A study published in The Lancet medical journal earlier this month is the first to look at the impact of the COVID-19 pandemic on paediatric cancer services worldwide. The study revealed that between June and August of last year, over three-quarters of the 200 hospitals that were surveyed reported that their care services had been impacted. Lower-income countries were disproportionately affected.
The findings are not particularly surprising.
The pandemic has put healthcare systems around the world in a pinch, and with clinical staff from all departments being pulled towards COVID-19-related services, non-COVID related care has often suffered.
Yet, at Red Cross War Memorial Children's Hospital in Cape Town, Head of Oncology, Professor Alan Davidson says that despite the pandemic, cancer care services at the hospital remained relatively unaffected.
Impact on diagnosis of childhood cancer
Comparing Red Cross Hospital data from March to August 2020 and 2019, Davidson says that there was no decrease in the number of new childhood cancer cases that were diagnosed. Contrary to the study's finding that globally over 40 percent of respondents noted diagnosing fewer cases than prior years, new diagnoses at Red Cross were up by roughly 30 percent last year, compared to 2019. "We didn't see fewer new diagnoses, [but] we were very anxious that children, or parents, would not attend hospitals for fear and on the whole that's probably true," he says.
Keeping The Lancet study in mind, Davidson highlights that before COVID-19, under-served areas of the country already under-diagnosed childhood cancer simply due to a lack of resources. "If you look at data, the ascertainment of cancer diagnoses should be somewhere around 100 new cases per million [children under the age of 15]. If you look at population stats for Mpumalanga or Limpopo, you won't see those kinds of numbers," he says.
The most comprehensive data on paediatric cancer in South Africa, the South African Children's Tumour Registry, is curated and analysed by the South African Children's Cancer Study Group (SACCSG). Speaking to Spotlight, Dr Gita Naidu, Chair of the SACCSG and head of paediatric oncology at Chris Hani Baragwanath Hospital in Johannesburg, expresses concern that overall the country is under-diagnosing childhood cancers.
"If we're basing our annual incidence on other countries, European countries or the USA for instance, then we have an idea based on our population base for children how many cancer [cases] we should have. Looking at our numbers, we are falling short of what we expect in our population," she says.
Naidu says that lower-income countries often under-diagnose due to a lack of healthcare facilities and diagnostics. "It's not a situation that is unique to South Africa," she says.
Similar to Red Cross, Naidu says that the number of new childhood cancer cases diagnosed at Baragwanath in 2020 were not much different from 2019. "In the first few months our numbers were down and that was really concerning. When I looked at our total numbers for last year, they are not different from 2019, so that was very heartening for me. The [children] came a little bit later, but we got them," she says.
According to Naidu, early diagnosis and early referral of paediatric cancer cases needs to be increased. "The important thing with children with cancer is we need to be aware. We need primary healthcare workers on the ground to be aware and we need them to pick-up on the warning signs and do early referrals," she emphasises.
Impact on treatment services
Last year Spotlight reported on delays in non-COVID related healthcare, particularly elective surgeries. Similarly, The Lancet study reports that the pandemic impacted one in three hospitals' ability to provide therapy. Either therapy was not initiated or was delayed by four or more weeks. This is known as treatment abandonment.
However, Davidson says that from his knowledge of two Cape Town hospitals, no child for non-clinical reasons had delays in chemotherapy or radiation.
Adding to this, Professor Jeannette Parkes, Head of Radiation Oncology at Groote Schuur, says that there has been almost no impact on the delivery of paediatric radiotherapy. "The one slight issue has been availability of paediatric anaesthesia since many anaesthetists were re-deployed to COVID-19 ICU services," she says.
Parkes notes that the impact on paediatric cancer surgeries was also minimal, and that the postponement of elective surgeries actually made it easier to book operating theatres for these procedures.
"I think tertiary paediatric cancer services in our large centre have been relatively protected. This is not the case in smaller centres where screening, [and] early management has been more of a problem. In smaller centres, we are concerned about families not seeking early management for children with symptoms due to fear, closure of some primary health facilities during lock down, [and] lack of imaging and biopsy services," says Parkes.
However, neighbouring countries faced more challenges, she says. Countries that rely on South Africa for machine engineers and drugs for chemotherapy, struggled due to the closed borders. As a result, many machines were down and drugs not available in these affected countries, explains Parkes.
Limitations of The Lancet study
The study, though the first of its kind to paint a picture of the pandemic's impact on childhood cancer services globally, has several limitations for the South African context. Davidson warns that while the study offers an interesting landscape, it can't be used to draw hard conclusions.
#COVID19 has impacted #childhoodcancer care worldwide. Paediatric cancer care was affected at 78% of 200 surveyed hospitals--43% made fewer new cancer diagnoses than expected & 34% saw a rise in patients abandoning treatment. Read @LancetChildAdol study: https://t.co/iKVu67yE7m pic.twitter.com/RXWNlRW1rZ
- The Lancet (@TheLancet) March 3, 2021
"Globally, what it shows is that on an unrelated illness, COVID-19 has had a dramatic impact. I would say that [Red Cross hasn't] suffered with many of these challenges, but that isn't to say it's been fun [and] that within our own country other [paediatric oncology] centres have had significant problems."
Davidson suggests that the study offers a baseline to measure two things-progress in paediatric cancer moving forward globally, and how to respond to future challenges.
"The other question I have is to what degree the reporting [in the study] exaggerates problems that are inherent in systems. I would suggest that where you have systems that are already fragile and you put something like [COVID-19] on top of it, you're going to inevitably have these kinds of problems."
Parkes adds that in terms of well or under-resourced centres, the study does not really say which centres are represented. In South Africa, there is quite a disparity in the centres that are available, she says, and the way information is represented between centres will be very different. "I think that the effects of COVID-19 on those smaller centres has been more profound than on the bigger centres."
Davidson also critiques the study's quantitive approach. |The reportage [in the study] is on 'did you have' [disruptions]. My question is how bad were [disruptions]," he says.
Looking at the supplementary appendix for the study, Davidson highlights that most questions used in the study are yes or no questions, which produces what he calls a quantitative analysis. "We got off pretty lightly compared to other [Lower- and middle-income countries or upper-middle-income countries] LMIC/UMIC, and likely [Red Cross was] better off than other parts of the country. That is because our systems are robust to begin with," he says.
"It's difficult to quantify how bad the issue is because it's not just a question of looking at the new patients presenting to oncology departments. It's also a question about understanding the patients who are not getting the imaging, or biopsy or operation that they need. I don't think we know all of that data yet," says Parkes.
Meanwhile, cancer experts are also looking to the future. Naidu is working on the National Cancer Care Plan for Children, which is set to be completed before the end of this year. Along with the National Department of Health, Naidu is collaborating with St Jude Children's Research Hospital in the United States, as well as the World Health Organization. The hope is that the plan can be widely used in South Africa as well as around the continent, she says.