|Year : 2020 | Volume
| Issue : 5 | Page : 97-101
COPING with CORONA: A developing country perspective on managing children with cancer during COVID-19 pandemic
Megha Saroha, Nirmalya Roy Moulik
Department of Medical Oncology, Division of Pediatric Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Submission||06-Apr-2020|
|Date of Decision||06-Apr-2020|
|Date of Acceptance||08-Apr-2020|
|Date of Web Publication||25-Apr-2020|
Nirmalya Roy Moulik
Tata Memorial Hospital, Dr Ernest Borges Rd., Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Saroha M, Moulik NR. COPING with CORONA: A developing country perspective on managing children with cancer during COVID-19 pandemic. Cancer Res Stat Treat 2020;3, Suppl S1:97-101
|How to cite this URL:|
Saroha M, Moulik NR. COPING with CORONA: A developing country perspective on managing children with cancer during COVID-19 pandemic. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jun 1];3, Suppl S1:97-101. Available from: http://www.crstonline.com/text.asp?2020/3/5/97/283298
The aim of this narrative commentary is to give an overview of the challenges of treating children with cancer during the COVID-19 pandemic. Unlike the various published guidelines on the general care of children on treatment for cancer, we intend to focus on the specific problems likely to be encountered during the care of children with cancer during this pandemic, from the perspective of a developing country. In addition, we also suggest some modifications in the existing treatment plans of specific conditions that are likely to be helpful and pragmatic during this uncertain period. The suggestions would need local adaptation depending on current practice as well as frequent updating given the dynamicity of the current situation.
| Covid-19 Pandemic|| |
The pandemic caused by SARS-CoV-2 (COVID-19) is rapidly affecting the delivery of health-care for all patients across the board worldwide, including children with cancer. Although current evidence suggests relatively milder illness in children and young people, more mature data are awaited. As of April 4, 2020, a total of 105,635 confirmed cases and 56,985 deaths due to COVID-19 have been reported across the world.
| Covid-19 in Children|| |
Till date a small number of cases of COVID-19 have been described in children, and our understanding of the spectrum of illness in them is limited. A retrospective study from Wuhan, China, in January 2020 reported COVID-19 infection in 6 of 366 (1.6%) children suffering from respiratory infections. Common clinical characteristics of these 6 patients included high fever (>39°C) (n = 6), cough (n = 6), and vomiting (n = 4). All of these patients recovered after hospitalization for a median of 7.5 days (range 5–13). Non-specific findings including small nodular ground glass opacities have in reported in computed tomography of lungs in children during early course of infection. In a bigger series from a later period, 2143 cases (731 laboratory-confirmed cases, rest suspected cases) of COVID-19 in children were reported to the Chinese Centre for Disease Prevention and Control. Infants and younger children (i.e., ≤5 years) in this series were found to be more likely to develop severe clinical manifestations than older children, which might be explained by relative immaturity of the immune system in younger children.
| Covid-19 in Children With Cancer|| |
Although data on the clinical features and outcome of COVID-19 infection in immunocompromised children with cancer are scarce, emerging data on adults with cancer suggest increased susceptibility and more severe clinical course. Furthermore, experience from previous pandemics, such as influenza A H1N1, suggests vulnerability of immunosuppressed patients in the face of a similar infection. To date, there are few published reports of COVID-19 in children with malignancies. The first confirmed case of COVID-19 in a child with acute lymphocytic leukemia was reported on March 8, 2020, in Wuhan, China. The patient's pulmonary lesions progressed rapidly necessitating respiratory support; the article, however did not mention on the further course or outcome of the case. An Italian report from at a major childhood cancer center in Lombardy, recently accepted for publication, has documented five positive cases in children with cancer, all of whom had a mild course and recovered. Apart from the concern of potentially severe illness in children with cancer, continuation/delivery of routine cancer care in children during this pandemic faces huge logistic challenges in view of the tremendous pressure on health-care delivery systems and resources posed by the COVID-19 pandemic in countries with a high caseload.
| Covid-19 Pandemic and the Response of International Childhood Cancer Treatment Groups|| |
Most childhood cancers are treated with curative intent and, therefore, would require a cautious balance between avoidance of intensive chemotherapy during the current pandemic or continuation of recommended curative treatment despite anticipating an increase in complications due to COVID-19 in the immunocompromised host with limited availability of supportive care. In the current era, treatment of cancer is mostly delivered in the outpatient setting, and hospital visits or intermittent hospital admission is unavoidable for appropriate delivery of therapy, which comes in the way of enforcing recommended social distancing to contain the pandemic. Hence, a strategic plan tailor-made for the setting, encompassing all aspects of prevention of transmission to managing COVID-19 outbreaks in pediatric hematology and oncology units as well as policies regarding modifying/deferring immunosuppressive chemotherapy, is an urgent need.
Taking cognizance of the rapidly escalating pandemic and its potential effect on children with cancer, the International Society of Pediatric Oncology (SIOP) has published early guidelines stating the general principles of care in children with cancer during this pandemic. SIOP in association with the St. Jude Children's Research Center and Hospital, Memphis, USA, and other stakeholders are promulgating a COVID-19 resource center, including an open registry and experience-sharing platform. Large co-operative groups like the Children's Oncology Group from North America, the Children's Cancer and Leukemia Group (CCLG) from the United Kingdom as well as the Pediatric Hematology-Oncology Chapter of the Indian Academy of Pediatrics have issued general guidance on managing children with cancer during this pandemic.,,,
In addition to issuing general guidance, the CCLG has also come up with disease-specific contingency plans from each of their disease-oriented special interest groups, which outline the recommendations pertaining to treatment modifications permissible during the pandemic. Although CCLG intends to treat patients on their existing trials and protocols, they acknowledge that it might not be pragmatic during this pandemic. The CCLG has recommended managing febrile neutropenia (FN), one of the most common complications during treatment, based on risk scoring, wherein low-risk patients would be preferentially managed on the domiciliary basis, which is a significant departure from the usual UK practice. The indications for stem cell transplants have been rationalized, and many patients qualifying for stem cell transplant previously can now be continued on chemotherapy on a case-to-case basis after discussion with the national expert groups. Similarly, modifications in standard-dose chemotherapy for various malignancies (solid and hematological) have been proposed to reduce hospital visits and duration of inpatient admission. Priority scoring for radiotherapy has been formulated where patients in absolute need for curative radiotherapy will be taken up on priority as the UK as a country anticipates major disruptions in radiation services.
| Delivery of Cancer Care to Children in the Developing Countries during the Covid-19 Pandemic|| |
Children with cancer face a host of issues when it comes to starting or continuing treatment during these uncertain times, which apart from including alterations and simplification of treatment schedules, also involve various logistic issues around the delivery of care. The challenges faced by such children from the resource-constrained settings and their families are even more than what are likely to be seen in resource-rich nations.
| Issues in Delivery of Care in Children With Cancer during the Pandemic|| |
- Travel restrictions: In situ ations of complete or partial lockdown of cities and countries (widely being adapted for containment of the outbreak), the journey from native place to a cancer center, which sometimes means traveling thousands of miles, can become even more tedious and expensive. This might lead to a delay in access to care and diagnosis. The prevailing uncertainty is more likely to increase the chances of treatment default and abandonment
- Problems with new presentations: Newly diagnosed patients or patients under evaluation are likely to face more problems due to delay in investigations and diagnosis due to limitations in non-essential scans and procedures in many hospitals, leading to delay in starting treatment
- Reduced staff strength: Due to the prevalent practice of reducing staff strength at any particular time and cohorting staff to prevent accidental exposure of a large number of health-care workers, making them liable to quarantine measures is leading to an acute shortage of staff working in clinical areas. Depending on the nature and commitments of the hospital, medical, and ancillary staff might be diverted to wards and newly created areas for screening, triage, and treatment of COVID-19 patients.
- Postponement/cancellation of intensive curative treatment: Intensive treatments, including planned surgeries or stem cell transplants might get deferred or cancelled in the worst-case scenario due to anticipated shortage of appropriate supportive care, scarcity of blood products and lack of intensive care bed vacancies.
- Shortage of drug supply: Risk of interruptions in the drug supply chains and the consequent shortage of indigenously produced and imported drugs are likely to adversely affect the quality of care and outcome thereof.
- Scarcity of blood products: As voluntary donations reduce due to travel restrictions as well as lack of motivation and fear of COVID-19 infection amongst potential donors, blood bank stocks dwindle, leading to compulsive rationing of blood products, which are indispensable in supporting cancer patients during surgery or chemotherapy
- Limited non-governmental organisations (NGO) participation, fund flow, and advocacy: In resource-constrained settings and otherwise, non-governmental agencies and charity organizations take an important part in fund-raising and organizing care for children with cancer. This pandemic situation is bound to hamper the functioning of these organisations leading to lack of adequate funding for treatment and supportive care. For example, international NGOs like World Child Cancer operating from >10 low-middle income countries had to temporarily suspend their planned/routine activities in many countries due to prevailing government sanctions
- Difficulty in running clinical trials: Clinical trials have immensely helped the progress and refinement of the treatment of childhood cancer over the last many decades, which unfortunately is going to take a backseat during the COVID-19 pandemic in view of the shortage of staff and difficulty in meeting ancillary trial-related regulatory requirements. The CCLG-UK, in their recent position statement, mentions the need for trial participation but acknowledges that it might not be a possibility depending on the escalation of the pandemic in the country.
| Local Response to Covid-19 Pandemic: Pediatric Oncology Perspective|| |
Tata Memorial Hospital, Mumbai, India being the largest tertiary cancer referral hospital of India, has taken significant steps in mitigating the effects of the current pandemic on patients with cancer. In addition to the general measures taken by the hospital, the pediatric services have modified their existing patient-care pathways and protocols to suit the current situation. The target of the current modification was to reduce the in-patient and out-patient load by at-least half and optimize treatment for curative diseases.
- Continuation of intensive treatment is being decided on a case-to-case basis; however, the broad guidelines to avoid intensive blocks of chemotherapy in children in remission have been put in place.
- Tweaking of chemotherapy blocks by administering the less intense blocks in the beginning with the hope of giving the more intense ones at a later stage once the worst of the pandemic is over.
- To consider oral chemotherapy for patients with diseases with expected poor outcomes, including leukemia not in complete remission despite two or more blocks of chemotherapy.
- Rationalizing transfusion cut-offs and in-patient management of FN within limits of safety.
- Deferral or omission of visits for patients on maintenance chemotherapy, including delaying or dropping doses of intrathecal chemotherapy depending on the stage of treatment
- Deferring follow-up visits indefinitely till the situation improves.
- Patients in complete remission post local therapy are being planned for less intensive adjuvant therapy on a case-to-case basis.
- Day 8 and Day 15 vincristine doses, which were an integral part of our sarcoma protocols but are not known to add to survival benefits are being dropped to reduce hospital attendance.
- Liberal use of G-CSF and using the pegylated formulation decrease health care attendance.
- Delaying local therapy, including planned surgery/radiotherapy whenever possible and bridging the gap period with cycles of chemotherapy, is also proposed.
- Rationalizing management of FN, including treating low-risk FNs on a domiciliary basis with oral antibiotics has being done.
In addition to the above specific measures, all patients with scheduled appointments and not on active intensive treatment are being called up for telephonic consultation, and future follow-up dates are being given as appropriate as per hospital policies. A resident-led outreach clinic has been set up at the largest home-away-from home center (lodging about 150 children and their families at any given time) attached to our hospital to reduce scheduled travels to the hospital during this time.
In [Table 1], we propose certain modifications in the usual treatment protocols of common pediatric malignancies in line with our current practice and the guidelines issued by international cooperative groups, namely the CCLG. The reader needs to be aware that these are suggestions which can be translated to clinical care only at the discretion of the treating physicians in discussion with their local multi-disciplinary teams.
|Table 1: Suggested treatment modifications for common cancers in children from developing countries during the COVID-19 pandemic|
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| Conclusion|| |
As the COVID-19 pandemic escalates and developed countries struggle to contain the virus and keep routine health-care delivery afloat, the situation in countries with already constrained health-care systems might turn into a massive tragedy. Therefore, proper planning in anticipation of the worst and making contingency plans for smooth and pragmatic delivery of care to non-COVID related illnesses, which are likely to take a backstage during this crisis, is the need of the hour to avert greater collateral damage. With the progression of the pandemic, we expect to have more data on children with cancer, and the question on how the above interventions and treatment modifications would pan out, in the end, is for the future to answer.
The authors wish to acknowledge all the members of the Pediatric Hematolymphoid and Pediatric Solid Tumor Disease management groups of Tata Memorial Hospital, Mumbai.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al
. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061. doi:10.1001/jama.2020.1585.
Feng K, Yun YX, Wang XF, Yang GD, Zheng YJ, Lin CM, et al
. Analysis of CT features of 15 Children with 2019 novel coronavirus infection. Zhonghua Er Ke Za Zhi 2020;58:E007.
Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al
. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020; (published online March 16). DOI:10.1542/peds.2020-0702.
Kotecha RS. Challenges posed by COVID-19 to children with cancer. Lancet Oncol 2020. pii: S1470-2045(20)30205-9.
Chen Z, Xiong H, Li JX, Li H, Tao F, Yang YT, et al
. COVID-19 with post-chemotherapy agranulocytosis in childhood acute leukemia: A case report. Zhonghua Xue Ye Xue Za Zhi 2020;41:E004.
Balduzzi A, Brivio E, Rovelli A, Rizzari C, Gasperini S, Melzi ML, et al
. Lessons After the Early Management of the COVID-19 Outbreak in a Pediatric Transplant and Hemato-Oncology Center Embedded within a COVID-19 Dedicated Hospital in Lombardia, Italy. Estote Parati. (Be Ready.). Available from: https://ssrn.com/abstract=3559560 or http://dx.doi.org/10.2139/ssrn.3559560
. [Last accessd on 2020 Mar 19].
Bouffet E, Challinor J, Sullivan M, Biondi A, Rodriguez-Galindo C, Pritchard-Jones K. Early advice on managing children with cancer during the COVID-19 pandemic and a call for sharing experiences. Pediatr Blood Cancer. Accepted Author Manuscript. 2020. doi:10.1002/pbc.28327.
Children's Cancer and Leukaemia Group (CCLG), UK. Guidelines from Special interest Groups Regarding Management of Specific Diseases during the COVID-19 Pandemic. Available from: https://www.cclg.org.uk/Coronavirus-advice
. [Last accessed on 2020 Apr 05].
PaediatricHaematology-Oncology Chapter of the Indian Academy of Pediatrics (PHO-IAP): Corona Virus Advisory Personal Communication for Pediatric Blood Diseases and Cancer Patients.
Holder AA, Wootton JC, Baron AJ, Chambers GK, Fincham JR. The amino acid sequence of Neurospora NADP-specific glutamate dehydrogenase. Peptic and chymotryptic peptides and the complete sequence. Biochem J 1975;149:757-73.
Kumar K, Radhakrishnan V, Dhanushkodi M, Kalaiyarasi JP, Mehra N, Kumar AR, et al
. Oral etoposide and cyclophosphamide: A low-cost palliative metronomic chemotherapy in advanced pediatric cancers. Cancer Res Stat Treat 2020;3:64-8