Discussion:
The COVID-19 pandemic is an unprecedented global crisis that impacted
pediatric cancer health care systems worldwide, with a greater effect on
low and middle-income countries (LMIC).2,3,12,15–17One year into the pandemic, the initial fears and concerns have evolved
along with treatment and prevention strategies for COVID-19 and multiple
effective vaccines have been developed in record time. As the pandemic
continues to unfold, our 4 surveys performed over the first year of the
pandemic in Latin America show the medium-term effects on the care of
pediatric cancer patients; and reveal how the medical systems and
medical professionals adapted to the different health care crises that
originated from the pandemic.
Worldwide, the need to adapt to an uncertain future led to rationing of
treatment delivery by suspensions of most pediatric cancer
services.13,16–18 A recent global study reported that
55.8% of children with cancer, had modifications in their
cancer-directed therapies during the pandemic. In India, a group
reported 36.1% of 1146 pediatric patients with cancer experienced
treatment delays after a country-wide lockdown. In alignment with these
findings, our data shows different levels of disruption of cancer
services, such as suspension of SCT, radiotherapy sessions, oncologic
surgeries, and chemotherapy modifications throughout the year.
Specifically, from April 2020 to October 2020, most countries
experienced the first wave with intense constraints imposed by
government lockdowns. Therefore, the answers to our surveys reflect
cautionary adaptation, as most medical systems organized to face
unpredictable health care delivery crises. Not surprisingly, higher
levels of treatment disruptions were reported in countries with HCE
below 7%, and in countries with higher national burden of COVID-19,
reflected by a higher incidence rate and case fatality rate above 2%.
However, by April 2021, amid the second wave in the region, the
respondents’ answers reflected a better understanding of the effect of
COVID-19 on children with cancer, a better preparedness of the medical
system to safely deliver cancer care and the resilience of pediatric
cancer professionals in the region, who were able to re-institute most
cancer care services, in the midst of the pandemic.
A recent questionnaire led by the World Health Organization on the
impact of COVID-19 on non-communicable diseases (NCDs) resources and
services showed that 66% of participating countries (mainly
upper-middle and high-income countries). included NCDs services in the
list of national essential health services19. However,
in LMIC, access to quality cancer care was limited even before the
pandemic, as health care systems struggled with strained
resources.20–22 The COVID-19 pandemic exacerbated the
scarcity of these resources; and institutions reported decreases in
financial support, as well as increased dependency on social
organizations to provide help in transportation and family accommodation
during treatments.17 By April 2021, almost half of the
participants in our surveys reported patients’ families experiencing
increased economic burden of cancer care, including out-of-pocket
expenses. This highlights the overall increased social impact of the
pandemic on cancer therapy delivery and financing.
Delayed diagnosis and treatment abandonment are well-described problem
in LMIC.21 Early in the pandemic, different studies
reported a decrease of newly diagnosed children with cancer, delays in
referral to tertiary centers7,9,22,23 and increased
treatment abandonment.7,9,15,22,23 However, by April
2021, our data show that even though one third of respondents reported
persistent delays in diagnosis, only 17.3% reported treatment
abandonment as a persistent problem, which might be related to an
increase in the use of telemedicine as a modality to assure continuity
of care. Telemedicine (including video, web and telephone-based
interventions) had been implemented pre-pandemic in malignant
hematologic patients; and proved to be a feasible and acceptable form of
intervention.24 The changing landscape of health care
delivery created by the pandemic opened the opportunity to implement
telemedicine to provide continuity of care to pediatric oncology
patients25,26. In our data, on average during all four
surveys, close to half of the participants reported not having access to
telemedicine. In addition, by April 2021, 50.4% of participants
reported only having access to non-professional communication channels,
such as WhatsApp, Facebook or Zoom, to provide continuity of care. Even
though those communication channels worked in areas with poor internet
connection, 84% of respondents reported interest in having a formal
telemedicine platform to manage and follow patients.
With multiple and effective vaccines developed, vaccine hesitancy, even
among health care professionals is one of the biggest challenges to
control the pandemic.27 In Latin America, vaccine
rollouts started with different levels of success, and governments
experienced difficulties to deliver doses to their population. By the
end of April 2021, vaccination rates in Latin America ranged from 0% to
35% for two doses and 0% to 15% for one dose (Supplementary data
Table S9).28 However, our data at that time point
revealed that 76.6% of participants had received two doses of a
vaccine, 16.4% one dose and only 1.5% refused the vaccine, reflecting
a high level of vaccine acceptance among pediatric oncologists in the
region.
Our study has several strengths and limitations. One of the biggest
strengths of this study is its high and stable participation rate from
20 Latin America countries with pediatric oncology programs. However,
responses are subjective, as surveys solicited pediatric oncologists’
insights on the impact of the pandemic, and on the barriers to cancer
care delivery. There is a disparity in the number of participants from
different countries throughout all four surveys and the calculated
proportion of answers at each time point is conditioned by the number of
participants per country. Therefore, it is difficult to compare
countries’ data within and between surveys. However, as most Latin
America countries shared a similar infection wave pattern during the
first year of the pandemic, we believe the information collected is
meaningful.
In conclusion, our data shows differences between participants’
responses during the first and second waves of COVID-19 in Latin
America. During the first wave, treatment disruptions (suspension of
SCT, radiotherapy sessions, outpatient procedures, surveillance
consultations, and surgeries) were prevalent. In addition, in countries
with high COVID-19 burden and HCE below 7%, pediatric oncologists
reported more extreme disruptions at the peak of the first wave.
Nonetheless, all countries reported an improvement and recovery of
pediatric cancer services during the second wave.