In a large nationwide analysis, Professor Evandro de Azambuja and colleagues assessed the impact of solid cancer on in-hospital mortality overall and among different subgroups of patients with COVID-19 following the first wave of the pandemic in Belgium.
Can you summarize the main results of this study? What was the most surprising outcome in youropinion?
“In this study, we worked in collaboration with the Belgian Society for Medical Oncology (BSMO) and Sciensano and analysed patients with solid tumours who were hospitalised and were diagnosed with COVID-19. Among 10,486 hospitalized patients, 8,5% had solid cancers. We analysed data of adult patients registered until 24 May 2020 in the Belgian nationwide database of Sciensano. The primary objective was in-hospital mortality within 30 days of COVID-19 diagnosis among patients with solid cancer versus patients without cancer. Severe event occurrence, a composite of intensive care unit admission, invasive ventilation and/or death, was a secondary objective. These endpoints were analysed across different patient subgroups. Patients with cancer were older and presented with less symptoms/signs and lung imaging alterations. The 30-day in-hospital mortality was found to be higher in patients with solid cancer in comparison to patients without cancer (31,7% vs 20,0%) which corresponds to a 34% higher likelihood of dying. This adverse prognostic effect was more pronounced among patients <60 years and/or those without other comorbidities. The adjusted OR was 3,84 (95% CI 1,94 to 7,59) among younger patients (<60 years) and 2,27 (95% CI 1,41-3,64) among patients without other comorbidities.”
Solid cancer appeared an independent adverse prognostic factor for in-hospital mortality among patients with COVID-19. This phenomenon was more pronounced among younger cancer patients and in those without other comorbidities. What can be the explanation for this?
“Indeed, this was a curious fact we saw with young patients. But we need to be aware of the fact that a proportion of older adults is expected to have had cancer before. They also often suffer from more indolent cancers, such as prostate cancer or hormone-receptor positive breast cancer, and are for those reasons less likely to receive immunosuppressive anticancer treatments compared with younger patients. And we have already established that these latter treatments increase the risk of severe COVID-19 or mortality. Moreover, given the poor COVID-19-related prognosis among older patients or among those with several comorbidities, the presence of cancer might not significantly worsen their already poor prognosis, and thus might have a smaller impact on COVID-19-related treatment decisions.”
‘Older cancer patients who contracted COVID-19 often stayed at home’
“On the other hand, among patients with a more favourable COVID-19-related prognosis (young age and/or absence of other comorbidities), the presence of cancer might significantly increase the risk of death. What we also need to be aware of is the fact that there was a lower degree of hospitalization among elderly patients, it was mostly younger patients who came to the hospital. Older cancer patients who contracted COVID-19 often stayed at home, and died there.”
What tailored containment measurements have been put in place in Belgian clinics for certain subgroups specifically?
“During the first wave of the pandemic, several measures were taken to prevent the spread of the pandemic. For instance, we switched to telemedicine: many consultations became phone calls and many physical appointments were postponed. Also breast surgeries have been moved to a later date whenever possible, and the use of neoadjuvant therapies, particularly endocrine therapy for luminal breast cancers, increased a lot. We needed to avoid as much as possible that cancer patients had to come to the hospitals. For that reason, we also gave preference for chemotherapies given at 3 weeks with G-CSF support. Meanwhile, the use of some subcutaneous instead of intravenous agents increased, in order to limit the time that patients had to stay in the hospital for their treatments.
Furthermore, we implemented rules regarding visits to clinics and hospitals, for instance we asked patients to come alone without accompanying partners unless really needed and in special occasions. We also sought to decrease contact among medical staff as well, by transforming many of our meetings, including tumour boards, to a virtual format, and this virtual format continues to this day, in order to minimize physical contact. Hygiene and protection methods have also heavily been implemented. In our hospital, as well as in most other hospitals, we created separate entrances and routes for patients without COVID-symptoms, for patients with possible COVID and for staff.”
‘We needed to avoid as much as possible that cancer patients had to come to the hospital’
How important is vaccination for cancer patients in your opinion? Which type of vaccination should be used preferably in patients with solid cancer and COVID-19?
“Vaccination strategies have been published worldwide, in order to prioritize vaccine administration in different populations. The World Health Organization (WHO) considers the elderly and healthcare professionals as first priorities, immediately followed by cancer patients. We have seen the same principle with the vaccination programme in the USA, where healthcare professionals are considered to be top priority for vaccination, followed by cancer patients and people over 65. Belgium, Luxembourg and Sweden have chosen to prioritize cancer patients and healthcare professionals at the same time.
Although no established safety concerns, different from the general population, are evident for patients with cancer, there is a clear need to generate data on preference of vaccine technology and interaction of the SARS-CoV-2 vaccines with antineoplastic therapies. We need to investigate the potential impact of the vaccines on efficacy, dosing or toxicity of anticancer therapies, via in-trial, post-trial and registry monitoring.
At this moment, we don’t have much information and all vaccines seem to be working. We do not exclude any cancer patient from receiving any type of vaccine. In collaboration with other European countries, we are launching a prospective study to investigate the percentage of protection of vaccines in cancer patients. We will have different cohorts with different tumour types and treatments. Patients will have a blood draw at 3, 6, and 12 months after the last dose of the vaccine, and we will look for antibody positivity in this patient population. This will enable us to determine how long antivirus protection will last. This study should start soon in 2021.”
De Azambuja E, Brandão M, Wildiers H, et al. Impact of solid cancer on in-hospital mortality overall and among different subgroups of patients with COVID-19: a nationwide, population-based analysis. ESMO Open. 2020 Sep;5(5):e000947.