Cancer Talk

Medical professionals have been concerned that people with cancer may be particularly vulnerable to severe cases of COVID-19. People with cancer tend to be older and have multiple health problems, both of which are factors associated with increased risk of death from COVID-19 regardless of whether someone has cancer. Doctors have also worried that cancer patients’ frequent medical visits could increase risk of exposure to the coronavirus, even as their practices take measures to try to reduce chances for infections. And doctors have wondered whether changes to patients’ immune systems due to cancer itself or to cancer treatments could increase risk.

Two groups gathering data on the outcomes of people with cancer who are infected with COVID-19 will present new data May 30 at the 2020 American Society of Clinical Oncology (ASCO) Annual Meeting, which is being held virtually.

The COVID-19 and Cancer Consortium (CCC19) started taking reports on March 17, 2020, on the outcomes of cancer patients who were infected with the coronavirus. As of mid-May, the group has gathered data on more than 2,000 patients.

​The first data from CCC19, based on information on 928 people from the registry’s first month, indicate that certain cancer patients with COVID-19 are at greater risk of death than others. The data were also published May 28 in the Lancet​.​​

“If you start looking at some subgroups, you start to see some very worrying, very high levels of mortality,” says Jeremy Warner, a medical oncologist and hematologist at Vanderbilt University Medical Center in Nashville, Tennessee, who is presenting the new data.

The researchers report that the majority ​of the patients lived in the U.S., with the remaining patients from Canada and Spain. The median age of the patients was 66. Half of the patients were hospitalized, 14% were admitted to the intensive care unit and 12% were intubated. After a median 21 days of follow-up, 121, or 13%, of the 928 patients had died.

Men were more likely than women to die from their infections, with 17% of men dying. The mortality rate in patients ages 75 and up was 25%. Former smokers and patients with multiple​ health conditions besides cancer also had an elevated risk of death.

The researchers also found cancer-related factors that were associated with increased mortality. Patients who had active, or measurable, cancer were at increased risk of death. Those whose cancer was currently progressing had a mortality rate of 25%, while 14% of patients with cancer that was stable or responding to treatment died.

Finally, the researchers looked at performance status, which is a measure of a patient’s level of functioning. A patient with an ECOG performance status of 0 is able to carry out activities without any restrictions, while a patient with ECOG performance status of 1 might struggle to perform strenuous activities but otherwise be able to work or do light housework. A patient with an ECOG performance status of 2 is able to care for himself or herself but cannot work, while those with higher performance status have more limited capabilities. The registry data indicate that 35% of people with an ECOG performance status of 2 or higher died.

“By definition, performance status 2 is only moderately impacted by the cancer. There’s substantial evidence that you can actually treat patients aggressively, with aggressive combination regimens, and outcomes are still better in the treatment groups, but what we’re finding is that that’s really a major risk factor,” says Warner. The risk from COVID-19 is leading to difficult conversations, especially for patients with low performance status, on whether to continue with cancer treatment. “I think those are in any setting difficult conversations, but these findings have obviously made it more difficult,” Warner says.

There were about double the number of infected African American patients in the registry than would have been expected based on census data from the areas represented in the study. However, African American patients who got COVID-19 did not appear to be at increased risk of death compared to other cancer patients with COVID-19.

Recent surgery, chemotherapy or having blood cancer versus a solid tumor did not appear to be associated with a change in mortality risk. “We’re cautious to make a sweeping statement, but it might be that those factors have less of an effect than the others that we found,” Warner says.

Warner notes that CCC19 lacks a control group of people without cancer, so it’s difficult to say exactly what cancer patients’ risk is compared to members of the general population. Data published April 28 in Cancer Discovery on patients treated in Wuhan, China, found that people with cancer and COVID-19 did appear to be at elevated risk of death compared to people of similar ages without cancer who got COVID-19. Research on patients treated at Montefiore Health System in New York City published May 1 in Cancer Discovery found an elevated rate of death from COVID-19 in cancer patients compared to COVID-19 patients without cancer in the health system.

Researchers will also present new data from TERAVOLT​, a consortium building a database of COVID-19 patients with lung cancer and other thoracic malignancies. Data presented April 28 at the American Association for Cancer Research Virtual Annual Meeting I on the first 200 patients in the database showed that nearly 35% of the patients died.

Data on 400 patients to be presented at ASCO show that higher mortality was associated with older age, poor performance status, multiple health conditions, and receiving chemotherapy in the three months before diagnosis with COVID-19. Prior use of corticosteroids or anticoagulants was also associated with increased risk of death. Treatment with immunotherapy or targeted drugs called tyrosine kinase inhibitors was not associated with increased risk of death. The mortality rate in the entire group of 400 patients after a median follow-up of 33 days was nearly 36%. The cause of death was COVID-19 in around 79% of the patients, while some other patients’ deaths were attributed just to cancer.

In the end, a goal of the registries is to help determine which cancer patients may be particularly vulnerable so that measures can be taken to protect them. Warner says that cancer centers are trying to mitigate risk by screening patients for COVID-19 symptoms, testing patients for COVID-19 and trying to minimize clinic visits. But there aren’t yet clear, evidence-based guidelines on how to proceed. “It’s really the Wild West in how these things are being approached,” he says.​ ​