In a Global Registry of COVID-19 in Childhood Cancer cohort study reported in The Lancet Oncology, Mukkada et al found that approximately one-fifth of children with cancer infected with COVID-19 worldwide had severe illness, with an associated mortality rate exceeding that reported in the general pediatric population.

Study Details

Availability of the registry was communicated through professional networks through email and conferences, with health-care providers being invited to submit all qualifying cases. A total of 1,500 patients aged < 19 years with cancer or who had received hematopoietic stem cell transplantation with laboratory-confirmed SARS-CoV-2 infections from sites in 45 countries were included in the study between April 15, 2020, and February 1, 2021. Primary outcomes were disease severity and modifications of cancer-directed therapy. Severe disease was defined as needing a higher level of care for any reason, or any oxygen support needed greater than regular nasal cannula or facemask but less than intubation. Critical disease was defined as evidence of organ dysfunction, intubation, or death due to COVID-19.

Key Findings

A total of 1,319 patients had 30-day follow-up data. A total of 259 (19.9%) of 1,301 patients had severe or critical COVID-19 infection. Death in a total of 50 (3.8%) of 1,319 patients was attributed to COVID-19 infection; mortality rates of 0.01% to 0.70% have been reported in cohorts of general pediatric patients.

Changes in cancer-directed therapy occurred in 609 (55.8%) of 1,092 patients receiving active treatment. The most common change was withholding of chemotherapy, occurring in 487 (80.0%) of 609 patients.  

On multivariate analysis, risk of severe or critical illness was significantly associated with World Bank low-income or lower middle–income country status (odds ratio [OR] = 5.8, P < .0001) and upper middle–income country status (OR = 1.6, P = .0024) vs high-income country status; age 15 to 18 years vs 1 to 9 years (OR = 1.6, P = .013); absolute lymphocyte count ≤ 300 vs > 300/mm³ (OR = 2.5, P < .0001); absolute neutrophil count ≤ 500 vs > 500/mm³ (OR = 1.8, P = .0001), and intensive cancer treatment (OR = 1.8, P = .0005). No significant differences in risk were observed for acute lymphoblastic lymphoma or acute lymphoblastic leukemia, other hematologic malignancies, or central nervous system tumors vs solid cancers (overall P = .14).

On multivariate analysis, factors significantly associated with increased or decreased risk of cancer treatment modification were: upper middle–income country status vs high-income country status (OR = 0.5, P = .0004); primary diagnosis of hematologic malignancies other than acute lymphoblastic lymphoma or acute lymphoblastic leukemia vs solid tumors (OR  = 0.5, P = .0088); presence of one or more vs no COVID-19 symptoms at presentation (OR = 1.8, P = .0002); and presence of one or more vs no comorbidities (OR = 1.6, P = .020).

The investigators concluded, “In this global cohort of children and adolescents with cancer and COVID-19, severe and critical illness occurred in one-fifth of patients and deaths occurred in a higher proportion than is reported in the literature in the general paediatric population. Additionally, we found that variables associated with treatment modification were not the same as those associated with greater disease severity. These data could inform clinical practice guidelines and raise awareness globally that children and adolescents with cancer are at high-risk of developing severe COVID-19 illness.”

Sheena Mukkada, MD, of the Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, is the corresponding author for The Lancet Oncology article.

Disclosure: The study was funded by the American Lebanese Syrian Associated Charities and National Cancer Institute. For full disclosures of the study authors, visit thelancet.com.