The clinical impact of COVID-19 on cancer patients
As patients with cancer may be at greater risk from COVID-19, there is a clear need to collect large datasets from representative patient cohorts in order to get a complete understanding of the clinical impact of COVID-19 on cancer patients. Therefore, the COVID-19 and Cancer Consortium (CCC19) gathered clinical reports on infected COVID-19 cancer patients from 104 institutions. Initial analyses of this data set indicate that the mortality risk of these patients was high and associated with general population risk factors as well as those unique to cancer patients.
The effects of COVID-19 on patients with cancer remains poorly understood. The currently published reports are small and often focus on one specific region or suffer from several other limitations. Patients with cancer are often older, present with comorbidities and need to visit hospitals at a regular basis. As a result, they may be at greater risk to get infected with COVID-19. Moreover, due to their cancer and/or cancer treatment, these patients have a decreased immune system and a generally lower performance status as compared to the general population. Therefore, there is an urgent need to collect data from a larger and more representative cohort to study the impact of COVID-19 on cancer patients.
To this end, the COVID-19 and Cancer Consortium (CCC19) was founded on March 15th, 2020. The consortium is open to site-level participation in the United States and Canada but also to reports from anonymous individuals in Argentina, Canada, Europe, the United States, and the United Kingdom. In total, 104 institutions are participating and 928 cases were included in this first analysis. Both real-time reports as well as reports after COVID-19 illness were included.
In total, 50% of the enrolled patients were male and the median age of the study participants was 66 years. This is much higher than the median age reported in other, more general, COVID-19 reports and is consistent with cancer diagnosis. Of note, approximately one third of the patients was older than 75 years. Most of the patients were white (50%) while African, American and Hispanic origin accounted for 16% of patients each. At the time of COVID-19 infection, 39% of the patients were on active anti-cancer treatment and 43% of the patients had active (measurable) cancer. Most patients (68%) had an ECOG performance status (ECOG PS) of 0-1 and 8% of the patients had an ECOG PS of 2. Half of the patients (52%) had never smoked, 37% were former smokers and 5% currently smoked (from 6% of the patients the smoking status remained unknown). The most common cancer types were breast cancer (21%), prostate cancer (16%), gastrointestinal cancers (12%), lymphoma (11%) and thoracic cancers (10%).
After a median follow-up of 21 days, 121 patients (13%) have died, with all deaths occurring within 30 days of their COVID-19 diagnosis. Unfortunately, this death rate among cancer patients is twice as high as the ‘average’ COVID-19 death rate across the globe, which is estimated at 6.5%. Male sex (17%), former smoker (20%), age above 75 years (25%), active stable/responding cancer (14%), active progressing cancer (25%) and an ECOG PS of two or more (35%) were independently associated with increased mortality. The only characteristic that was associated with a lower mortality rate (2%) was the absence of comorbidities, although the number of deaths in that group was very small (N=3) and no statistical significance was reached. Furthermore, no statistically significant different death rates were seen based on race or ethnicity. Of the cancer patients with a COVID-19 infection, 50% had to be hospitalized and 23% of them died. In addition, 14% of the infected patients had to be admitted to the intensive care unit of whom 38% died. Especially in the subgroup of patients above 75 years of age and in the subgroup of patients with an ECOG PS of 2 or more, very high death rates (54% and 68%, respectively) were observed. Finally, 12% of the patients had to be intubated of whom 43% died. Again, patients of older age or with a weak performance status were of much higher risk of dying (59% and 85%, respectively).
The mortality rate among cancer patients with a COVID-19 infection was high at 13%. This mortality rate was associated with general population risk factors (such as sex and smoking status) and with unique cancer-related factors (disease progression, etc.). Independent factors that are associated with increased mortality were older age, male sex, former smoker, number of comorbidities, an ECOG PS ≥ 2 and active cancer. Interestingly, also combination treatment with azithromycine and hydroxychloroquine proved to be associated with an increased mortality. However, the validity of this observation remains uncertain due to high risk of residual confounding factors. In addition, older age, poor performance status and progressing cancer were strongly associated with increased mortality, especially in subsets of patients that were admitted to the intensive care unit and/or had to be intubated. Larger sample size and longer follow-up are even though needed to more completely understand the impact of COVID-19 on specific patient subsets over time.
Warner JL, Rubinstein SM, Grivas P, et al. Clinical impact of COVID-19 on patients with cancer: Data from the COVID-19 and Cancer Consortium (CCC19). Presented at ASCO 2020; Abstract LBA110.