Effect of the COVID-19 outbreak on paediatric cancer care in low-income and middle-income countries

Childhood cancer is a highly curable disease when health-care systems provide timely, accurate diagnoses and appropriate therapy. In Latin America, the paediatric cancer survival rate is significantly lower than in high-income countries, and approximately one in two children diagnosed with cancer will die of the disease. This disparity is due to health system challenges such as limited access to early detection and effective treatment and care.¹ During the COVID-19 outbreak, children with cancer have been particularly at risk of suffering the consequences of resource reallocations by having treatments delayed, interrupted, or substantially modified. The pandemic has forced paediatric oncology units to alter their basic operationality to minimise the risk of the virus spreading while providing the best possible management of cases found positive for COVID-19 and, above all, to ensure that children and adolescents are able to access their oncology treatment.

In The Lancet Child & Adolescent Health, Dylan Graetz and colleagues² present the results of a cross-sectional survey (from June 22 to Aug 21, 2020) distributed to 311 health-care professionals at 213 institutions in 79 countries. The study aimed to investigate the effect of the COVID-19 pandemic on childhood cancer care worldwide, and assessed the institution's characteristics, the number of patients diagnosed with COVID-19, and disruptions and adaptations to cancer care. The authors concluded that although the COVID-19 pandemic has substantially affected childhood cancer diagnosis and management worldwide, its effect has been more prominent in low-income and middle-income countries than in high-income countries. For example, unavailability of chemotherapy agents (p=0·022), treatment abandonment (p<0·0001), and interruptions in radiotherapy (p<0·0001) were more frequent in low-income and middle-income countries.

In a similar study in April, 2020, Vasquez and colleagues³ evaluated the early effects of the pandemic on haematology and oncology practices across Latin America, revealing that COVID-19 had negatively affected the prognosis of children with cancer. The study showed that paediatric oncology units made efforts to provide chemotherapy for children with newly diagnosed cancer and those who required active ongoing treatment. Health-care providers reported an indefinite delay of follow-up appointments, outpatient procedures, cancer surgeries, radiotherapy schedules, outpatient consultations, stem-cell transplantation, and palliative care. Additionally, 36% of cases required modification of chemotherapy regimens because of a shortage of drugs, and 79% of survey participants reported a shortage of blood products. Discontinuation of or modification to therapy was significantly more frequent in countries with travel restrictions.³

These studies emphasised the challenges of delivering childhood cancer treatment and care during the pandemic, especially in resource-constrained settings. In low-income and middle-income countries, including in Latin America, the common issues of late diagnosis and treatment abandonment or interruptions have worsened during the pandemic.⁴

During the COVID-19 early crisis in March, 2020, the region's governments enforced the WHO guidelines, mainly social distancing. When the first cases were reported in mid-March in Latin America, country leaders closed both air and land borders and implemented quarantine measures. These lockdown measures, lasting until June or July in some countries,⁵ included either partial or complete suspension of public transportation, which decreased mobility and considerably reduced patients' flow in health-care centres. As many households lost their wages, the expectation of substantial economic effect on families might have led to treatment abandonment in children with cancer or non-adherence to treatment (such as intermittently missing medication doses or appointments).6, 7

In response to the challenges, countries have implemented new policies and distributed resources. Hospitals are inclined to decrease the need for hospital visits when patients have a high risk of death due to SARS-CoV-2 infection.⁸ In El Salvador, the national paediatric cancer programme team recognised the importance of expanding telemedicine to optimise care through video calls. The health-care system affected by the lockdown imposed fear and forced patients to embrace telemedicine. Telemedicine attempted to safeguard resources in the oncology programme by seeing follow-up patients through it, while the medical team optimised the care to the newly diagnosed patients or those under active treatment. By mid April, the traveling restrictions became more severe, forcing patients to stay home. Eventually, as of September, the team provided care through telemedicine to all follow-up patients, and many patients in active treatment started receiving their post-chemotherapy laboratory evaluation results by telephone. Different paediatric oncology units have also reported implementing physical distancing measures, reorganising staff in 12-h shifts per group, or sending non-essential personnel to do telework to reduce exposure.⁹

Health-care systems in the Latin-America region need to reorganise health-care infrastructure to address the emergency to ensure sustained curative outcomes for children with cancer while maintaining public health and safety. The COVID-19 pandemic created an opportunity to develop legislation for childhood cancer services. For instance, the Peruvian legislature proposed the Childhood Cancer Law in April, 2020, which will have a substantial effect in the fight against childhood cancer in Peru, despite a global pandemic.¹⁰ The Childhood Cancer Law strives to benefit children and adolescents with cancer by implementing universal health coverage, conferring parents a financial allowance (the equivalent of two minimum-wage salaries) while their child is under treatment, and building a National Program for Children and Adolescents with cancer that incorporates a population-based pediatric cancer registry. The law will effect the life of at least 650 patients per year, improving the survival rate of childhood cancer in Peru.

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