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.