Received: 21 June 2020 Revised: 15 August 2020 Accepted: 10 September 2020 Pediatric Blood & Cancer DOI: 10.1002/pbc.28729 C O M M E N TA R Y The American Society of Pediatric Hematology/Oncology Timely pediatric cancer diagnoses: An unexpected casualty of the COVID-19 surge Allison F. O’Neill1 Catherine B. Wall1 Carolyn Roy-Bornstein2 1 Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts 2 Merrimack Valley Child & Adolescent Health, Haverhill, Massachusetts Lisa Diller1 Correspondence Allison F. O’Neill, 450 Brookline Ave, DA3-111, Boston, MA 02215. Email: allison_oneill@dfci.harvard.edu The waiting room and halls of the pediatric outpatient clinic at the an appointment, are unable or unlikely to attend. As more literature Dana-Farber Cancer Institute are tempered by an unfamiliar calm. A emerges regarding the natural history of COVID-19 in children, high- thick plexiglass shield guards the front desk, floor tape demarcates a lighting a generally mild course, as well as the efficacy of personal pro- safe distance, and patients and families float in and out of invisibly tection equipment (PPE) in mitigating COVID-19 spread in the medical bound spheres of social isolation. The quiet is unsettling, while partially environment, these fears are likely unfounded.8–10 by design and the product of rapid implementation of virtual visits and On May 6, just at the “COVID-19 peak” in Boston, our patient direct-to-floor admissions to limit exposures and clinic volume, there coordinator received a call from a pediatrician in the community who is the unspoken recognition of a decline in new patient diagnoses cor- had detected an abdominal mass on exam in a healthy 12-month old relating all too closely with the coronavirus disease 2019 (COVID-19) at his scheduled well-child care visit. Ultrasound revealed a large, quarantine. multicystic mass within the right renal fossa with no normal-appearing Limited published and institutional data suggest a surprisingly mild right kidney appreciated. A follow-up pan computed tomography (CT) clinical course and low asymptomatic carriage rates for pediatric oncol- scan demonstrated a large (11.9 × 9.8 × 3.6 cm) right renal mass, COVID-19.1–5 ogy patients infected with In light of this, the care of splaying and thinning the right renal parenchyma, with internal regions pediatric oncology patients on active therapy has remained relatively of hypoattenuation thought to represent necrosis or hemorrhage. unchanged with life-saving inpatient and outpatient chemotherapy There was no definite vascular invasion. Imaging characteristics were courses delivered as scheduled except, perhaps, for patients requir- most consistent with Wilms tumor, however, the differential diagnosis ing high-dose chemotherapy or stem cell transplant conditioning. As included a rhabdoid tumor, clear cell sarcoma of the kidney, or cystic COVID-19 testing becomes increasingly available, decisions surround- nephroma. No nodal or distant metastases were identified by imaging. ing administration of chemotherapy to COVID-positive patients and The patient underwent a right nephrectomy 4 days later at Boston the conservative management of patients with COVID-positive fever Children’s Hospital, with a diagnosis of stage II Wilms tumor made and neutropenia will continue to evolve. But what about the data based on disease extent and histology. Treatment is expected to be affecting the prediagnostic course of a pediatric oncology patient? curative in over 90% of cases with this presentation. This case under- What is the impact of COVID-19 on the delivery of pediatric pri- scores the indispensable role of the primary care provider not only mary care, this being at the very core of early detection of pediatric in the diagnosis of an occult solid tumor, but on a timeline potentially cancer-related symptoms? The American Academy of Pediatrics and crucial in preventing capsular rupture or tumor spread, either of the Center for Disease Control have posted guidelines surrounding which would have resulted in more intensive therapy and possibly a continued in-person well-child visits and consistent administration of decreased chance of cure. How many children with stealth tumors childhood vaccinations.6,7 Despite these recommendations, the reality or new cancer diagnoses remain at home, failing to benefit from the finds great variation in regional pediatric primary care provided; many sensitive exam of their primary care providers? How many cancers primary care clinics have restricted hours, others have converted to have gone undiagnosed and what will the health status of children virtual or drive-through vaccination-only visits, and some find them- presenting with new diagnoses be in the coming weeks to months? selves under-resourced in the ability to care for traditional patient vol- Solid tumor new-patient numbers at our institute not surprisingly, umes. In addition, families remain fearful of leaving their homes during and presumed secondary to the COVID-19 quarantine, have dipped quarantine, particularly to go to a doctor’s office, and even if offered substantially and our colleagues nationally have noted similar trends. Pediatr Blood Cancer. 2020;67:e28729. https://doi.org/10.1002/pbc.28729 wileyonlinelibrary.com/journal/pbc © 2020 Wiley Periodicals LLC 1 of 2 WALL ET AL . 2 of 2 We compared year-over-year trends in new-patient numbers to quan- remain indebted to our primary care colleagues and the active vigilance titate the observed difference. First, we examined data from the pre- they provide the community. We must stand united in the difficult deci- COVID period to establish anticipated trends in growth—there was sions surrounding practice-implementation we will undoubtedly face a 25% year-over-year increase in new-patient diagnoses comparing going forth. January-February in 2019 versus 2020. Comparing the March-to-May periods in 2019 versus 2020, there was a 56% decline in cases. Assess- CONFLICT OF INTEREST ing a longer time period pre-COVID to further validate the findings The authors declare that there is no conflict of interest. confirmed a 59% decline in new cases comparing September 2019 to February 2020 (ie, a 6-month span pre-COVID) to March-May 2020. ORCID We examined whether this decline was secondary to a decrease in Allison F. O’Neill https://orcid.org/0000-0002-8957-3870 regional, national, or international referrals, but instead found that the decline was primarily in local patients. In examining a rebound in REFERENCES new cases with state reopening from June-July 2020, we discovered 1. Bouffet E, Challinor J, Sullivan M, Biondi A, Rodriguez-Galindo C, Pritchard-Jones K. Early advice on managing children with cancer during the COVID-19 pandemic and a call for sharing experiences. Pediatr Blood Cancer. 2020;67(7):e28327. 2. Balduzzi A, Brivio E, Rovelli A, et al. Lessons after the early management of the COVID-19 outbreak in a pediatric transplant and hematooncology center embedded within a COVID-19 dedicated hospital in Lombardia, Italy. Estote parati. Bone Marrow Transplant. 2020. https: //doi.org/10.1038/s41409-020-0895-4 3. Fuerrari A, Zecca M, Rizzari C, et al. Children with cancer in the time of COVID-19: an 8-week report from the six pediatric onco-hematology centers in Lombardia, Italy. Pediatr Blood Cancer. 2020;67:e28410. 4. de Rojas T, Perez-Martinez A, Cela E, et al. COVID-19 infection in children and adolescents with cancer in Madrid. Pediatr Blood Cancer. 2020;67:e28397. 5. Boulad F, Kamboj M, Bouvier N, Mauguen A, Kung AL. COVID-19 in children with cancer in New York City. JAMA Oncol. 2020;6(9):14591460. 6. American Academy of Pediatrics. Guidance on Providing Pediatric WellCare During COVID-19. Last updated 5/8/2020. American Academy of Pediatrics; 2020. 7. Santoli JMLM, DeSilva MB, Kharbanda EO, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration - United States, 2020. MMWR Morb Mortal Weekly Rep. 2020;69(19):591-593 8. Mehta NS, Mytton OT, Mullins EWS, et al. SARS-CoV-2 (COVID-19): what do we know about children? A systematic review. Clin Infect Dis. 2020. https://doi.org/10.1093/cid/ciaa556 9. Castagnoli R, Votto M, Licari A, et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review. JAMA Pediatr. 2020;174(9):882889. 10. Steensels D, Oris E, Coninx L, et al. Hospital-wide SARS-CoV-2 antibody screening in 3056 staff in a tertiary center in Belgium. JAMA. 2020;324(2):195-197. 11. Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki disease: novel virus and novel case. Hosp Pediatr. 2020;10(6):537-540. an increase in new cases with only a 19% residual decline compared with June-July 2019, reflecting gradual recovery. Undoubtedly, there is a contribution both from a decrease in in-person primary care visits, and also the reluctance of families to risk exposing children to the virus, especially on the heels of a recent report documenting a severe hyperinflammatory postviral complication reported in pediatric patients.11 What will be the toll of delayed solid tumor diagnoses, or pediatric cancer diagnoses in general, on the pediatric population? How will the COVID-19 quarantine inequitably impact underresourced communities, where the virus’ high prevalence may augment family reluctance to seek primary care or in emerging economies with already limited treatment facilities for pediatric cancer care? More importantly, as communities begin to relax precautions and quarantine measures, will primary care clinics be able to manage the predicted uptick in visits? Will providers have allocated the precious time needed to evaluate patients on the level required to detect indolent or occult diseases? To complicate matters, what challenges will oncology programs face as quarantine guidelines relax and patients present on a later timeline in the natural history of disease? The latter concern is of particular relevance to solid tumor patients for whom earlier diagnoses may impact disease stage and possibly outcomes. Adding to this stress, previously diagnosed and treated patients have likely had tumor surveillance scans delayed through this crisis, children with cancer predisposition syndromes have not undergone their routine surveillance, and survivors due for follow-up testing and care may be falling behind in detection and management of late toxicities of therapy. Well-child care visits, at a minimum aligned with required vaccinations, should remain a priority both for primary care providers and families. The future trajectory of the COVID-19 crisis remains uncertain, but the epidemiology of pediatric cancer diagnoses remains a certainty. While rare, these are diagnoses that cannot be missed. Existing literature regarding the mild COVID-19 clinical course in children, with or without an oncologic diagnosis, coupled with the efficacy of PPE in How to cite this article: O’Neill AF, Wall CB, Roy-Bornstein C, preventing nosocomial spread should encourage families to seek care, Diller L. Timely pediatric cancer diagnoses: An unexpected and primary care providers to maintain standard practice hours partic- casualty of the COVID-19 surge. Pediatr Blood Cancer. ularly as we navigate an unpredictable future with the potential for a 2020;67:e28729. https://doi.org/10.1002/pbc.28729 second wave of COVID-19 cases. As pediatric oncology providers, we