By Ian Ingram

During the recent months of the pandemic, cancer patients undergoing active treatment saw their risk for death increase 15-fold with a COVID-19 diagnosis, real-world data from two large healthcare systems in the Midwest found.

Among nearly 40,000 patients who had undergone treatment for their cancer at some point over the past year, 15% of those diagnosed with COVID-19 died from February to May 2020, as compared to 1% of those not diagnosed with COVID-19 during this same timeframe, reported Shirish Gadgeel, MD, of the Henry Ford Cancer Institute in Detroit.

And in more than 100,000 cancer survivors, 11% of those diagnosed with COVID-19 died compared to 1% of those not diagnosed with COVID-19, according to the findings presented at the American Association for Cancer Research (AACR) COVID-19 and Cancer meeting.

"Certain comorbidities were more commonly seen in patients with COVID-19," said Gadgeel. "This included cardiac arrhythmias, renal failure, congestive heart failure, and pulmonary circulation disorders."

For their study, Gadgeel and colleagues examined data on 154,585 malignant cancer patients from 2015 to the present day with active cancer or a history of cancer treated at two major Midwestern health systems. Among the 39,790 patients with active disease, 388 were diagnosed with COVID-19 from February 15 through May 13, 2020. For the 114,795 patients with a history of cancer, 412 were diagnosed with COVID-19.

After adjusting for multiple variables, older age (70-99 years) and several comorbid conditions were significantly associated with increased mortality among COVID-19 patients with active cancer:

Older age: OR 3.4 (95% CI 1.3-9.3)

Diabetes: OR 3.0 (95% CI 1.5-6.0)

Renal failure: OR 2.3 (95% CI 1.1-4.9)

Pulmonary circulation disorders: OR 3.9 (95% CI 1.4-10.5)

In COVID-19 patients with a history of cancer, an increased risk for death was seen for those ages 60 to 69 years (OR 6.3, 95% CI 1.1-35.3), 70 to 99 years (OR 18.2, 95% CI 3.9-84.3), and those with a history of coagulopathy (OR 3.0, 95% CI 1.2-7.6).

Despite Black patients consisting of less than 10% of the total study population, Gadgeel noted that 39.4% of COVID-19 diagnoses in the active cancer group were among Black patients, as were a third of diagnoses in the cancer survivor group.

And the proportion of COVID-19 patients with a median household income below $30,000 was also higher in COVID-19 patients in both groups, he added.

COVID-19 carried a far greater chance for hospitalization, both for patients with active cancer (81% vs 15% for those without COVID-19) as well as those with a history of cancer (68% vs 6%), with higher hospitalization rates among Black individuals and those with a median income below $30,000. Even younger COVID-19 patients (<50 years) saw high rates of hospitalization, at 79% for those with active cancer and 49% for those with a history of the disease.

While few cancer patients without COVID-19 required mechanical ventilation (≤1%) during the study period, 21% of patients with active disease and COVID-19 needed ventilation, as did 14% of those with a history of cancer, with higher rates among those with a history of coagulopathy (36% and 23%, respectively).

CCC-19 Data Triples in Size

Another study presented during the meeting again showed higher mortality rates for cancer patients with COVID-19, with lung cancer patients appearing to be especially vulnerable.

Among 2,749 cancer patients diagnosed with COVID-19, 60% required hospitalization, 45% needed supplemental oxygen, 16% were admitted to the intensive care unit, and 12% needed mechanical ventilation, and 16% died within 30 days, reported Brian Rini, MD, of Vanderbilt-Ingram Cancer Center in Nashville, Tennessee.

"When COVID first started there was a hypothesis that cancer patients could be at adverse outcome risk due to many factors," said Rini, noting their typically "advanced age, presence of comorbidities, increased contact with the healthcare system, perhaps immune alterations due to their cancer and/or therapy, and decreased performance status."

Rini was presenting an updated analysis of the COVID-19 and Cancer Consortium (CCC-19), which now includes 114 sites (includes comprehensive cancer centers and community sites) collecting data on cancer patients and their outcomes with COVID-19.

Initial data from the consortium, of about 1,000 patients, were presented earlier this year at the American Society of Clinical Oncology (ASCO) annual meeting and published in The Lancet. The early analysis showed that use of hydroxychloroquine and azithromycin to treat COVID-19 in cancer patients was associated with a nearly threefold greater risk of dying within 30 days.

Notably, in the new analysis, decreased all-cause mortality at 30 days was observed among the 57 patients treated with remdesivir alone, when compared to patients that received other investigational therapies for COVID-19, including hydroxychloroquine (adjusted odds ratio [aOR] 0.41, 95% CI 0.17-0.99) and a trend toward lower mortality when compared to patients that received no other investigational therapies (aOR 0.76, 95% CI 0.31-1.85).

Cancer status was associated with a greater mortality risk. Compared to patients in remission, those with stable (aOR 1.47, 95% CI 1.07-2.02) or progressive disease (aOR 2.96, 95% CI 2.05-4.28) were both at increased risk of death at 30 days.

Mortality at 30 days reached 35% for patients with an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or higher, as compared to 4% (aOR 4.22, 95% CI 2.92-6.10).

"As you start to combine these adverse risk factors you get into really high mortality rates," said Rini, with highest risk seen among intubated patients who were either 75 and older (64%) or had poor performance status (75%).

"There are several factors that are starting to emerge as relating to COVID-19 mortality in cancer patients," said Rini during his presentation at the AACR COVID-19 and Cancer meeting. "Some are cancer-related, such as the status of their cancer and perhaps performance status, and others are perhaps unrelated, such as age or gender."

Other factors that were significantly associated with higher mortality included older age, male sex, Black race, and being a current or former smoker, and having a hematologic malignancy.

"Importantly, there were some factors that did not reach statistical significance," said Rini, including obesity.

"Patients who received recent cytotoxic chemotherapy or other types of anti-cancer therapy, or who had recent surgery were not in the present analysis of almost 3,000 patients at increased risk," he continued. "I think this provides some reassurance that cancer care can and should continue for these patients."

For specific cancer types, mortality was highest in lung cancer patients (26%), followed by those with lymphoma (22%), colorectal cancer (19%), plasma cell dyscrasias (19%), prostate cancer (18%), breast cancer (8%), and thyroid cancer (3%).

"The COVID mortality rate in cancer patients appears to be higher than the general population," said Rini. "Lung cancer patients appear especially vulnerable by our data, as well as TERAVOLT's."