Childhood cancer control during the COVID-19 pandemic
Authors: Sandra Luna-Fineman, Roberta Ortiz, Andre Ilbawi
Journal: The Lancet Oncology (2021)

In early 2020, the COVID-19 pandemic set the research community on a new path to understand the virus, how it affects different populations, and how it influences access to essential services. The ensuing research could have been done in isolation or with a competitive spirit. In childhood cancer, the opposite occurred; the research community united in solidarity, offering another opportunity to use investments in data systems and collaborative networks, which have defined childhood cancer research for the past half century. It is in this context that the value of the publication in The Lancet Oncology by Sheena Mukkada and colleagues1Mukkada S Bhakta N Chantada GL et al.Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort study.Lancet Oncol. 2021; 22: 1416-1426Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar can be understood. This prospective cohort study of the characteristics and outcomes of children and adolescents (<19 years) with cancer and COVID-19 around the world, reports data from 1500 patients from 131 institutions in 45 countries. 259 (19·9%) of 1301 patients had a severe or critical infection, with 50 (3·8%) of 1319 cases resulting in death. In adults with cancer, the death rate is higher (28%) than that for children and correlates with age.2Lee LYW Cazier JB Angelis V et al.COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study.Lancet. 2020; 395: 1919-1926Summary Full Text Full Text PDF PubMed Scopus (840) Google Scholar Mukkada and colleagues found a high percentage (35·0%) of asymptomatic children with cancer. Furthermore, patients from low-income and lower-middle-income countries had a higher proportion of severe or critical outcomes (41·7%) than patients from upper-middle-income countries (16·5%), and high-income countries (7·4%). Deaths from COVID-19 were also higher in patients from low-income and lower-middle-income countries than patients from upper-middle-income countries, and high-income countries, despite the under-representation of low-income countries (African, South-East Asian, and Western Pacific Regions), probably secondary to the scarcity of SARS-CoV-2 testing or overwhelmed services that were unable to report cases. The strength and merits of the Article's conclusions were achieved because of the legacy of global collaborative networks that have driven innovation, advanced research priorities, and, ultimately, improved childhood cancer care. Unfortunately, the results from Mukkada and colleagues also show a known tragic reality, that inequities in health systems globally have been exacerbated by the COVID-19 pandemic. Children living in low-income and middle-income countries have the greatest burden of childhood cancer and experience the greatest inequities.3Ward ZJ Yeh JM Bhakta N Frazier AL Atun R Estimating the total incidence of global childhood cancer: a simulation-based analysis.Lancet Oncol. 2019; 20: 483-493Summary Full Text Full Text PDF PubMed Scopus (200) Google Scholar, 4Bhakta N Force LM Allemani C et al.Childhood cancer burden: a review of global estimates.Lancet Oncol. 2019; 20: e42-e53Summary Full Text Full Text PDF PubMed Scopus (230) Google Scholar The pandemic has exposed weaknesses in health systems and capacities to control childhood cancer. As described by Vasquez and colleagues5Vasquez L Sampor C Villanueva G et al.Early impact of the COVID-19 pandemic on paediatric cancer care in Latin America.Lancet Oncol. 2020; 21: 753-755Summary Full Text Full Text PDF PubMed Scopus (75) Google Scholar and summarised by Moreira and colleagues6Moreira DC Millen GC Sands S Kearns PR Hawkins DS The care of children with cancer during the COVID-19 pandemic.Am Soc Clin Oncol Educ Book. 2021; 41: 1-10PubMed Google Scholar on the early and overall effect of the pandemic on childhood cancer care globally, there have been reductions in access to diagnostic and therapeutic services, worsened access to essential medicines, postponement of chemotherapy administration, delay and even indefinite postponement of radiotherapy, and lower rates of follow-up and surveillance. Disruptions to childhood cancer services have not been as severe in high-income countries. Therein lies the problem: resilient health systems can absorb shocks during times of crisis (such as the pandemic, conflict, and climate change). Although childhood cancer functions to some extent in its own health ecosystem, services still rely on investments in health systems and prioritisation of the broader cancer and non-communicable disease agenda, as part of universal health coverage. Such investments continue to lag in low-income and middle-income countries. Childhood cancer should be a strategic priority. It is among the most curable group of cancers, with an 80% overall survival in high-income countries.7Atun R Bhakta N Denburg A et al.Sustainable care for children with cancer: a Lancet Oncology Commission.Lancet Oncol. 2020; 21: e185-e224Summary Full Text Full Text PDF PubMed Scopus (166) Google Scholar This probability of cure is feasible and sustainable in all countries with appropriate resources.7Atun R Bhakta N Denburg A et al.Sustainable care for children with cancer: a Lancet Oncology Commission.Lancet Oncol. 2020; 21: e185-e224Summary Full Text Full Text PDF PubMed Scopus (166) Google Scholar Yet, in low-income and middle-income countries, which have about three-quarters of the global burden of childhood cancer, only 20–30% of individuals have long-term survival. Delays in early detection; poor access to diagnostic services and technologies; absence of full access to required anticancer drugs (as defined on the WHO list of essential medicines); higher rates of comorbidities (eg, malnutrition, infection, and poverty); and refusal and abandonment of therapy are common, resulting in increased morbidity and treatment-related mortality.8Lam CG Howard SC Bouffet E Pritchard-Jones K Science and health for all children with cancer.Science. 2019; 363: 1182-1186Crossref PubMed Scopus (181) Google Scholar All these factors result in lower survival rates and higher amounts of morbidity than in high-income countries. Added to the disadvantages of children with cancer in low-income and middle-income countries, the COVID-19 pandemic is worsening inequalities. The past 4 years have seen improved positioning of childhood cancer in the global health agenda. With the mandate given by governments in the World Health Assembly resolution on cancer (WHA 70.12), in 2018, WHO, alongside St Jude Children's Research Hospital (Memphis, TN, USA) and other key strategic partners like the International Society of Pediatric Oncology, both of whom are leading the Global Registry of COVID-19 in Childhood Cancer,1Mukkada S Bhakta N Chantada GL et al.Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort study.Lancet Oncol. 2021; 22: 1416-1426Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar launched the Global Initiative for Childhood Cancer with the overall target to cure 60% of all children with cancer globally and decrease suffering for all.9WHO Global Initiative for Childhood CancerAn overview. World Health Organization, 2020https://www.who.int/docs/default-source/documents/health-topics/cancer/who-childhood-cancer-overview-booklet.pdfDate accessed: August 24, 2021Google Scholar The CureAll Framework for childhood cancer outlines the steps necessary to improve access to care and reduce inequalities as part of building more resilient health systems and achieving universal health coverage (figure).10WHO CureAll FrameworkWHO Global Initiative for Childhood Cancer Pamphlet.https://cdn.who.int/media/docs/default-source/documents/health-topics/cancer/cureall-framework-who-global-initiative-for-childhood-cancer-pamphlet.pdf?sfvrsn=6e9c5b1b_8Date: 2021Date accessed: August 24, 2021Google Scholar This framework is feasible for all countries and in all contexts. The data from Mukkada and colleagues' study1Mukkada S Bhakta N Chantada GL et al.Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort study.Lancet Oncol. 2021; 22: 1416-1426Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar provide us with a new understanding of childhood cancer during the pandemic. When combined with the legacy of global collaboration in childhood cancer and political prioritisation through the WHO Global Initiative for Childhood Cancer, there is a unique opportunity to develop and implement mitigation strategies, tailored to the current threats encountered in specific health systems, and to reduce globally inequalities. Collaboration and solidarity drive progress in childhood cancer care. This approach has been shared among the childhood cancer community for decades and is needed now more than ever. SL-F declares support from St Jude Children's Research Hospital and WHO, Unit of Management of Noncommunicable diseases. SL-F, AI, and RO are staff members or consultants of WHO. The authors alone are responsible for the views expressed in this Comment and they do not necessarily represent the decisions, policy, or views of WHO. Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort studyIn this global cohort of children and adolescents with cancer and COVID-19, severe and critical illness occurred in one fifth of patients and deaths occurred in a higher proportion than is reported in the literature in the general paediatric population. Additionally, we found that variables associated with treatment modification were not the same as those associated with greater disease severity. These data could inform clinical practice guidelines and raise awareness globally that children and adolescents with cancer are at high-risk of developing severe COVID-19 illness. Full-Text PDF