Pediatric cancer care management during the COVID-19 pandemic: a review of the literature and a single-centre real-life experience of an Italian pediatric oncology unit

ABSTRACT

Introduction

The severe acute respiratory syndrome coronavirus-2 pandemic significantly affected clinical practice, also in pediatric oncology units. Cancer patients needed to be treated with an adequate dose density despite the SARS-CoV-2 infection, balancing risks of developing severe COVID-19 disease.

Areas covered

Although the pandemic spread worldwide, the prevalence of affected children was low. The percentage of children with severe illness was approximately 1–6%. Pediatric cancer patients represent a prototype of a previously healthy immune system that is hampered by the tumor itself and treatments, such as chemotherapy and steroids. Through a review of the literature, we reported the immunological basis of the response to SARS-CoV-2 infection, the existing antiviral treatments used in pediatric cancer patients, and the importance of vaccination. In conclusion, we reported the real-life experience of our pediatric oncology unit during the pandemic period.

Expert opinion

Starting from the data available in literature, and our experience, showing the rarity of severe COVID-19 disease in pediatric patients with solid tumors, we recommend carefully tailoring all the oncological treatments (chemotherapy/targeted therapy/stem cell transplantation/radiotherapy). The aim is the preservation of the treatment’s timing, balanced with an evaluation of possible severe COVID-19 disease.

KEYWORDS:

• SARS-CoV-2
• pediatric cancer
• chemotherapy
• immune system
• mRNA COVID-19 vaccine
• remdesivir
• nasal swab
• COVID-19 disease

Article highlights

• The percentage of children with symptomatic SARS-Cov-2 is lower than in adults and the presence of previous comorbidities increases the risk of severe COVID-19.

• There are still limited and heterogeneous data on this topic, but it seems that tumors may be a risk factor for severe infection.

• A substantial proportion of children with cancer is potentially curable; but most of them, with tumors characterized by known biological aggressiveness, need well-defined timing and dose intensity of treatments that are crucial to achieve the expected results.

• An adequate balance between the risk of cancer progression or relapse correlated to the delay/interruption of chemotherapy and the risk of severe COVID-19 is crucial.

• The indication to treat immunocompromised pediatric cancer patients affected by mild-to-moderate COVID-19 with preventive antivirals (remdesivir, nirmatrelvir/ritonavir) and anti-SARS-CoV-2 monoclonal antibodies is still a controversial one. This study supports this indication in selected categories: unvaccinated children, patients on active chemo-immunotherapy treatments or transplant recipients, and in the case of additional risk factors for severe COVID-19 (i.e. obesity, cardio-pulmonary or neurological chronic impairment).

• Based on published safety data, we recommend COVID-19 mRNA vaccines to all pediatric (from 5 years of age) patients undergoing active oncological treatments, with a personalized timing.

• Prospective studies and further data from national/international registries are required to draft final guidelines on the correct approach to patients with pediatric solid tumors concomitant with SARS-CoV-2 infection.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Institutional review board statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Fondazione IRCCS Istituto Nazionale dei Tumori di Milano (protocol code INT 104/22 and date of approval: 22 May 2022).

Author contribution statement

All authors contributed to the study conception and design. The first draft of the manuscript was written by Anonymized and all authors commented on multiple versions of the manuscript. All authors have read and agreed to the published version of the manuscript.

Additional information

Funding

This paper received no funding.