A study of patients in the pandemic epicenter found that the outcome of COVID-19 is worse among those with cancer and will have a lasting impact on those undergoing treatment.
A study of patients at Memorial Sloan Kettering Cancer Center (MSKCC), published in Nature Medicine, indicated that the outcome of coronavirus disease 2019 (COVID-19) is worse among those with underlying health conditions, including cancer.
Additionally, similar to what was observed with the SARS epidemic, researchers suggested that the continued risk of contracting the illness and indirect consequences of treatment disruptions are predicted to have a lasting impact on the health and safety of patients undergoing treatment for cancer.
“Continuous preparedness is paramount as routine cancer care is resumed in the coming weeks and months amidst the unpredictable threat posed by COVID-19,” the authors wrote. “Informed approaches with universal screening, aggressive testing, and rigorous control measures will be essential for the safe ongoing delivery of oncologic care.”
Between March 10 and April 7, 2020, 423 cases of symptomatic COVID-19 were identified from a total of 2035 patients with cancer tested at MSKCC. Notably, the majority of patients were adults over the age of 60 years (56%).
The most frequent types of cancer observed in the study included solid tumors such as breast (20%), colorectal (9%) and lung (8%). Lymphoma was the most common hematologic malignancy (11%). Over half of the cases were metastatic solid tumors (56%). Even further, in 248 individuals (59%), at least one of the following specified comorbid conditions was present: diabetes, hypertension, chronic kidney disease, and cardiac disease.
Of the patients diagnosed with COVID-19, 168 (40%) had to be hospitalized, 87 (20%) developed severe respiratory illness (including 47 [11%] who required high-flow oxygen and 40 [9%] who required mechanical ventilation), and 51 (12%) died within 30 days. Case fatality for hospital and intensive care unit (ICU) admittance were 24% (41 of 168) and 35% (17 of 48), respectively.
In multivariate analysis, non-white race, hematologic malignancy, a composite measure of chronic lymphopenia and/or corticosteroid use, and treatment with immune checkpoint inhibitor (ICI) therapy were independently associated with hospitalization. The risk factors for severe respiratory illness due to COVID-19 were similar to those for hospitalization.
In univariate analysis, age older than 65 years, former or current smoker, hypertension and/or chronic kidney disease, and history of cardiac disorder were all significant predictors, though not in multivariate analysis. Moreover, treatment with ICIs were predictors for hospitalization and severe disease in those aged 65 years and older, though metastatic disease, receipt of chemotherapy, and major surgery were not.
“A notable finding of our study is the association of checkpoint inhibitor immunotherapy as a risk factor for severe outcomes in patients treated with ICI, which was independent of age, cancer type, and other comorbid conditions,” the authors wrote. “Although we observed more severe COVID-19 in ICI recipients with underlying lung cancer, patients with non-lung cancer who were treated with ICI also demonstrated severe outcomes.”
“A possible explanation for this observation is an exacerbation of ICI-related lung injury or ICI-triggered immune dysregulation by T-cell hyperactivation, which in turn might facilitate acute respiratory distress syndrome, a dreaded COVID-19 complication,” the authors continued.
With consideration to the findings of the current study, the investigators stressed that until further evidence is available, it is important that treatment decisions not be altered, but increased vigilance with SARS-CoV-2 testing in patients or continuing treatment with ICIs be considered, regardless of symptoms. In addition, researchers indicated that the association observed between ICI and COVID-19 outcomes requires further study in tumor-specific cohorts.
Furthermore, with the current study population and design, investigators were unable to produce a reliable comparison of COVID-19-related outcomes between cancer and non-cancer populations. However, the researchers indicated that, “such an analysis should be conducted in homogenous cohorts with adequate adjustment for comorbidities, inclusion of patients with cancer on active therapy, a similar testing strategy and the ability to measure the effects of interrupting oncologic care.”
Robilotti EV, Babady NE, Mead PA, et al. Determinants of COVID-19 disease severity in patients with cancer. Nature Medicine. doi:10.1038/s41591-020-0979-0.