Evidence Update – Covid-19 and Cancer

Speciality Trainee in Medical Oncology Dr Sam Kestenbaum gives an update on some recent evidence about Covid-19 in patients with cancer

Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study

Kuderer NM, Choueiri TK, Shah DP et al. 28/06/20, The Lancet

Background: Due to the high prevalence of cancer and the high transmissibility of SARS-CoV-2, an understanding of the disease course of COVID-19 and factors influencing clinical outcomes in patients with cancer is needed. This prospective cohort study determines outcomes of cancer patients with SARS-CoV-2 infection and identifies potential prognostic factors for mortality and severe illness. 

Methods: The COVID-19 and Cancer Consortium (CCC19) database contains de-identified data on patients aged ≥18 with a haematological malignancy or invasive solid tumour and PCR confirmed SARS-CoV-2 infection from the USA, Canada and Spain. Patients with non-invasive cancers including non-melanomatous skin cancer, in-situ carcinoma, or precursor haematological neoplasms were excluded. Baseline data was added between March 17 and April 16, 2020. The primary endpoint was all-cause mortality within 30 days of diagnosis of COVID-19. Secondary outcomes were: a composite of severe illness (death, severe illness requiring hospital admission, ICU admission, mechanical ventilation, or a combination of these); admission to hospital; admission to ICU; mechanical ventilation; and need for oxygen. 

Findings: 928/1035 patient records entered into the CC19 database met inclusion criteria. Median age was 66 (range 18-90), 30% aged ≥ 75 (n=279) and 50% were male. The highest prevalence malignancies was breast (21%) and prostate (16%). 366 (39%) patients were on SACT and 396 (34%) had measurable cancer.121 (13%) of patients died (all-cause mortality) within 30 days of diagnosis of SARS-CoV-2.  Independent factors associated with increased 30-day mortality were increased age (partially adjusted odds ratio (pAOR) 1.84 95% CI 1.53-2.21), male sex(pAOR 1·63, 1·07–2·48), smoking status (former smoker vs never smoked: pAOR  1·60, 1·03–2·47), number of comorbidities (two vs none: pAOR 4·50, 1·33–15·28), ECOG PS ≥ 2 (status of 2 vs 0 or 1: pAOR 3·89, 2·11–7·18) and active cancer (progressing vs remission: pAOR 5·20, 2·77–9·77). Race and ethnicity, obesity status, cancer type, anticancer therapy, and recent surgery were not associated with 30-day all-cause mortality. 242 (26%) patients met the composite severe illness endpoint; 132 (14%) patients were admitted to ICU, 116 (12%) required mechanical ventilation and 466 (50%) required hospital admission. 

Learning points for Edinburgh Cancer Centre: 

1.       Delays in elective cancer surgery or SACT can lead to deleterious outcomes. In this analysis, there was no association between 30-day all-cause mortality and recent surgery or recent SACT (cytotoxic and non-cytotoxic) suggesting that standard oncological care should always be offered if feasible.

2.       Patients with cancer and SARS-CoV-2 have a high risk of mortality and composite severe illness although this is likely to be largely explained by the known risk factors for severe Covid-19 rather than by the presence of cancer itself or use of anti-cancer treatment.

3.       Poor prognostic factors in cancer patients are increasing age, male sex, increased comorbidity, poor ECOG PS and active cancer. We need to encourage our cancer patients, particularly with these risk factors, to follow the shielding advice and take every effort to minimise their exposure to health care facilities unless it’s for essential treatment.