53.  Back to cited text no. 9
    
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Sullivan M, Bouffet E, Rodriguez-Galindo C, Luna Fineman S, Sagir Khan M, Kearns P, et al. The COVID-19 pandemic: A rapid global response for children with cancer from SIOP, COG, SIOP-E, SIOP-PODC, IPSO, PROS, CCI, and St Jude Global. Pediatr Blood Cancer 2020;67:e28409.  Back to cited text no. 10
    
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Howard SC, Davidson A, Luna-Fineman S, Israels T, Chantada G, Lam CG, et al. A framework to develop adapted treatment regimens to manage pediatric cancer in low- and middle-income countries: The Pediatric Oncology in Developing Countries (PODC) Committee of the International Pediatric Oncology Society (SIOP). Pediatr Blood Cancer. 2017;64 Suppl 5:10.1002/pbc.26879. doi:10.1002/pbc.26879.  Back to cited text no. 11
    
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Interim Guidelines on the Screening, Assessment and Clinical Management of Pediatric Patients with Suspected or Confirmed Coronavirus Disease 2019 (covid-19) version 2, 12 april 2020. Phillipines Pediatric Society. Available from: http://www.pidsphil.org/home/wpcontent/uploads/2020/04/INTERIM-GUIDELINES-ON-THE-SCREENINGV2.pdf. [Last accessed on 2020 May 18].  Back to cited text no. 14
    
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