Results:
From 795 pediatric oncologists, medical directors and residents/fellows contacted, the response rate among all four surveys ranged between 43-57%. A total of 453 of 795 pediatric onco-hematologists from 20 countries responded to the first survey. The participation for subsequent surveys remained above 85% among the original respondents: 408 participants in June 2020 (90%), 386 in October 2020 (85.2%) and 389 in April 2021 (85.9%). (Supplementary data Table S1). In all four surveys, respondents were pediatric oncologist (50-59%), medical directors (31%) and residents/fellows (10%). Participants were affiliated to public hospitals (58-63%), public-private (22-24%) or private (15-17%). The most frequent facility type was children’s hospitals (41%), followed by general hospital (35%) and cancer centers (23%).
The first three surveys took place during the beginning, peak and resolution of the first wave in most participating countries, except for Uruguay, whose first wave started late in April 2021 (Figure 2 and 3). During those first three surveys, on average, respondents reported partial or complete suspension of outpatient procedures (54.2%), decreases in surgical services (43.6%), radiation therapy sessions (28.4%), SCT (69.3%) and off therapy surveillance consultations (81.2%) (Table 1). Even though more than 95% of the participants surveyed reported that new and active patients received oncologic treatment during all four surveys, they also reported disruptions in treatment availability that conditioned the type of treatment they offered (Figure 1, 2 and 3).
Univariate logistic regression analysis was performed on each survey. Factors including incidence rate of more than 100 cases per 100,000, case fatality rate above 2% and HCE less than 7% were significantly associated with suspensions of some or all of the following services: outpatient procedures, oncologic surgeries, patient surveillance, radiotherapy sessions and SCT. In contrast, suspension of treatment of new and active ongoing patients was not, as physicians continue treating patients with the treatments modalities that were available. Multivariable logistic regression analysis showed that when COVID-19 cases were rising at the beginning of the first wave (June 2020), LATAM countries with an HCE below 7% were more likely to report a decrease in outpatient procedures (OR:1.84, 95%CI: 1.19;2.8) and surgeries (OR:3, 95%CI: 1.9;4.6), controlling for other indicators of COVID-19 burden. In addition, suspension of radiation therapy sessions also increased in those countries with HCE less than 7% (OR:6, 95%CI: 3.5;10.44). Surveillance consultations were suspended in countries with a case fatality rate above 2% (OR:3, 95%CI:1.4;6.2); and SCT were suspended in countries where COVID-19 incidence rate was above 100 cases per 100,000 (OR: 3.48, 95%CI: 1.6;7.45) (Supplementary data Table S4). At the end of the first wave, in October 2020, the association between HCE and the suspension of outpatient procedures, surgeries, radiotherapy sessions and SCT suspensions remained, even as the first wave resolved and indicators of national burden of COVID-19 improved in most countries (Supplementary data Table S5).
In April 2021 (beginning of the second wave), with cases of COVID-19 rising exponentially again in most countries, most participants reported an improvement in pediatric cancer services availability. Only 36% of respondents reported suspension of outpatient procedures (down from 50% in June 2020), 30.6% reported suspensions in surgeries (down from 41% in June 2020), 16% suspension of radiotherapy sessions (down from 25.1% in June 2020), 37.5% suspension of SCT (down from 68.1% in June 2020); and 48.1% reported suspension of surveillance consultations (down from 80.7% in June 2020) (Table 1). In April 2021, only countries with HCE below 7% continued to have an increase in radiotherapy sessions suspension (OR:3.16, 95%CI:1.7;5.89) and in SCT suspensions (OR:7.16 – 95%CI:3.17;16.15), while other indicators of national COVID-19 burden did not show any association (Supplementary data Table S6).
At the beginning of the pandemic, 35.6% of participants reported chemotherapy regimen modifications due to drug shortages and 45.2% a significant decrease in access to blood products. Deeper into the pandemic, (June-October 2020), chemotherapy availability improved as only 15% and 18% of participants reported chemotherapy shortages. However, an average of 55% still reported decrease in access to blood products during the last 3 surveys (Supplementary data Table S7).
As shown in Figure 4, participants reported that since the beginning of the pandemic there were frequent delays in diagnosis (33%), frequent treatment abandonment (17.2%) and an increase in family out-of-pocket expenses (42.2%).
Responses about access to SCT and radiation therapy varied within countries and between surveys. During all four surveys, on average, 48.5% of participants reported not having access to SCT and 15.4% of participant reported not having access to radiation therapy.
Notably, during all four surveys, from 60% to 82% of respondents reported some percentage of hospital staff reduction due to COVID-19 infection or quarantine, but only maximum of 3.75% reported more than a 50% staff reduction (in April 2020). In addition, a maximum of 1.5% of respondents reported more than a 50% displacement of pediatric oncologist to work in other sectors of the hospital due to COVID-19 (in June 2020) (Table1).
On average, 55% of participants had access to some form of telemedicine during the first year of the pandemic (including institutional telemedicine platforms and non-professional communication channels such as WhatsApp, Facebook or Zoom). In April 2021, more than 80% of participants reported that they would like to have an institutional telemedicine platform to follow their patients, as more than half of them (50.4%) had only access to non-professional communication channels.
By April 2021, 99 (25%) participants reported having contracted COVID-19, 298 (76%) reported being immunized with two doses of a SARS-CoV2 vaccine, and 64 (16.4%) with only one dose. Only 5 participants (1.5%) refused to be vaccinated (Supplementary data Table S9)