During a recent tweet chat with Sheena Mukkada, MD, MPH, an assistant member of the St. Jude Children’s Research Hospital, joined Targeted Oncology to discuss how the COVID-19 pandemic has impacted pediatric cancer care.
The COVID-19 pandemic has created unique challenges for treating pediatric cancer patients. While COVID-19 infections in children tend to mild, patients with pediatric cancer are more prone serious disease.1
During a recent tweet chat, Sheena Mukkada, MD, MPH, an assistant member of the St. Jude Children’s Research Hospital, and faculty in the Global Pediatric Medicine Department, Infectious Disease Department, at St. Jude Graduate School of Biomedical Sciences, discussed new findings of a new study on outcomes in pediatric cancer patients who are infected with COVID-19.
During the study, 1500 patients were included from across 45 countries between April 2020 and February 2021. Data was submitted to the St. Jude Global and International Society of Peadiatric Oncology Global Registry of COVID-19 in Childhood Cancer, which is housed in an application developed by Vanderbilt University Medical Center in Nashville, Tennessee. Children included had a laboratory-confirmed COVID-19 infection and a concurrent or past diagnosis of cancer or have received a hematopoietic stem-cell transplantation.1
“Children with cancer have knocked down immune system due to the cancer diagnosis, and then the treatment that they received a treat it. So, when the immune cells don't have the capacity to respond the way that they should to infections, we think that they're at risk for worse outcomes. And that's essentially what we were afraid of seeing, and with the data seem to show in our study,” said Mukkada in an interview with Targeted OncologyTM.
According to the analysis, severe or critical disease was seen in 19.9% of patients overall. However, in low-income countries, severe disease was seen in 41.7%, compared to 16.5% in middle-income countries and 7.4% in high-income countries. Overall, COVID-19 infection caused treatment modifications in 55.8% of patients. In low-income countries, treatment modifications were seen in 67.9% of patients, in middle-income countries, 48.1%, and 63.9% of patients in high-income countries.
In cases where death occurred, 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 the most likely to happen 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
Considering the impact of the pandemic on pediatric cancer care, adaptations were necessary in order to continue to keep providing care. According to a report published in the American Society of Clinical Oncology Education Book, the quick spread of both information and misinformation presented a new kind of public health challenge.2
Within weeks of the declaration of a pandemic, the overall recommendation was to continue with the standard care, diagnosis, and treatment of pediatric cancer patients whenever possible. However, the report found that in a survey of 20 countries in Latin America, 36% of responders reported that chemotherapy regimens had to be modified due to chemotherapy shortages. Across, West Asia, North Africa, and the Middle East, treatment disruptions were reported between 29% and 44% of institutions. Additionally, 24% of those institutions restricted the acceptance of new patients.2
“We know that interruptions in therapy could correlate with a worse control of disease. But we don't collect the data within this study to be able to tell whether that actually correlated. We'll only find that out later on. And because the registry looks at a distinct time period, we can't tell how long treatment interrupted or how many doses really missed, and whether that had an impact. But we know that there are interruptions in therapy, which is never a good thing,” said Mukkada.
Additionally, the COVID-19 pandemic initially caused a sharp decline in clinical trial enrollment. However, recruitment in Europe and the United States has grown.2
An article published in Pediatric Blood Cancers in September 2020, raised concerns that the pandemic was causing pediatric cancer diagnosis to go missed. At the Dana-Farber Cancer Institute, there was a 25% increase in new patient diagnosis when comparing January-February in 2019 versus 2020. However, comparing March to May in the same year, there was a 56% decline in cases. While some of this reflects gradual recovery, article authors say that the decline is undoubtedly contributed to by both a decrease in in-person primary care visits and also a reluctance on the part of parents to expose their children to the virus.3
COVID-19 Outcomes in Pediatric Cancer Patients
Compared to children without cancer, children with cancer tend to have worse outcomes when 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 the 0.01-0.7% mortality seen in the general pediatric population. Additionally, severe infections were more common among pediatric cancer patients than the general population.
According to Mukkada, location and socioeconomic status played a major role in outcomes as well. Patients in low and middle-income countries had a higher chance of severe infections than those living in high-income countries, highlighting the gap in care that exists globally.
“When you look at our analysis, the point that is perhaps most interesting to me, is the fact that factors beyond the biologic, the socioeconomic status of the country that is actually reporting the case, is correlated with outcomes such that cases reported out of low- and middle-income countries have nearly 6 times the odds of the severe critical outcomes relative to those who live in and/are treated in high-income countries,” said Mukkada.
Currently, individuals 12 years and older are eligible to receive a COVID-19 vaccine.4-6 However, while authorization for a vaccine is expected for children between the ages of 5 and 12 in the next few weeks, one is not available at the time of writing. This creates a unique challenge for younger patients.
The report published by St. Jude found that in the 1301 COVID-19 cases evaluated, Children between the ages of 1 and 9 made up the largest sample, with 707 reported cases. Of those cases, 37.7% were symptomatic, 44.6% were mild or moderate, and 18.1% were severe.1
Children between the ages of 10 and 14 made up the next largest cohort, with 336 reported cases. Of those 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.”
“If we're going to get approval on it, the data for it will be good in terms of protective immunity against getting severe disease, and hopefully decrease some of the transmission potential. So, it can only be positive in terms of protecting everyone in the community, and certainly the vulnerable population from getting exposure opportunities,” said Mukkada.
Until then, patients with weak immune systems should continue wearing a face mask, washing hands often, avoiding crowds, and maintaining physical distancing.