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People with cancer who get the new coronavirus appear to be at increased risk for severe disease and death from COVID-19, but this may depend on their stage of cancer and the type of treatment they are receiving, according to recent research. In fact, people with early-stage cancer can do as well as people who have not had cancer.
Researchers from some of the earliest and most affected epicenters of the COVID-19 pandemic described the results among cancer patients with the coronavirus (officially known as SARS-CoV-2) during a special session of the Association’s annual virtual meeting. American for Cancer Research (AACR) last week. Shortly after the conference, another group of researchers published a mortality analysis among cancer patients in New York City.
Early reports from China, where the pandemic originated in late December, showed that older people, those with compromised immune systems, and those with underlying health conditions are more susceptible to severe COVID-19. One study found a 6% death rate for people with cancer, more than double the estimated death rate for COVID-19 in China, but lower than the rates seen for people with diabetes (7%) or cardiovascular disease (eleven). %)
Chemotherapy drugs and some targeted cancer therapies can cause neutropenia, a temporary depletion of white blood cells in the immune system that fight infection. People who receive bone marrow stem cell transplants or CAR-T therapy or for blood cancers usually receive strong chemotherapy to remove existing blood cells and make room for new ones. Conversely, immunotherapies, such as checkpoint inhibitors and CAR-T therapy, trigger natural or genetically engineered T cells to fight cancer, which in some cases can trigger an excessive immune response leading to damaging inflammation .
Two reports at the AACR meeting provided updates from China. Li Zhang, MD, PhD, of Tongji Medical College described the results among 28 cancer patients with COVID-19 in Wuhan, the initial epicenter of the pandemic.
Seven had lung cancer and the rest had 13 other types of cancer. Just over a third had stage IV or metastatic cancer. Almost 30% acquired the coronavirus at medical facilities. Approximately half had severe disease, 10 patients required mechanical ventilators and eight died, mainly from acute respiratory distress syndrome, giving a 29% mortality rate.
Although three-quarters had undergone surgery, radiation, or chemotherapy, most had not recently received treatment. Only one person received radiation, three received chemotherapy, two received targeted therapy, and one received immunotherapy within two weeks prior to their COVID-19 diagnosis. Recent cancer treatment was associated with a fourfold increased risk of serious outcomes. However, the only patient treated with a checkpoint inhibitor (for liver cancer) had mild COVID-19 and a short hospital stay.
Similarly, as part of his discussion on immunotherapy for cancer in the COVID-19 era, Paolo Ascierto, MD, of the National Tumor Institute in Naples, noted that only two out of 400 immunotherapy patients at his institute tested positive. from the coronavirus, they were asymptomatic and recovered quickly, leading him to speculate that immunotherapy might somehow protect against COVID-19.
Dr. Hongbing Cai, from Zhongnan Hospital of Wuhan University, presented data on 105 cancer patients and 536 people without cancer of similar age at 14 hospitals in Hubei province who developed COVID-19. The results were also published on Cancer Discovery. Twenty-two had lung cancer, 13 had gastrointestinal cancers, 11 each had breast cancer and thyroid cancer, nine had blood cancers such as leukemia or lymphoma, which affect white blood cells that carry out immune responses, and six had cancer. cervical and esophageal. .
“Overall, cancer patients deteriorated faster than cancer-free patients,” Cai’s team reported. Cancer patients with COVID-19 were almost three times more likely to have a serious or critical illness (34%), to be admitted to an ICU intensive care unit (19%) or to receive a ventilator (10% ). Additionally, people with cancer were approximately twice as likely to die as COVID-19 patients without cancer (11% versus 5%, respectively).
People with blood cancer or lung cancer, as well as those with metastatic cancer, had an increased risk of serious events. Two-thirds of blood cancer patients and half of lung cancer patients had such events. Among lung cancer patients, 18% received ventilators and 18% died. In contrast, no one with breast, thyroid, or cervical cancer required ventilators or died.
In particular, those with blood cancers, more than half of whom had severe immune suppression, had an approximately 10-fold increased risk of serious events or death. Two thirds had severe symptoms, 22% were placed on ventilators, and 33% died. “All of these patients had a rapidly impaired clinical course once infected with COVID-19,” the researchers wrote.
People with metastatic cancer had a six-fold increased risk of serious events or death. But people whose cancer had not yet spread were not significantly more likely to have serious events or die than COVID-19 patients without cancer. People who are currently on cancer treatment and those with a history of cancer who had completed treatment were at increased risk.
People who had surgery in the past 40 days had higher rates of serious events, ICU admission, ventilator use, and death, but this was not the case for those who received radiation only. In this study, unlike Zhang and Ascierto, people treated with immunotherapy did not fare as well. Four of the six patients who recently received checkpoint inhibitors had critical symptoms and two died.
“Based on our analysis, COVID-19 cancer patients tend to have more severe outcomes compared to the noncancerous population,” the researchers wrote. “Although COVID-19 is reported to have a relatively low death rate of 2% to 3% in the general population, cancer and COVID-19 patients not only have a nearly threefold increase in death rate than the of COVID- 19 cancer-free patients, but they also tend to have a much greater severity of their disease.
In a related study, Marina Chiara Garassino, MD, from the Fondazione IRCCS National Tumor Institute in Milan, presented the first data from the international registry TERAVOLT, which is collecting data on COVID-19 among people with lung cancer and other thoracic malignancies. He noted that TERAVOLT recorded around 70 new cases per week worldwide per week.
This population may be especially vulnerable to COVID-19 due to advanced age, lung damage, smoking and underlying health conditions, Garassino said. Furthermore, the symptoms of COVID-19 overlap with lung cancer, making the diagnosis very challenging.
Garassino described the results of the first 200 cancer patients with COVID-19 in more than 20 countries. Non-small cell lung cancer was the most common type, and nearly three-quarters had metastatic disease. About 20% received targeted therapy alone, 33% received chemotherapy alone, and 23% received immunotherapy alone.
Most (76%) were hospitalized, but most were not offered intensive care for COVID-19; only 9% were admitted to an ICU and 3% were placed on ventilators. More than a third (35%) died, mainly from COVID-19 instead of cancer. Specific types of cancer treatment were not significantly associated with an increased risk of death.
But not all studies have seen worse COVID-19 results among people with cancer. Fabrice Barlesi, MD, PhD, and colleagues observed 137 COVID-19 cancer patients at Gustave Roussy, a cancer center near Paris. They had a variety of cancers, with blood cancers and breast cancer being the most common. Almost 60% had advanced active disease, while 40% were in remission or undergoing treatment with potentially curative therapy.
Within this group, 25% had worsened COVID-19 after admission, 11% were admitted to the intensive care unit (ICU), and 15% died. Again, people with blood cancer were more likely to have worse results. Chemotherapy treatment in the last three months, but not targeted therapy or immunotherapy, doubled the likelihood of worsening disease. But this only applied to people with active or metastatic cancer, not those with localized disease or in remission.
The 15% death rate among people with cancer in Gustave Roussy was lower than the 18% rate for all COVID-19 patients in Paris and France, Barlesi said. His team concluded that both the incidence and outcomes of COVID-19 among cancer patients appear to be comparable with the general population. However, people with blood cancer, those treated with chemotherapy, and fragile patients are at higher risk.
Discussing how to manage cancer patients during the COVID-19 pandemic, Cai recommended isolation of self-protection, strict infection control in hospitals, and the change of some online medical services.
Regarding cancer treatment, he said, doctors should develop individualized plans based on the type of tumor and the stage of the patient’s disease. He added that postponing surgery, if applicable, should be considered in areas with current outbreaks. Radiotherapy, he said, could continue according to existing treatment plans with intensive protection and surveillance. He said whether people with early-stage cancer need to postpone their treatment remains an unanswered question.
Click here to read summaries of the AACR COVID-19 and Cancer session.
Learn about “What people with cancer need to know about the new coronavirus.”
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