By Catlin Nalley
In the current COVID-19 pandemic, cancer patients are considered a highly vulnerable group. However, the impact of the disease on these individuals remains largely unknown. During a special session at the AACR 2020 Virtual Annual Meeting, Li Zhang, MD, PhD, of Tongji Hospital in Wuhan, China, shared experiences and data from the frontlines.
"We have invited physician-scientists who have been at the epicenters of the COVID-19 pandemic, taking care of patients with cancer," noted AACR President-Elect Antoni Ribas, MD, PhD, FAACR, who served as Chair of the COVID-19 and Cancer session.
"I consider them the true heroes of cancer research. They were taking care of patients, putting their lives at risk. Not only this, they gathered perspective information to understand the effects of COVID-19 in patients with cancer, tested new treatments, and have been fast in making all this knowledge available to the research community, so we can all benefit from their experience."
Zhang shared insights from a retrospective cohort study of three Wuhan hospitals that looked at clinical characteristics and the treatment of cancer patients with COVID-19 infection. Some of this data was previously published in the Annals of Oncology (2020; https://doi.org/10.1016/j.annonc.2020.03.296).
The researchers performed univariate and multivariate analyses to assess the risk factors associated with severe events, which were defined as admission to an intensive care unit, the use of mechanical ventilation, or death.
Twenty-eight COVID-19 infected cancer patients were included in this analysis. Enrolled patients had a median age of 65 years and 60.7 percent were male. The most common cancer type was lung (n=7) followed by esophageal (n=4), and breast (n=3).
Zhang noted that 35.7 percent of patients had stage IV cancer and 28.6 percent were infected with COVID-19 via hospital-associated transmission. The rest were community acquired.
COVID-19 Treatment & Outcomes
Twenty-two patients received oxygen therapy and 10 were put on invasive mechanical ventilation. Systemic therapies administered, included antibiotic treatment (n=23), corticosteroids (n=15), intravenous immunoglobulin (n=10), and tocilizumab (n=1).
Zhang reported that 71.4 percent of patients were prescribed at least one antiviral agent, including umifenovir (n=14), lopinavir/ritonavir (n=10), ganciclovir (n=9), and ribavirin (n=1). A combination of these agents was given to nine patients (32.1%).
None of the patients were enrolled in a clinical trial; therefore, no one received hydroxychloroquine or remdesivir, according to Zhang.
Fifteen (53.6%) patients had severe events with the mortality rate of 28.6 percent. The median time from a COVID-19 diagnosis to severe events was 7 days.
By April 4, 50 percent of patients were cured and discharged, Zhang noted. "Median duration of hospitalization for those discharged was 18.4 days," she explained. "The duration of hospitalization for those still admitted was 29.4 days."
The most common cause of death was acute respiratory distress syndrome (5), followed by septic shock (1), suspected pulmonary embolism (n=1), and acute myocardial infarction (1).
The researchers performed follow-up CT scans 7-14 days after admission. They showed improvement in 13 patients, no changes in five, and deterioration in six.
The multivariable analysis showed that the administration of antitumor treatment within 14 days of COVID-19 diagnosis was associated with severe events (HR=4.079, 95%CI 1.086-15.322, P=0.037). Seven patients received at least one form of treatment, including chemotherapy, targeted therapy, radiotherapy, and immune checkpoint inhibitors. Five of these patients had severe events, according to Zhang.
"The common chest CT findings were ground-glass opacity (21, 75.0%) and patchy consolidation (13, 46.3%)," the study authors reported. "The patchy consolidation on CT had a higher risk for developing severe events (HR=5.438, 95%CI 1.498-19.748, P=0.010)."
"Cancer patients showed aggressive presentation and poor outcomes with the COVID-19 infection," they concluded, recommending that vigorous screening for COVID-19 infection should be performed among these patients.
Immune Checkpoint Inhibitors
The researchers also followed another group of cancer patients and their family members to better understand the impact of immune checkpoint inhibitors on COVID-19 risk.
This group included 124 cancer patients who received immune checkpoint inhibitors for at least 2 months. The median age was 59 years and 61.8 percent were male. The majority of patients had stage IV disease (95.2%). The most common cancers were lung (54.0%), followed by esophageal (18.6%), and head and neck (10.7%). The median cycles of immune checkpoint inhibitors was four, according to Zhang.
Among these patients, the investigators reported that only one cancer patient developed COVID-19. In another case, a patient's spouse developed the infection, while the patient did not.
"In conclusion, cancer patients with COVID-19 presented poor outcomes with higher occurrence of clinical severe events and mortality," Zhang said. "Anti-tumor treatment within 14 days of COVID-19 diagnosis increased the risk of developing severe events.
"Limited information did not suggest that cancer patients treated with immune checkpoint inhibitors were more vulnerable to the COVID infection or with worse outcome compared to the others," she concluded. "On behalf of my co-authors, we thank the patients, their families, and the medical workers involved in the study and the fight with COVID-19."
Catlin Nalley is a contributing writer.