'Continue Cancer Care With Caution' Despite Pandemic

Kristin Jenkins

October 07, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Potentially practice-changing new data out of New York City add to growing evidence that not all cancer patients with COVID-19 are at increased risk of coronavirus-related complications and death compared with the general population.

The results suggest that cancer care can be continued despite the pandemic in patients with cancer and limited comorbidities, say the researchers.

However, experts approached for comment emphasized the need for more data.

The new results come from an analysis of data on 585 adults who tested positive for COVID-19 and were admitted to two NewYork-Presbyterian hospitals between March 3 and May 15. 

A total of 117 patients with cancer were matched 1:4 to controls without cancer for age, sex, and number of comorbidities. Almost half of the patients with cancer were undergoing treatment, with 45% receiving cytotoxic or immunosuppressive therapy within 90 days of admission.

The analysis showed no statistically significant difference in the rate of intensive care admission, ventilation, or death (P = .894) between patients with and without cancer.

The study was published online September 28 in the Journal of Clinical Oncology.

"This finding suggests that a diagnosis of active cancer alone and recent anticancer therapy do not predict worse COVID-19 outcomes," the authors write. "Our results suggest that patients with cancer with limited comorbidities may continue their cancer care with caution."

"This is important information that we believe is practice changing," lead author Manish A. Shah, MD, chief of the solid tumor service and director of the gastrointestinal oncology program at Weill Cornell Medicine/NewYork-Presbyterian, told Medscape Medical News.

Cancer Treatment Halted by Pandemic

Early in the pandemic, initial data suggested that patients with cancer were at increased risk of death from COVID-19.

As a result, there was a move to limit their potential exposure to the virus, and visits to clinics and hospitals for cancer treatments were postponed. 

Since then, however, growing evidence indicates that it may be safe for select patients with cancer and COVID-19 to continue cancer treatment. For example, a prospective cohort British study in about 800 patients found no association between treatment with chemotherapy or immunotherapy and increased mortality risk with COVID-19. "Mortality from COVID-19 in cancer patients appears to be principally driven by age, gender, and comorbidities," the researchers say.

Now, this study in 600 patients with cancer in New York also reports no increased risk of COVID-19 complications.

"During the COVID-19 pandemic, we may be able to deliver anticancer care safely to patients who are younger with limited comorbidities," the team concludes.

These data support continuing cancer treatment in younger patients under the age of 40, said Shah, adding that obesity and age are the main risk factors for worse COVID-19 outcomes.

A more conservative approach might be considered in older patients with metastatic cancer and multiple comorbidities, including obesity, who may be at higher risk of significant morbidity with COVID-19, Shah said. 

"In this context, if the benefit of treatment is marginal, it can be weighed against the risk of severe COVID-19 illness. So, oncologists with patients who have more risk factors, and are contemplating further therapy even after several lines of treatment have not worked, should consider the relative value of their treatment," he said.

How Representative Was NYC Cohort?

Experts approached for comment on the new study emphasized the need for more data, and also questioned just how representative the patients with cancer in this New York cohort were.  

Martin J. Edelman, MD, chair of the Department of  Hematology/Oncology at Fox Chase Cancer Center in Philadelphia, Pennsylvania, pointed out that the study cohort contained just a single patient with lung cancer.

"While perhaps a 'cancer diagnosis' by itself does not automatically result in a higher mortality, specific types of cancer/therapies/cancer populations/risk factors likely are [at higher risk]," he told Medscape Medical News.

"The publication in question has only one patient with lung cancer (the major cause of cancer death in the US)," Edelman noted. He pointed out that the  TERAVOLT analysis of over 1000 thoracic cancer patients with COVID-19 infection found that lung cancer patients with higher stage, smoking history, poorer performance status, and other factors were at risk for higher mortality.

Bhavana Pothuri, MD, a gynecologic oncologist at NYU Langone Perlmutter Cancer Center and professor of obstetrics and gynecology at NYU Grossman School of Medicine in New York, agreed that the dataset in the current study was limited.

"I think this needs to be evaluated in a group of patients with more comorbidities as the data may suggest something different," Pothuri told Medscape Medical News.

The New York team noted that 75% of the cohort had one or fewer morbidities. "This may explain why other medical conditions were not independently associated with a worse composite outcome or death," they say.

The analysis also revealed that 25% of the New York patient population was obese, a factor that was independently associated with an increased risk of composite outcome and death. "In NYC, a BMI of >25 kg/m2 was associated with a risk of hospital admission with COVID-19, but only a BMI >40 kg/m2 predicted critical illness, which accounted for 6% of the population studied," the investigators report.

Pothuri also noted that "only half of patients received treatment and the question remains whether this needs to be evaluated in a larger cohort of patients to determine if anti-cancer treatment really does impact COVID-19 outcomes." 

But her group has also found that patients with cancer may not be at increased risk from COVID-19 complications. They recently reported a case fatality rate of 14% among gynecologic oncology patients with COVID-19 infection. This is similar to what was reported in the general NYC population with COVID-19 during the initial surge, she said. Her group also found no association between cytotoxic chemotherapy and cancer‐directed surgery and COVID-19 severity or death.

Data from the current study "should provide comfort…in that patients with cancer do not have outcomes which differ from those who don't," Pothuri said. "Moreover, anti-cancer treatments did not seem to impact outcome and careful consideration to continue these treatments should be exercised."

The European Society of Medical Oncology (ESMO) issued expert consensus guidelines in July advising against cancellation or delay of cancer treatment that could impact survival. "We now need to step away from the assumption that all cancer patients are vulnerable to COVID-19," said first author Giuseppe Curigliano, MD, PhD, of the European Institute of Oncology, Milan, Italy, as reported at the time by Medscape Medical News.

Shah reported relationships with Astellas Pharma, Lilly Japan, Merck (Inst), Oncolys BioPharma (Inst), and Bristol-Myers Squibb (Inst). A number of study coauthors also disclosed relationships with industry. Edelman reported relationships with WindMiIL Therapeutics, Biomarker Strategies, Astra Zeneca, Takeda, Glaxo Smith Kline, Apexigen, Nektar, BMS, Armo, Bergen Bio, and Apexigen. Pothuri disclosed relationships with Tesaro/GlaxoSmithKline, AstraZeneca, Merck, Genentech/Roche, Clovis Oncology, Eisai, and Mersana.

J Clin Oncol.  Published online September 28, 2020. Full text

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