DISCUSSION
To date, available evidence suggests that children with cancer are at low-risk of developing COVID-19 related complications or mortality.4,5 At the same time, abandonment of therapy is known to be a major cause of treatment failure among LMIC children with cancer.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.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.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.9At 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.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.