The impact of COVID-19 is being felt at the American Society of Clinical Oncology (ASCO) annual meeting as much as anywhere else, typically held at McCormick Place in Chicago but this year conducted virtually because of the pandemic.
At a press briefing ahead of the meeting’s official Friday start, ASCO highlighted an analysis that examined all-cause 30-day mortality in 525 cancer patients also diagnosed with COVID-19. Cancer progression and treatment with both hydroxychloroquine and azithromycin were associated with a 5.2-fold and 2.89-fold greater risk of death at 30 days compared with patients in remission/with no evidence of disease. Lead author Jeremy Warner, associate professor of medicine and biomedical informatics at Vanderbilt University Medical Center in Nashville, called the data “early and evolving” but “provocative.”
Specifically, 13% of patients (121) died within 30 days of COVID-19 diagnosis. After partial adjustment for several baseline factors, patients with progressing cancer were found to be 5.2 times more likely to die within 30 days compared with patients in remission or with no evidence of disease. Although the use of the hydroxychloroquine/azithromycin pair to treat COVID-19 was associated with a 2.89-fold greater risk of 30-day mortality than use of neither drug, there was no significant increase in risk associated with the use of either drug alone. Patients who received the combo and later died were more likely to have had slightly diminished daily physical function, received cancer therapy less than two weeks before their COVID-19 diagnosis, have Rh-positive blood type, be of non-Hispanic ethnicity, and use statins at baseline, ASCO said.
Warner said about 20% got the combo and 10% hydroxychloroquine alone. “One of the notable things is that only two of these patients got these drugs as part of a clinical trial,” he said, with the rest prescribed off label. “Since these drugs are generally available, it’s at the discretion of the treating provider, but still notable.” Being in the hospital made getting the drugs more likely, he said, but noted that “hospitalization policies vary from country to country as well as from region to region. Taking hospitalization as a proxy for the criticality of illness is something to be done with caution.”
Diminished ability to perform daily living activities – measured by an Eastern Cooperative Oncology Group (ECOG) Performance Status score of two or greater – was associated with a 3.89 times greater risk of 30-day mortality compared with greater physical ability (ECOG score of 0/1). Risk of death at 30 days increased nearly twofold (1.83) with each decade of life. Stable, non-progressing cancer was associated with a 1.79 times greater risk of death than no evidence of disease, and men had a 1.63 times greater risk of 30-day mortality than women. Former smokers had a 1.6 times greater risk of mortality than non-smokers.
The researchers also reported on clinical outcomes, too. Half of patients included in this analysis (466) were hospitalized following onset of the virus. Overall, 14% of patients were admitted to the intensive care unit. Mechanical ventilation was required for 12%, and additional oxygen was required by 44%.
Data were taken from the COVID-19 & Cancer Consortium registry, which is open to site-level participation in the U.S. and Canada and to inclusion of anonymized individuals in Argentina, Canada, the European Union, the U.S. and the U.K. As of April 16, 2020, half of patients in the registry were men; half white, 16% black, 16% Hispanic, and 15% other races and ethnicities. Breast cancer (21%) was the most common cancer, followed by prostate (16%), gastrointestinal (12%), lymphoma (11%) and thoracic (10%). In all, 43% of patients had active (measurable) cancer, 39% were on cancer treatment and 45% were in remission.
Investigators plan to conduct further analyses on this dataset and longer follow-up as the registry continues to accrue. Funding for the work was provided in part by the NIH and the American Cancer Society.
The crossing of COVID-19 and cancer surfaced in another study that ASCO chose to put center stage. Results of an analysis of 400 patients showed that chemotherapy given within three months of a virus diagnosis was associated with an increased risk of death by 64% in patients with thoracic tumors.
Only patients treated with chemo (alone or in combination with other therapies) within three months of COVID-19 diagnosis had a significantly increased risk (64%) of dying from the virus compared with patients not receiving chemotherapy. Of the 144 patients who died, 79.4% (112) passed away due to COVID-19 and 10.6% (15) because of cancer. Patients with thoracic malignancies, which include lung cancer, mesothelioma, thymic neoplasms and carcinoid tumors, are considered high risk given their older age, multiple co-morbidities and pre-existing lung damage, among other factors, ASCO noted.
Treatment with anticoagulants and corticosteroids prior to COVID-19 were also associated with an increased risk of death. The risk has been cited previously of SARS-CoV-2 infection and of boosted severity of COVID-19 among those using corticosteroids for chronic disease. In the study, treatment with corticosteroids ahead of viral infection was associated with 1.5 times greater risk of death in patients with thoracic cancer, compared with patients not on corticosteroids. With regard to anticoagulants, the study had too few patients for multivariate analysis. More data will be needed to understand how COVID-19 affects clotting in patients with thoracic cancer, ASCO said. Factors such as pre-existing lung damage, smoking status, advanced age and co-morbidities make patients with thoracic cancers especially vulnerable to COVID-19.
The type of treatment given for COVID-19 didn’t seem to affect a patient’s risk of death. The proportions of patients receiving anticoagulants, antibiotics, antivirals, antifungals, corticosteroids, drugs targeting IL-6 and hydroxychloroquine were the same or similar for patients who recovered and those who died. Twenty-seven percent of patients who recovered received antibiotics vs. 27% who died; for anticoagulants, the number was 24% vs. 23%, for steroids 10% vs. 16%, and for hydroxychloroquine 23% vs. 19%.