key: cord-0901314-bi0dblgn authors: Ding, Yang‐Yang; Ramakrishna, Sneha; Long, Adrienne H.; Phillips, Charles A.; Montiel‐Esparza, Raul; Diorio, Caroline J.; Bailey, L. Charles; Maude, Shannon L.; Aplenc, Richard; Batra, Vandana; Reilly, Anne F.; Rheingold, Susan R.; Lacayo, Norman J.; Sakamoto, Kathleen M.; Hunger, Stephen P. title: Delayed cancer diagnoses and high mortality in children during the COVID‐19 pandemic date: 2020-06-26 journal: Pediatr Blood Cancer DOI: 10.1002/pbc.28427 sha: 0e7013fc0dc83a655d6b004be9a6b0b488e95d74 doc_id: 901314 cord_uid: bi0dblgn nan To the Editor, Although the effects of the SARS-CoV-2 virus on infected patients are increasingly documented, the indirect consequences for uninfected patients are less well described. 1 We report five cases of children who presented critically ill to two U.S. tertiary referral centers (Children's Hospital of Philadelphia [CHOP] and Lucile Packard Children's Hospital at Stanford [LPCH] ) in April 2020. All patients tested SARS-CoV-2 negative and experienced delays in cancer diagnosis due to the COVID-19 pandemic with grave consequences. Each patient required emergent life-saving interventions shortly after presentation (Table 1) , including resuscitation following cardiac arrest (N = 2), emergent intubation (N = 4), and emergent pericardiocentesis for tamponade (N = 1). Two patients died within days of presentation. Although pediatric cancers can present with severe initial findings, the clustered frequency and acuity of these recent initial presentations is striking. Coinciding with the rapid rise in regional COVID-19 cases and initiation of stay-at-home orders, both institutions noted significant changes in the timing and severity of new patient presentations. The first COVID-19 case in Pennsylvania was reported on March 6, 2020. Despite a five-year historical mean of 2.96 days between new leukemia patients, CHOP did not see any patients with a new leukemia diagnosis for 35 days (March 2, 2020 , to April 6, 2020 Pediatric cancers are relatively rare, and thus delays in diagnosis can occur. 2 However, our experience suggests that additional factors specific to the ongoing COVID-19 pandemic contributed to care delays and higher patient acuity. The family of one patient expressed reluctance to seek care due to fear of COVID-19 exposure. The other four patient families had repeated contact with the healthcare system prior to ultimate diagnosis. This suggests that healthcare system factors may play a role, including decreased referrals to emergency departments or laboratories, and transition to alternative evaluation methods such as telemedicine. Diagnostic bias may also occur, since pre-senting signs of malignancy (fever, malaise, and respiratory symptoms) can initially be mistaken for symptoms of COVID-19. Furthermore, endemic areas have reported that children are less likely to become critically ill from COVID-19 disease as compared with adults, 3 which may delay referral of children for emergency services or laboratory studies. Two patients had multiple telehealth visits prior to in-person evaluations. Telemedicine utilization among primary and acute care providers is increasing during the pandemic. 4 The limitations of telemedicine, including lack of ability to detect critical physical exam findings such as unstable vital signs, pallor, and hepatosplenomegaly, are underscored by these cases. For example, after two telehealth visits and one visual assessment outside the primary care provider's office, patient 1 re-presented hours later to a local emergency department with overwhelming sepsis that progressed to cardiac arrest and brain death. Such an outcome is particularly difficult given the extremely favorable prognosis of childhood ALL. Indeed, the pediatric cancer diagnoses presented here are highly curable in North America with expected cure rates ranging from 67% to over 95% depending on diagnosis. 5 These cases illustrate the indirect impact of this pandemic on morbidity in COVID-19-negative patients for whom care delays can be fatal. We highlight the unintended consequences of a pandemictransformed healthcare system for a vulnerable pediatric population. More work is critical to quantify these consequences and to develop solutions that protect severely ill but treatable children, while also balancing public health and the needs of those infected during this COVID-19 pandemic. No specific support for this project. The authors have no conflicts of interest/financial relationships relevant to this article to disclose. Deceased (HD 5) AML, acute myeloid leukemia; ALL, acute lymphoblastic leukemia; BMA, bone marrow aspirate; DLBCL, diffuse large b-cell lymphoma; ED, emergency department; EMS, emergency medical services; HD, hospital day; Hgb, hemoglobin; PMD, primary medical doctor; WBC, white blood cell. Phillips 1 Vandana Batra 1 Hunger 1 Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia California Correspondence Yang-Yang Ding, Children's Hospital of Philadelphia Delayed access or provision of care in Italy resulting from fear of COVID-19 Childhood cancer and factors related to prolonged diagnostic intervals: a Danish population-based study Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China Virtually perfect? Telemedicine for Covid-19 SEER) Program (seer.cancer.gov). Accessed * Y. Ding and S. Ramakrishna contributed equally as co-first authors to this manuscript.