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\begin{document}

\title{The Impact of the COVID-19 pandemic on diagnosis rates and abandonment
of treatment in West Java, Indonesia}



\author[1]{Nur Sari}%
\author[1]{Susi Susanah}%
\author[1]{Nur Suryawan}%
\author[1]{Riyadi Adrizain}%
\author[1]{Anggraini Alam}%
\author[1]{Djatnika Setiabudi}%
\author[2]{Sumit Gupta}%
\affil[1]{Universitas Padjadjaran}%
\affil[2]{SickKids}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\begin{abstract}
The impact of the Covid-19 pandemic on the care of children with cancer
in LMIC is of great concern, particularly on diagnosis and abandonment
of treatment rates. Data supporting this concern however is limited to
survey and anecdotal information. A retrospective with two cohorts
design was used to compare new diagnosis and monthly abandonment rate in
Java, Indonesia. We found that new diagnoses rates had dropped
significantly during Indonesia's first wave as compared to a
pre-pandemic cohort {[}rate ratio 0.57, 95th (CI) 0.41-0.79){]} and that
as the first wave progressed, abandonment rates also rose in a
statistically significant manner.%
\end{abstract}%



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\textbf{INTRODUCTION}

More than a year into the COVID-19 pandemic, its impact on children with
cancer is still not fully described. In addition to the direct
infectious risk among children undergoing treatment, pediatric
oncologists in high-income countries have noted an increased incidence
of delayed diagnosis and treatment.\textsuperscript{1} Though issues
like under-diagnosis and abandonment of treatment were major issues in
low- and middle-income countries (LMIC) prior to the pandemic, whether
these have worsened because of COVID-19 is suspected but not
known.\textsuperscript{2} We therefore aimed to assess the impact of the
pandemic in one Indonesian tertiary hospital upon the rate of new
diagnoses and abandonment rates.

\textbf{RESULTS}

Dr. Hasan Sadikin Hospital (RSHS) is a large referral hospital in West
Java, Indonesia with nearly 1,000 beds. The pediatric oncology service
serves a population of around 45 million, has a 32-bed capacity, and
sees 300 to 400 new cases annually. Similar to other LMIC centers,
insufficient psychosocial and medical personnel and limited financial
assistance for families constitute major challenges. Abandonment of
treated has been identified as a significant cause of treatment failure
in the past. RSHS identified its first COVID-19 positive patient in
March, 2020. Stringent lockdowns were implemented between March and June
of 2020, with closure of public spaces and businesses and severe travel
restrictions. Elective surgeries were postponed and limitations on
outpatient clinics imposed.

A retrospective cohort design with two cohorts was used. The first
comprised of patients with childhood cancer admitted to RSHS before and
during the COVID-19 pandemic (November 2019--May 2020). Both newly and
previously diagnosed patients were included. A comparison cohort
(November 2018 -- May 2019) was also identified comprising all analogous
patients a year before the pandemic. The number of new diagnoses was
determined through hospital databases. Abandonment was defined as
failure to start or continue scheduled curative-intend treatment for
four or more consecutive weeks\textsuperscript{3}, excluding patients
transitioning to palliation, and was determined monthly through review
of medical charts. Outcomes were compared between cohorts using Poisson
regression (rate of new diagnoses) and Fisher's exact tests (monthly
abandonment rate). Two tailed p-values less than 0.05 were considered
statistically significant at 95\% confidence. The study was approved by
the RSHS research ethics board. Compared to the prior year, the rate of
new childhood cancer diagnoses decreased by over 40\% {[}rate ratio
0.57, 95\textsuperscript{th} confidence interval (CI) 0.41-0.79){]}.
Monthly abandonment rates are shown in Table 1. No differences in
abandonment were seen in November through March. However, a trend
towards higher abandonment was seen in April 2020 as compared to April
2019 (12.8\% vs. 8.6\%; p=0.06); a substantial and statistically
significant increase was seen in May 2020 (14.8\% vs. 6.7\%;
p\textless{}0.001).

\textbf{DISCUSSION}

To date, available evidence suggests that children with cancer are at
low-risk of developing COVID-19 related complications or
mortality.\textsuperscript{4,5} At the same time, abandonment of therapy
is known to be a major cause of treatment failure among LMIC children
with cancer.\textsuperscript{6,7,8} In our study, we show that the onset
of the COVID-19 pandemic was associated with a statistically significant
and substantial increase in abandonment rates in our center in West
Java. Our results suggest that the indirect effects of COVID-19 are a
far greater contributor to poor outcomes among this population than
direct infection-related impacts.

The reasons for the increased abandonment rate are likely
multifactorial. In our setting, elective surgeries were rescheduled and
often canceled, leading to prolonged times to treatment that may have
given more opportunities to abandon therapy. In some cases, COVID-19
positivity led to further delays in asymptomatic children, again giving
more opportunity for abandonment. Costs of treatment are also a major
factor for abandonment. During the pandemic, a portion of the mandatory
screening COVID-19 tests were also charged to families, leading to
increased costs and very likely in increase in the likelihood of
abandonment. Though not assessed by this study, fear of COVID-19 itself
may have caused families to stop therapy.\textsuperscript{4} Finally, as
reported in Peru, national lockdowns, with resultant loss of income and
transportation restrictions, are also likely to have impacted access and
thus increased abandonment rates.\textsuperscript{6}

Several mitigating strategies are possible. Strong relationships between
health services providers and families to explain the risks of COVID-19
as opposed to the risks of stopping therapy are
key.\textsuperscript{9}At a system level, engagement of health services
and health ministries with childhood cancer professionals and parent
support organizations in the development and implementation of regional
COVID-19 response strategies specific to children with cancer will
also.\textsuperscript{10} Measures to control and decrease COVID-19
transmission in the broader community will ultimately benefit children
with cancer, though only if these children are also prioritized during
acute waves of infection. Finally, protecting the physical and mental
health of medical professionals themselves is crucial to maintain the
necessary childhood cancer services.

Since the study period, a new and more devastating wave of COVID-19 has
hit Java, Indonesia, leading to further and more severe disruptions of
healthcare services. Our results suggest that the impact of children
with cancer will be profound and will likely reverse recent improvements
in outcome.

\textbf{Acknowledgements}

The authors thank My Child Matters for their support of the Indonesian
Pediatric Cancer registry and of other data capture personnel who
contributed to this study.

\textbf{Conflict of Interest}

The authors declare no conflict of interest.

\textbf{Author Contribution}

N. Sari contributed to the design and implementation of the research, to
the analysis of the results and wrote the first draft of the manuscript.
S. Susanah,~N. Suryawan,~R. Adrizain,~A. Alam,~D. Setiabudi were
involved in planning and supervised the work. S. Gupta helped design the
methodology. All authors were involved with editing the manuscript.

\textbf{ORCID}

Nur Melani Sari https://orcid.org/0000-0002-9062-9624

Susi Susanah https://orcid.org/0000-0003-4052-512X

Nur Suryawan https://orcid.org/0000-0003-3316-6958

Riyadi Adrizain http://orcid.org/0000-0001-6939-3306

Anggraini Alam https://orcid.org/0000-0001-6740-2002

Djatnika Setiabudi https://orcid.org/0000-0002-7488-4377

Sumit Gupta https://orcid.org/0000-0003-1334-3670

\textbf{Correspondence}

Nur Melani Sari, Division of Hematology Oncology, Department of Child
Health Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin
Hospital

Jl. Pasteur No. 38 Bandung, West Java Province, Indonesia

Email: nur.melani.sari@unpad.ac.id

\textbf{REFERENCES}

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\textbf{Hosted file}

\verb`Table 1 Monthly Abandonment.docx`  available at \url{https://authorea.com/users/733363/articles/711095-the-impact-of-the-covid-19-pandemic-on-diagnosis-rates-and-abandonment-of-treatment-in-west-java-indonesia}

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