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.