Increased Early-Mortality in Children With Solid Tumors During the COVID-19 Pandemic in a Middle-Income Country

Abstract

Background: Measures to control COVID-19 transmission disrupted childhood cancer care. Data on the effects of the COVID-19 pandemic on childhood cancer mortality are lacking. This study describes the impact of the pandemic on childhood cancer early-mortality (≤ 24 months).

Methods: A multicenter prospective cohort was conducted in 10 Colombian cities. Children with newly diagnosed cancer registered in the Childhood Cancer Clinical Outcomes Surveillance System (VIGICANCER) were included. Our primary outcome was cumulative mortality at 3, 6, 12, and 24 months. The exposed cohort (EC = March 25, 2020-December 31, 2021) was compared with a historic cohort (HC = January 1, 2017-March 24, 2020). Covariates included sociodemographics, place of residence, health insurance type, and tumor classification.

Results: The cohort included 4124 children, comprised of 1627 children in the EC and 2497 children in the HC. Hematolymphoid, central nervous system, and extracranial solid tumors represented 57%, 15%, and 28% of patients, respectively. Participants' median age was 6.7 years (IQR, 3.2-11.3), 54% were male, 7% were Afro-descendant, and 47% had public insurance. In the EC, the 6-month and 24-month mortality adjusted hazard ratio (aHR) in children with solid tumors was 1.7 (95% CI, 1.1-2.7) and 1.3 (95% CI, 1.0-1.7), respectively, and in children with bone tumors 4.0 (95% CI, 1.2-13.0) and 2.1 (95% CI, 1.2-3.6), respectively. These associations persisted after accounting for metastatic disease. Six-month mortality aHRs for retinoblastoma, bone tumors, and soft tissue sarcomas due to progressive disease were 4.3 (95% CI, 1.3-14.5), 4.0 (95% CI, 1.4-11.3), and 5.4 (95% CI, 2.2-13.5), respectively. In the EC, the adjusted odds ratio (aOR) for metastatic solid tumors vs. nonmetastatic was 1.4 (95% CI, 1.0-1.8) and in children with retinoblastoma and public insurance the 24-month mortality aHR was 4.9 (95% CI, 1.1-21.7).

Conclusions: We observed increased early-mortality for solid tumors, particularly bone tumors and retinoblastoma, likely attributed to more advanced-stage presentation and loss of treatment effectiveness due to healthcare disruptions. Early-mortality was higher in patients with public insurance, a vulnerable population that warrants attention.

Keywords: COVID‐19; bone neoplasms; epidemiological monitoring; hospital; mortality; neoplasms; oncology service; pediatrics; retinoblastoma.

FIGURE 1

Flowchart of study participants by cohort. CNS, central nervous system tumors; H/L, hematolymphoid tumors; Solid, solid tumors; POU, pediatric oncology unit. Exposed cohort, January 1, 2017, to March 24, 2020; historical cohort, March 25, 2020, to December 31, 2021). Children's age range was 0.2–14.9 years. The flowchart illustrates the distribution of patients in the exposed and historical cohort, the number of events (relapse, death, or treatment abandonment where no further information was available), and deaths.

FIGURE 2

Cumulative mortality of patients with malignant bone tumors and retinoblastoma by health insurance group between cohorts. (A) In children with bone tumors and semiprivate insurance, 24‐month mortality was 1.4 times higher in the exposed cohort compared with the historical cohort (aHR, 1.4; 95% CI, 0.6–3.3). (B) In children with bone tumors and public insurance, mortality at 24 months was 3.1 times higher in the exposed cohort compared with the historical cohort (aHR, 3.1; 95% CI, 1.4–6.9). (C) In children with retinoblastoma and semiprivate insurance, no deaths were registered in the exposed cohort follow‐up. (D) In children with retinoblastoma and public insurance, mortality at 24 months was 4.9 times higher in the exposed cohort compared with the historical cohort (aHR, 4.9; 95% CI, 1.1–2.7). Including metastatic status in the regression model with 24 months exit time changed the β coefficient by 7%. *Children's age range was 0.2–14.9 years.