Background The COVID-19 pandemic had led the Indian government to announce a nationwide lockdown on the 23rd of March 2020. This study (InPOG-ACC-20-04) aimed to explore the impact of this on the accessibility of care of children with cancer in India and to see strategies adopted by hospitals for service delivery during the lockdown. Procedure Weekly average childhood cancer (<18 years) patient registrations during pre-lockdown period (Jan 1st, 2020 to March 23rd 2020) were compared with the post-lockdown period (Mar 24th, 2020 to May 31st, 2020). The effect on the scheduled treatment was investigated for the post-lockdown period. A survey of health care providers was conducted to determine centres’ strategies to deal with the effect of COVID-19. Results In 30 centres participating in this study, 1146 childhood cancer patients were registered from Jan 1st, 2020 to May 31st 2020. The weekly average patient registration was 67.3 pre-lockdown and 35.5 post-lockdown which was a decline of 47.3% with travel distance being a factor. While most centres experience this decline, there were a few who saw an increase in patient registrations. Of those patients scheduled for treatment during the post-lockdown period, 36.1% experience delays in one or more modalities. Centres adopted several strategies to including modifications to treatment protocols, increased use of growth factors, and increased support from social organisations. Conclusion Our multicentre study from India suggests that the COVID19 pandemic and the lockdown impacted two out of three children with cancer. The effect of this on survival remains to be established.

The value of reporting on end-of-treatment outcome of patients in low-income settingsTrijn Israels MD PhD1,2, Ramandeep Singh Arora DCH, MD3, Lillian Sung MD PhD41 Collaborative African Network for Childhood Cancer Care and Research (CANCaRe Africa), 2 Kamuzu University of Health Sciences, Blantyre, Malawi, 3 Max Super Speciality Hospital, New Delhi, India, 4 Sick Children’s Hospital, Toronto, CanadaCorresponding author:Dr Trijn Israels, CANCaRe Africa, Department of Paediatrics, Kamuzu University of Health Sciences (KuHES), Blantyre, Malawi. Email: [email protected] count: 1256 wordsNumber of Tables: 0Number of Figures: 0Short running title: End-of-treatment outcome reportingKey words: childhood cancer, survival, LIC, indicatorsLIC Low-income countryHIC High-income countryGICC Global Initiative for Childhood CancerEFS Event-free survivalOS Overall survivalTRM Treatment related mortalityDRM Disease related mortalityCANCaRe Africa Collaborative African Network for Childhood Cancer Care and Research

Introduction: The InPOG-HL-15-01, a multi-centric prospective study used a risk-stratified and response-based approach with a doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) backbone to treat children with newly diagnosed Hodgkin Lymphoma (HL) and reduce the use of radiation therapy (RT). Children/adolescents with bulky disease or inadequate response at early response assessment (ERA) after 2 cycles of chemotherapy were assigned to receive RT. For ERA, positron emission tomography computed tomography (PET-CT) was recommended but not mandatory in view of limited access. This study aimed to compare the impact of using contrast enhanced computed tomography (CECT) vs PET-CT on treatment decisions and outcomes. Methodology: 396 patients were enrolled and 382 had an ERA at the assigned time point. Results: At ERA, satisfactory response was documented in 277/382 (72.5%) participants and this was significantly higher in PET-CT (151/186, 81.2%) as compared to CECT (126/196, 64.3%) respectively (p value<0.001). Amongst the 203 patients with non-bulky disease (wherein the indication for RT was entirely dependent on ERA), 96/114 (84.2%) and 61/89 (68.5%) patients achieved a satisfactory response according to the PET-CT and CECT (p value=0.008) respectively and hence a lesser proportion of patients in the PET-CT arm received RT. Despite a lower usage of RT the 5 year overall survival (OS) of both groups- ERA based on CECT (91.8%) vs PET-CT (94.1%) was comparable (p value=0.391) and so was the 5 year event free survival (EFS) (86.7 vs 85.5%, p value=0.724). Conclusion: Use of PET-CT as the modality for ERA is more likely to indicate a satisfactory response as compared to CECT and thereby decreases the need for RT in response-based treatment algorithm for HL afflicted children. The reduction in the application of RT did not impact the overall outcome and plausibly would lower the risk of delayed toxic effects.

Background The delivery of Radiation therapy (RT) needs a level of coordination and planning which can be challenging in resource-limited settings. In this retrospective study we describe the profile of children undergoing radiation and analyze deviation from accepted norms. Procedure Data on all children (< 18 years age) with cancer who completed RT from Jan 2009 to Dec 2019 were retrieved. Diagnostic groups with more than 5 patients, were included in the analysis for deviations in RT (Time to start (TTS); total dose delivered (TDD) in Grays; and time to complete (TTC)). We investigated reasons for deviation. Results 207 received RT as front-line treatment (68% Indian, 59% male and 32% received treatment preceding RT outside). Most common diagnosis were brain tumors (44%), lymphoma (13%). leukemia and soft tissue sarcoma (10% each). 23.6% had deviation in TTS, 6.0% in TDD and 24.7% in TTC while 43.4% had at least one deviation in any of these three parameters. Deviation in TTS varied significantly by location of preceding treatment and by cancer (greatest deviation in sarcomas) with issues around access to healthcare the most common reason. Deviation in TTC varied significantly by cancer (greatest deviation in sarcomas and medulloblastoma) with myelotoxicity the most common reason. Conclusions Our study adds to the limited literature on RT quality for children with cancer in LMIC. Certain cancers (sarcomas and medulloblastoma) and patient groups (preceding treatment outside our institute) had the maximum deviation. Barriers to accessing care and myelotoxicity were the two main reasons for this deviation.

Survivorship care is a major area of focus in the holistic management of childhood cancer with current knowledge and information almost exclusively from high-income countries. In this review, we summarize the state of scientific knowledge, service delivery, advocacy initiatives and research efforts in this field in India. 21 single centre studies published till date (20 in the last decade) confirm some of the well-documented issues in childhood cancer survivors and also highlight the high prevalence of hepatitis B and hepatitis C infection in our survivors. Heterogeneity in methodology, outcome metrics and quality precludes drawing further conclusions and the ongoing multicenter Indian Pediatric Oncology Group study would address this. Besides the usual model of follow-up clinics in hospital settings, innovative models of service delivery led by not-for-profit organisations are being developed. Advocacy initiatives driven by survivors and support groups are also underway. All of these portend a promising future.