Why COVID Takes A Harsher Toll On Children With Cancer

Early in the pandemic, some encouraging news was that children were not as vulnerable to COVID-19 as adults.

But doctors treating children with cancer had special concerns.

These kids have reduced white blood cells — the ones that fight infection. This can be a result of the cancer itself or of cancer treatments such as chemotherapy. So when it comes to common respiratory infections like the flu, children with cancer tend to show more severe symptoms.

Would COVID also be more severe in this population?

To answer that question, doctors at St. Jude Children’s Research Hospital collected reports of COVID cases among 1,500 cancer patients under the age of 18, from institutions in 45 countries. The data has been entered into a global registry of COVID-19 in childhood cancer co-developed with the International Society of Pediatric Oncology.

The study’s findings are reported Thursday in The Lancet Oncology: “Global Characteristics and Outcomes of SARS-CoV-2 Infection in Children and Adolescents with Cancer.”

dr. Sheena Mukkada, an infectious disease specialist in St. Jude and one of the lead authors of the study, spoke to NPR about how pediatric cancer patients have fared over the course of the pandemic. Her comments have been edited for length and clarity.

What did you think you would find when you started this study?

We were concerned because children with cancer do worse with respiratory viruses. So we were always worried that they wouldn’t get it right.

Were your fears justified?

Of the children with cancer, 20% had a serious critical infection with COVID. And death occurred in about 4% of all patients — significantly more than the general pediatric population with COVID.

How do those rates of serious infection and death compare to the rates in the general population of children?

We did not make a direct comparison with children in the general pediatric population. But from the literature, serious illness [in that population] is between 1 and 6%. In many of these studies, death is even less than 1%.

What was the cause of death of the children whose deaths were reported in your study?

We specifically teased the group that was due to COVID – that was 4%. The overall death rate [among the 1,500 children in the database] was more than 6% total.

And those extra deaths were due to…?

I would speculate. Some of it is related to cancer, some to delays in care – all sorts of factors.

Were the rates of serious illness and death among children with cancer the same around the world?

The outcomes of serious and worse [coronavirus] disease were more pronounced in low- and middle-income settings. It further illustrates a fact we already know: how health care interruptions and access to treatment in those countries affect outcomes. It’s always sad to see that. It underscores why we should have equal access to everything: coronavirus vaccines, supportive care.

And that lack of access to care is not just a pandemic problem.

80% of children in high-income countries survive their cancer. In low-income countries it is more likely to be 10 to 20%.

I’m curious: Are children with cancer affected by the pandemic in other ways?

We see the disruption of the supply of blood products, other supportive care interventions. There was a pretty good study in The Lancet earlier this year that explored that point.

What advice do you have for families where a child has cancer during this pandemic?

If children with cancer are of the age indicated for vaccines, they should get the vaccines. People around them should be vaccinated to prevent spread.

Are there other ways to protect children with cancer from getting a COVID infection?

I cannot say enough about the importance of washing hands and wearing masks. Because caregivers and children with cancer were already working on better hygiene, that could have mitigated some of the impact of the pandemic.

How do children with cancer react to infection?

For many of them it is annoying to have to be isolated.

Is this study optimistic or pessimistic in its findings?

Most kids do well. 80% of pediatric cancer patients had an asymptomatic, mild or moderate course of COVID-19 disease. But I think the real message is that 20% of kids aren’t doing well. We need to monitor them better, decide if they should get therapy for COVID, worry about what we’re giving them.

Why hurt?

It is always a question of the risk of administering a drug versus the benefit. We are pediatricians and we don’t like to give children medicine unless we think it would help them.

Just before speaking to you, I was responding to an email about a patient who is infected, and I was in doubt as to whether the child would be given monoclonal antibody therapy or whether the child would do well without that therapy.

And you also need to decide whether to interrupt cancer treatments if the patient gets COVID.

Majority of patients with COVID can do quite well [with cancer treatment]. If a child has a low white blood cell count, we hold the next cycle of chemotherapy pending the disappearance of COVID. But we don’t want to wait forever.

The data for COVID is still too new and numbers in children still too low to make clear who we treat and how we treat them. With our data, we hope to be able to make recommendations about which patient characteristics are associated with severe disease, so that we do not interrupt cancer therapy for everyone. We do not want treatment interruptions to threaten cancer-related outcomes.

And now there’s the delta variant to worry about.

I hate to leave a note that isn’t so positive. But with delta, we see more cases in the general pediatric population with symptoms they never really had in the first wave — airway symptoms that require hospitalization because they can’t breathe properly. We’re a little worried about what’s going to happen to the pediatric population that has cancer.

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