There is no room for ambivalence in cancer care

Cancer & COVID-19: How to deal with the nefarious duo?

James Fleck: Anticancerweb 20(10), 2020

Data from a national analysis conducted in China and published in Lancet Oncology in February, 2020 revealed that 39% of COVID-19 positive-cancer patients had severe events. They were defined as a composed endpoint including admission to intensive care unit, need for invasive ventilation or death. This preliminary report included only 18 COVID-19 positive-cancer patients. When compared with patients without cancer, they were older, more likely to have history of smoking, had more polypnea and more severe baseline CT manifestations. A retrospective cohort analysis, conducted in three designated hospitals in Wuhan, confirmed the previous reported higher incidence of severe events. Between January 13th, 2020 and February 26th, 2020, a total of 1276 COVID-19 positive patients were admitted to the hospitals and 28 patients also had a cancer diagnosis (2.2%). The majority were male (60.7%), the median age was 65 and the most frequent tumor type was lung cancer (25%). Severe events were reported in 53.6% of the COVID-19 positive-cancer patients, leading to a mortality rate of 28.6%. Shortly thereafter, COVID-19 was declared a pandemic by the World Health Organization. Since then, worldwide efforts have been made to better understand the consequences of the nefarious duo.

The first COVID-19 positive-cancer patient's prognosis report in USA was conducted at Mont Sinai Health System in New York. A total of 334 cancer-patients were depicted after reviewing 5688 COVID-19 positive electronic medical records (EMR) from March 1st, 2020 to April 6th, 2020. Without adjusting for age, COVID-19 positive-cancer patients were significantly more intubated (RR=1.89), but the rate of death was not significantly different. However, patients younger than 50 years-old had a significantly higher mortality rate (RR=5.01). Almost contemporarily, the COVID-19 and Cancer Consortium Database (CCC19) reviewed 1035 COVID-19 positive-cancer patient's records. The most prevalent malignancies were breast (21%) and prostate cancer (16%) and 39% of the patients were on active anticancer treatment. The results were published in Lancet on June 20th, 2020 and revealed a general mortality rate of 13% after a medium follow-up of 21 days. In logistic regression analysis, independent factors associated with increased 30-days mortality were increased age (OR=1.84), male gender (OR=1.63),former smoker (OR=1.60), two comorbidities (OR=4.5), PS ECOG 2 (OR=3.89), progressing cancer (OR=5.20) and receipt of azithromycin + Hydroxychloroquine (OR=2.93). In a more recent cohort study published in July, 2020 in Cancer Discovery the Montefiore Medical Center reported the outcome of 218 COVID-19 positive- cancer patients and showed a higher case fatality rate (CFR) among hematologic malignancies (37%), when compared with the CFR observed in solid tumors (25%). More impressive was the 55% CFR observed in the 11 patients with lung cancer. Gradually, more robust data appeared, sustained by a matched cohort study and a systematic review. A retrospective observational cohort study was conducted by two New York Presbyterian Hospitals (Weill Cornell Medicine and Lower Manhattan Hospital) and published in the Journal of Clinical Oncology on September 28th, 2020. COVID-19 positive-cancer patients (Arm A: C+C+) were matched 1:4 to COVID-19 positive patients without cancer (Arm B: C+C-). Nearly 45% of arm A patients were receiving cytotoxic or immunosuppressive treatment within 90 days of admission. Curiously, there were no significant difference in morbidity and mortality between the two arms. The death rate for C+C+ patients (Arm A) was 24.8% compared to 21.4% for C+C- (Arm B) patients (P=0.894). Despite the limitation of a non-prospective randomized trial, the two arms were well-balanced for some important prognostic factors (smoke history, obesity and comorbidities). There were no difference in composed outcomes between hematologic and solid malignancies, as well as, in patients C+C+ subjected to cytotoxic therapy within 90 days of admission (P=0.446). The results suggest that the diagnosis of active cancer alone and recent cytotoxic therapy do not predict worse COVID-19 outcome. Finely, ScienceDirect published an international systematic review and pooled analysis of 52 studies, showing a 25.5% probability of death in COVID-19 positive-cancer patients, however with study heterogeneity (I2 = 48.9%). Although the data sounds a little contradictory, we have to admit that the nefarious due is a dangerous liaison, expressing high incidence of morbidity and mortality. Aggressive preventive measures should be implemented to protect cancer patients against COVID-19 infection and recommendations to limit cancer-directed therapy must be considered carefully in relation to cancer specific risk of death and other surrogate endpoints.



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8. Photo by Tim Mossholder on Unsplash