Challenges Burden Pediatric Oncologists Following the Peak of COVID-19

Pediatric oncologists are facing unprecedented challenges in the aftermath of the COVID-19 pandemic. In Boston, one cancer institute still has reminiscent encounters with pediatric patients.

BOSTON, MASS. – In May 2020, which some refer to as the peak of the pandemic, Allison F. O’Neill, MD, remembers the uneasy feeling of isolation which surrounded the hallways and waiting rooms of the pediatric outpatient clinic at the Dana-Farber Cancer Institute (Dana-Farber).

Thick plexiglass surrounded each room and invisible tape lined the floors, suggesting social distancing to separate patients and families from others around the clinic.

“If you look at the pre-COVID era in the clinic, you had patients congregating in a unique way in the resource room. They were interacting with one another, there weren't plexiglass dividers up, providers congregated more in common spaces,” noted O’Neill, clinical director, Solid Tumor Program, Pediatric Hematology/Oncology at Dana-Farber, in an interview with Targeted OncologyTM. “With the onset of COVID, a lot of that changed. Many of us stayed in our offices during the clinic and only came in and out when we saw patients. We had to orchestrate how we could spend a minimal amount of time with patients whereas not to expose them.”

For oncologists like O’Neill, even the ways to see patients had been altered. With an increased use of telehealth, patients were not coming in person as often. At Dana-Farber, experts worked to operationalize virtual visits seamlessly, to best care for their patients while remaining socially distant.

“For a time, we were seeing patients more routinely in a virtual setting. We would skip visits or have them scan, but then do a virtual exam or check in knowing that if they had scans done, they were less likely to need an in person visit, unless they were clinically complex,” said O’Neill. “We've returned to seeing most patients in person on the timeline in which they should be seen, which is great. You can never replace an in person visit with virtual, but it's so nice to have the zoom option now.”

Even though over 2 years has passed since the peak, very little published and institutional data exists focusing on pediatric patients with cancer.1

Surprisingly, the few studies which have examined COVID-19 in this patient population have revealed patients to have a mild clinical course and low asymptomatic carriage rates. This has allowed for the care of pediatric oncology patients on active therapy to remain relatively unchanged with them still able to receive treatments, including chemotherapy courses delivered as scheduled, stem-cell transplant conditioning, and more.

“Our goal was always to uphold the standard of care that we would have provided independent of COVID. It was remarkable the number of administrative meetings we had on a regular basis. Everything changed every other day, but it was changing in real time and adapting. It was remarkable how fast we as a community were able to adapt to make sure that we didn't compromise on quality of care,” O’Neill said.

While pediatric oncology patients may not have been developing severe cases of COVID, there was a strong decline in new patient diagnoses which correlated closely with the time of quarantine.

“We saw there be a dip in new diagnoses, a delay in some diagnoses, and then a huge rebound, about a year and a half into COVID,” O’Neill added.

A study published in the American Society of Clinical Oncology Educational Book led by study author Gerard C. Millen, MD, focused on how the care of children with cancer was affected due to the COVID-19 pandemic.2

“Pediatric oncology care relies on prompt evaluation and diagnosis, referral to tertiary centers, multidisciplinary subspecialized teams, timely and coordinated multimodal therapy, and access to supportive care—all of which have been affected by the pandemic. Prioritizing patients with COVID-19, combined with lockdowns and restricted transportation, has contributed to delayed and fragmented attention to children with cancer,” wrote the study authors led by Millen, cancer research United Kingdom clinical trials unit, Institute of Cancer, and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham.

In the United States and globally, patients and families were too nervous to seek care, adding yet another barrier during the midst of the pandemic. There were fewer emergency visits by pediatric patients with cancer, a reduction in outpatient visits, decreased hours of operation by hospitals and clinics, all which possibly could have influenced the timeliness of diagnoses for these patients.2,3

Over past decades, clinical trials have been crucial in continuing to improve outcomes for children with cancer. But with health care systems being overwhelmed with the amounts of patients coming in with COVID-19, there was a delayed opening of new clinical trials and limited accrual of existing trials. This highlighted the need to consider vulnerable populations, including children with cancer.

During the first wave of the COVID-19 pandemic which lasted approximately between March 1, 2022, and April 30, 2020, trial recruitment was dramatically affected, according to data published in the Innovative Therapies for Children with Cancer consortium. A total of 48.5% of phase 1 trials, 61% of phase 2 trials, and 64% of molecular platform trials were closed to recruitment in at least 1 site and an additional 16% of sites stopped all clinical trial recruitment for pediatric patients with cancer.3

Overall recruitment was 61% lower compared to a year prior in 2019 and concerningly, there was also a reduction in site initiation visits and monitoring visits during the start of the pandemic, with 67% of site initiation visits and 64% of monitoring visits canceled completely.

Not only was it unclear in the beginning whether patients with cancer would be symptomatic or develop advanced disease, but the pandemic also created many obstacles for diagnosing patients and providing quality care for children with cancer across the globe.

“Fewer patients enrolled for a period because they couldn't travel to enroll or were less interested in enrolling on trials because it meant more frequent visits or exposures. Now, I think we're seeing what we would predict to be normal enrollments per month by patient,” stated O’Neill. “There was a period of time where even if patients were enrolled on trial, we couldn't do the research on the back end that was associated with learning more about how those patients respond to therapies and how their bodies responded.”

However, since this dramatic reduction in clinical trial recruitment, recruitment in both the United States and Europe has been robust with enrollment increasing and patients being able to come in person.

“Now that we are back in person on a regular basis, so much of that has rebounded. There are fewer delays to startup treatment, fewer barriers to patients enrolling on clinical trials, and fewer barriers to the research being conducted, thankfully,” added O’Neill.

Everyone has been impacted by the additional barriers created by the pandemic. For those in the pediatric oncology field, pediatric cancer providers and institutions have been resilient in these unprecedented times with enormous obstacles.

“There is hope that the effects of the pandemic will subside and the adaptations it has imposed will bring a brighter future for the care of children with cancer,” wrote Millen in the study.

Still, not much is known about the long-term consequences that may come for those who have had COVID, including pediatric patients with cancer. For patients and providers alike, the impact of COVID-19 on the overall survival and outcomes of children with cancer is unclear and worrisome.

“We don't know or understand whether there'll be long term consequences to COVID. There are multiple ongoing studies at Dana-Farber looking longitudinally at response to COVID from an immune perspective and longer-term follow-up with these patients, pediatric and adult alike and whether our cancer population is different from the non-cancer population or providers, so there's multiple cohorts being followed. There's a lot to be learned there and a lot to understand as it pertains to whether COVID has impacted disease or general health in our patient population. That will take a while to understand, but it hasn't impacted how we've approached the care of our patients yet in the short term,” said O’Neill.

With vaccines now accessible to children, O'Neill urges her patients to get it as it will be crucial to evaluate their protective value in this patient population.

“We recommend our patients to be vaccinated and we can operate under the assumption that if they should get COVID, we have so many therapies we can give preemptively if there are patients who are exposed or if they are positive for COVID that can protect them,” said O’Neill. “We are so fortunate to be in a different medical situation than we were prior with the knowledge that we have ways to protect, prevent, and treat our patients, should they become COVID-positive, that we are able to operationalize ourselves closer to normal.”

Now, experts like O’Neill are focusing on ways to reestablish their community at work. Though the social aspects have not fully normalized yet, physicians at Dana-Farber congregate in their work room more frequently, have lunches together, talk fluidly about patient care, socialize with their patients on their daily rounds, and mingle in the halls.

“It's just trying to reestablish that collaborative, intellectual community that fosters support of one another and of new trainees. As we return to that degree of normalcy, we try to reestablish the true culture that makes work so special. To me, that's been a challenge and a very important thing to rebound from,” added O’Neill.

References:
  1. O'Neill AF, Wall CB, Roy-Bornstein C, et al. Timely pediatric cancer diagnoses: An unexpected casualty of the COVID-19 surge. Pediatr Blood Cancer. 2020;67(12):e28729. doi:10.1002/pbc.28729
  2. Moreira DC, Millen, GC, Sands S, et al. The care of children with cancer during the COVID-19 pandemic. American Society of Clinical Oncology Educational Book. 2021;(41). doi: 10.1200/EDBK_321497
  3. Rubio-San-Simón A, André N, Cefalo MG, et al. Impact of COVID-19 in pediatric early-phase cancer clinical trials in Europe: A report from the Innovative Therapies for Children with Cancer (ITCC) consortium. Eur J Cancer. 2020;141:82-91. doi:10.1016/j.ejca.2020.09.024