Children With Cancer At Higher Risk for Severe Illness from COVID-19

Approximately 20% of pediatric patients with cancer infected with COVID-19 experienced severe illness, according to data published in The Lancet Oncology. Furthermore, deaths due to the infection were proportionally higher in this patient population compared with the general pediatric population, providing evidence that children with cancer are at higher risk of developing severe illness from COVID-19.¹

Among 1319 evaluable children with cancer examined on a cohort study, 259 (19.9%) experienced severe or critical illness due to COVID-19, compared with just 1% to 6% in the general pediatric population. Fifty (3.8%) patients with cancer died of causes associated with the infection. Additionally, of 1092 patients actively receiving cancer-related therapy, 609 (55.8%) required treatment modifications due to COVID-19 infection..

“The results clearly and definitively show that children with cancer fare worse with COVID-19 than children without cancer,” corresponding author Sheena Mukkada, MD, an assistant member of the St. Jude Departments of Global Pediatric Medicine and Infectious Diseases, said in a press release.² “This global collaboration helps clinicians make evidence-based decisions about prevention and treatment, which, unfortunately, remain relevant as the pandemic continues.”

Although previous studies have examined the impact of COVID-19 on adult patients with cancer, data on how the infection impacts pediatric patients with cancer is scarce, and clinical risk factors for COVD-19 among this patient population have not been established. As such, the St. Jude Global programme of St. Jude Children’s Research Hospital and the International Society of Paediatric Oncology created the Global COVID-19 Observatory and Resource Center for Childhood Cancer to collect data on disease severity and risk factors among pediatric patients with cancer, or those who had undergone hematopoietic stem-cell transplantation.

In April 2020, investigators launched the St. Jude Global and International Society of Paediatric Oncology Global Registry of COVID-19 in Childhood Cancer, collecting data on confirmed cases of COVID-19 from 131 institutions in 45 countries. Patients included in the registry were younger than 19 years-old, had a current or past diagnosis of cancer, or who had undergone hematopoietic stem-cell transplantation.

Patient data collected included: oncological diagnosis, treatment phase, non-oncological comorbidities, imaging findings, anatomical location of infection, and COVID-19-directed therapy. Additionally, outcome data collected for the study included: requirement for higher level of care, respiratory support requirements, laboratory and clinical status of the COVID-19 infection, vital status, and interruptions in cancer-directed treatment.

Among the 1500 patients from whom data was collected, the median age was 8 years old (range, 4-13), and a majority were 1 to 9 years old (54.9%), geographically located in the

Americas (56.5%), and male (59.4%). Additionally, 49.1% of patients had acute lymphoblastic leukemia or acute lymphoblastic lymphoma, 24.2% had solid tumor cancers, 17.7% had other hematologic malignancies, 8.4% had central nervous system tumors. Eight (0.5%) had undergone hematopoietic stem-cell transplantation.

Most patients examined had received cancer-directed therapy (82.9%), and 1171 of 1203 (97.3%) of those receiving chemotherapy got their last dose within 30 days of COVID-19 infection.

Among the 1319 patients evaluable at 30-day follow-up, 45.0% had mild to moderate symptoms, 35.0% were asymptomatic, 19.9% had severe or critical symptoms. A majority of those on active cancer treatment (n = 609/1092; 55.8%) had to have their treatment modified due to COVID-19 infection. Additionally, 889 of these patients (67.4%) were hospitalized at ward status or higher.

Of the 83 deaths reported on study, 50 were due to COVID-19 infection (60.2%) and 33 were from other causes (39.8%). Among the patients who died due to COVID-19, the median time to death was 8 days (range, 3-14).

Higher rates of severe or critical symptoms from COVID-19 infection were reported in low- or lower-middle-income countries (41.7%) compared with upper-middle (16.5%) or high-income counties (7.4%).

Additional data from a univariate logistic regression analysis showed that variables such as income group, cancer type, age, absolute lymphocyte count, absolute neutrophil count, presence of comorbidities, and treatment intensity were associated with higher rates of severe or critical illness. Moreover, results from a multivariable analysis showed that low- or lower–middle-income, upper–middle-income, age of 15 to 18 years old, an absolute lymphocyte count of 300 or less cells per mm³, an absolute neutrophil count of 500 or less cells per mm³, and intensive treatment were associated with increased severity of COVID-19 infection.

“Understanding a global crisis like COVID-19 requires our entire childhood cancer community around the world to come together to respond,” senior author Carlos Rodriguez-Galindo, MD, director of St. Jude Global, said in a press release. “The impact of this disease has been felt in every corner of the world, but particularly in low- and middle-income countries compared with high-income countries. There are critical differences based on where a child lives. This registry is a tool that is helping us understand what that means for children with cancer everywhere.”

References

1. Mukkada S, Bhakta N, Chantada GL, et al. Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort study. Lancet Oncol. Published online August 26,2021. doi:10.1016/S1470-2045(21)00454-X
2. COVID-19 in children with cancer: Severe disease and disrupted treatment. News release. St. Jude Children's Research Hospital. August 26, 2021. Accessed August 30, 2021. https://bit.ly/38qHhaA