Children with cancer ‘at no higher risk’ for COVID-19 infection, morbidity
Children and adolescents with cancer do not appear at higher risk for infection or morbidity from COVID-19 compared with their cancer-free counterparts, according to single-center findings published as a research letter in JAMA Oncology.
“We are reassured by these findings,” Andrew L. Kung, MD, PhD, researcher in the department of pediatrics at Memorial Sloan Kettering Cancer Center, told Healio. “Due to a lack of specific data, we were concerned that children being treated for cancer might be at heightened risk for infection by COVID-19. However, our data reassure us that children with cancer are at no higher risk for infection by COVID-19 and that the symptoms of infection are generally mild.”
Between March 10 and April 12, Kung and colleagues established a screening and testing procedure at Memorial Sloan Kettering Cancer Center that aimed to mitigate risks associated with COVID-19 infection among pediatric patients with cancer.
Researchers assessed exposure to contacts with known COVID-19 infection and the presence of COVID-19 symptoms among 178 pediatric patients (mean age, 11.1 years; 107 male) receiving treatment for cancer and their adult caregivers.
Overall, 11.2% of patients (n = 20; mean age, 15.9 years) tested positive for COVID-19, as did 17.6% (n = 13 of 74) of their adult caregivers.
Nearly one-third (29.3%; 95% CI, 18.1-42.7) of symptomatic children tested positive for COVID-19, and 95% of those infected with the virus had mild symptoms and did not require hospitalization. Among the 2.5% (95% CI, 0.5-7.1) of asymptomatic children who tested positive for COVID-19, approximately 15% of their adult caregivers tested positive.
All but three of the 20 pediatric patients with cancer and COVID-19 were male.
“One finding that was a surprise was that most COVID-19 infections were found in boys,” Kung told Healio. “In adults, there is a male skewing in patients with critical symptoms, which has been attributed in part to comorbidities that are more common in men. Our results would suggest that there is some biological basis as to why males are more likely to be infected than females.”
Although most patients who tested positive for COVID-19 had mild symptoms and were managed at home, one patient required noncritical care hospitalization and three patients were admitted for concomitant fever and neutropenia, cancer morbidity or planned chemotherapy.
Moreover, researchers observed simultaneous detection of virus in five patient/caregiver dyads, whereas five patients tested negative for COVID-19 despite close contact with caregivers who were COVID-19-positive.
“These findings allow us to forge ahead with cancer-directed therapies,” Kung told Healio. “These results allow us to not compromise on the intensity of treatment, even [for] patients who have COVID-19 infection. As a community, the best research will be empowered by sharing and aggregating all data across our specialty, which we are committed to doing. We wanted to disseminate this early experience since it may help guide physicians in regions less affected by COVID-19.” – by Jennifer Southall
For more information:
Andrew L. Kung, MD, PhD, can be reached at Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065; email: kunga@mskcc.org.
Disclosures: The authors report no relevant financial disclosures.
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Boulad and colleagues report rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children with cancer and their caregivers treated at a large tertiary care referral center in New York City — a global epicenter of the pandemic — between March 10 and April 12. This information is critically important to inform cancer care in the COVID-19 era.
As the authors note, the study faces limitations reporting retrospectively on an emerging pathogen in the context of a global pandemic that is just beginning. Nevertheless, there is valuable information to be gleaned. Among 178 unique pediatric patients tested for SARS-CoV-2 using an RT-PCR assay, 11.2% were infected, while 17.6% of 74 adult caregivers tested were infected. For asymptomatic pediatric patients and adult caregivers without known exposures, infection rates were 2.5% and 14.7%, respectively.
These data suggest that either children may be less prone to infection which has been reported in other studies; that they are less likely to be exposed than their adult caregivers, or that they may clear the virus more quickly. Serologic testing could better inform these hypotheses and would have important epidemiologic and clinical implications.
The authors also note that males were more likely to test positive than females (15.9% vs. 4.2%), which has been reported by others, and that only one symptomatic patient required hospitalization. A small sample size makes it difficult to draw definitive conclusions on these observations, which are notable and deserve further study.
Notably, the authors do not differentiate between individuals with symptomatic COVID-19 infection and those with asymptomatic infection. Additionally, viral load, time to viral clearance and comorbidities were not reported, including cancer type and whether patients were receiving an immunosuppressive therapy or were under surveillance. In the case of other respiratory viruses, including SARS-CoV-1 and influenza, whether a person develops mild disease or pneumonia depends not only on how much virus is in their lungs but also their immune response and general health.
Of importance, 26 states in the U.S. are now reporting increasing cases of a multisystem inflammatory syndrome in children (MIS-C), with a case definition from the CDC suggesting exposure to or test positivity for SARS-CoV-2 within the preceding 4 weeks. The cross-sectional, retrospective nature of this study would not capture this clinical disease should it develop or patient outcomes following a prolonged duration of cancer treatment during a pandemic that will continue for the foreseeable future.
Robust research efforts to address COVID-19 in adults with cancer are needed and underway, including the NCI COVID-19 in Cancer Patients Study (NCCAPS), which will be expanded to children with cancer soon. Multicenter, prospective cohort studies will be essential to understand how cancer treatment and outcomes are affected by the virus. Until then, we have to know that we do not know what we do not know — and reflect on this important article as the first of its kind, with guarded optimism of the virus’s effects on children being treated for cancer, while leveraging these findings to inform broader population-based work.
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