Delayed presentations of pediatric solid tumors at a tertiary care hospital in the Bronx due to COVID‐19

Abstract

To the Editor: In March 2020, United States declared a national emergency secondary to COVID-19 and issued stay-at-home orders. Several weeks later, the American Cancer Society released a statement encouraging individuals to postpone cancer screenings.1 Routine pediatric visits were postponed or canceled, and emergency rooms were reserved for the sickest patients requiring emergent evaluation. Pediatric emergency room visits and pediatric hospital inpatient censuses significantly decreased. Patients with new onset diabetes presented with diabetic ketoacidosis for fear of exposure to health care institutions.2 Patients with appendicitis were noted to have delayed presentation and higher rates of complications.3 The Children's Hospital at Montefiore, an urban academic tertiary care hospital with a designated oncology floor, is the only Children's Hospital in the Bronx, the borough with the highest SARS-CoV-2 infection rate in New York City.4 The volume of patients admitted to Montefiore Medical Center at the height of the pandemic was so large that one floor of the Children's Hospital was converted into a unit for adult COVID patients, as were several conference rooms. We hypothesized that fewer pediatric cancers presented to the hospital during this time. We conducted a retrospective chart review of the number and type of new cancer diagnoses that presented to our hospital during March through June 2020 and compared it to these same months during each of the previous 5 years. During the months of March-May 2015-2019, we saw an average of 13.6 ± 4.5 (mean ± SD) new solid tumor diagnoses (Table 1). In 2020, we saw no new diagnoses in March or May; in April we saw only four new patients with solid tumors, three of whom were sarcoma patients who presented with a long duration of symptom and were found to have metastatic disease. The fourth child had a brainstem glioma. These patients were each diagnosed and treated urgently, without any delay secondary to COVID-19. In contrast, during that same period we had an average of 5.2 ± 1.2 (mean ± SD) new leukemia diagnoses, and saw four new leukemia patients during the pandemic in 2020. In contrast, in June 2020 we saw three new leukemia patients and six new patients with solid tumors (one sacrococcygeal teratoma, one renal cell carcinoma, one medulloblastoma, one CNS germinoma, and two patients with Wilms tumor). Hematologic malignancies typically present acutely, making it harder for patients/parents to delay seeking care, while solid tumors present more indolently.5-7 This probably explains the decrease in diagnoses of solid tumors during the height of the pandemic with no change in the rate of diagnosing acute leukemias. The delay in presentation correlates with advanced disease at diagnosis. Advanced disease at presentation has been linked to worse outcomes and overall survival. Patients with metastatic disease generally present with a shorter symptom duration, which likely reflects the aggressive nature of the tumor.6 However, we saw patients with metastatic disease presenting with a prolonged symptom duration during the pandemic, which probably reflects a reluctance on the part of patients and their families to seek care during that time. Of note, two of these patients are Hispanic and one is Black, which may suggest yet another way in which the pandemic disproportionately adversely affected the health of minority populations. Other institutions in the United States have seen a delay in seeking care for pediatric leukemia, with significantly increased morbidity and mortality.8 Adult oncologists are urging patients to resume routine screening. Even with stay-at-home orders and social distancing measures, it is imperative that children receive necessary imaging, diagnostic procedures, and prompt treatment for pediatric cancers. Further investigation is necessary to explore measures to ensure our vulnerable population of children receive timely and safe care in the event of another pandemic wave or a future similar national emergency. The authors would like to thank Ms Annette Pedro for help with data collection. Miriam A. Knoll reports consulting fees from Bristol Myers Squibb and AstraZeneca, outside of the submitted work.

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