Pediatric cancer registration fluctuation in Greece due to COVID‐19 pandemic and changes in health care delivery – Kourti – – Pediatric Blood & Cancer

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To the Εditor:

The impact of the coronavirus disease 2019 (COVID‐19) pandemic on the timely diagnosis and therapy of childhood cancer is currently being explored.1-4 Reports from Italy and the United States showed reduced likelihood of pediatric cancer patients accessing referral centers with expected worse chances of a timely diagnosis1, 2 It is also speculated that parental fear of exposure to COVID‐19 may have played a role in delayed diagnosis2, 3 in Greece; severe restrictive measures and general lockdown was implemented from March 23 to May 4, 2020, followed by a gradual lifting. Converging to a similar global pattern, considerable routine pediatric visits were postponed or canceled along with a decrease in the emergency room visits. Our Nationwide Registry of Childhood Hematological Malignancies and Solid Tumors (NARECHEM‐ST) monitors—through daily reporting and complementary sources—the incidence of six types of childhood cancer (central nervous system cancer, leukemia, liver cancer, lymphoma, neuroblastoma, renal cancer). We compared monthly and overall registration of cases during the period January‐August 2020 versus the respective average number of cases during the respective 8‐month period of years 2015‐2019 assuming constant populations of children 0‐14 years (Supporting Information, Figure S1). Small numbers and random fluctuation do not allow formal statistical evaluation; yet, these preliminary data show no deficit in the overall number of cases registered (131 actual vs 130 expected, based on the previous 5‐year registrations); if anything, more leukemia cases were diagnosed during the first 8 months of 2020 (54 vs 49.4). In contrast, a noticeable peak was observed in July followed by a deficit of incident cases during the month of August; this pattern possibly indicates alertness to earlier diagnosis.

Alongside, we conducted a survey among health personnel for children with cancer revealing possible delay in diagnosis for a boy born in January 2020 with a unilateral right polycystic kidney; he was diagnosed with stage III Wilms tumor in the left kidney when the recommended 3 months ultrasound appointment was eventually performed, delayed by another 3 months due to lockdown. Furthermore, they reported death of a 14‐year‐old girl who had developed severe gingivitis (May 2020) a fortnight earlier, and died with intracranial hemorrhage due to a second malignancy (acute myeloid leukemia; white blood count 200 000/mm3) the day after referral to the treating hospital. Osteosarcoma of the right upper femur had been previously diagnosed (February 2019) and successfully treated with surgery and chemotherapy. Summary results on concurrent changes in COVID‐19 era health care delivery and perceived stress are presented in the Supplemental Files.

In conclusion, fluctuations in pediatric cancer registration have been observed, reflecting variable response of parents and providers in a small country characterized as a “success story” for maintaining relatively low infection rates by imposing lockdown at the beginning of the pandemic. New practices and changes in the health care delivery routines for children with cancer are pending cautious evaluation in order to protect this fragile population exquisitely exposed to the indirect effects of the COVID‐19 pandemic, and further explore pending etiological hypotheses through research.4

ACKNOWLEDGMENTS

Special thanks are due to: Baka M. and Doganis D. from the Department of Pediatric Hematology‐Oncology, P & A Kyriakou Children’s Hospital, Athens, Greece; Hatzipantelis E. and Ioannidou M. from the Hematology‐Oncology Unit, 2nd Pediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece; Malama A. from the Department of Imaging, National and Kapodistrian University of Athens, Agia Sofia Children’s Hospital, Greece; Markogiannakis G. from the Department of Neurosurgery, P & A Kyriakou Children’s Hospital, Athens, Greece; Mitsios A. from the Department of Neurosurgery, Agia Sofia Children’s Hospital, Athens, Greece; Moschovi M. from the Pediatric Hematology‐Oncology Unit, First Department of Pediatrics, National and Kapodistrian University of Athens, Agia Sofia Children’s Hospital, Athens, Greece; Papadakis V. from the Department of Pediatric Hematology‐Oncology, Agia Sofia Children’s Hospital, Athens, Greece; Pourtsidis A. from the Pediatric Hematology‐Oncology Department, Mitera Children’s Hospital, Athens, Greece; Stefanaki K. from the Department of Pathology, Agia Sofia Children’s Hospital, Athens, Greece; Strantzia A. from the Pathology Laboratory, P & A Kyriakou Children’s Hospital, Athens, Greece; Tzanoudaki M. from the Immunology Laboratory, Agia Sophia Children’s Hospital, Athens, Greece.