Racial/ethnic disparities of cancer treatment disruptions among patients with breast cancer with SARS-CoV-2 infection: An analysis of the ASCO Survey on COVID-19 in Oncology Registry

Background: The COVID-19 pandemic has led to disruptions in cancer treatment delivery among breast cancer patients in the U.S. However, it is currently unknown whether racial/ethnic disparities exist in cancer treatment disruptions among patients with breast cancer and SARS-CoV-2 infection. Methods: We obtained data from the ASCO Survey on COVID-19 in Oncology Registry (March 2020-July 2021) describing breast cancer patients diagnosed with SARS-CoV-2 during their care treated at 46 practices across the US. Data included patient demographics, SARS-CoV-2 diagnosis and treatment, breast cancer characteristics, and modifications to cancer treatment plans. Breast cancer treatment delay or discontinuation (TDD) was defined as any treatment postponed more than two weeks from the originally scheduled date. We computed adjusted odds ratios (aOR) using multivariable logistic regression, accounting for non-independence of patients within hospitals to evaluate racial/ethnic disparities of TDD. Multivariable models were adjusted for age, sex, number of comorbidities, cancer extent, ECOG performance score, pandemic period based on case peaks (< 06/2020, 06-12/2020, 01-07/2021), and COVID-19 severity (death/hospitalization/ICU admission/mechanical ventilation). Results: Breast cancer patients (n = 804) with SARS-CoV-2 were mostly aged 50 years and above (75%) and urban residents (83%). The racial/ethnic makeup of the sample included: 13.3% non-Hispanic Black/African American (NH-Black), 11.7% Hispanic/Latinx, 4.9% American Indian/Alaskan Native (NH-AI/ AN), 4.6% NH-Asian, and 65% NH-White. At SARS-CoV-2 diagnosis, 736 patients (91%) were scheduled to receive drug-based therapy (78%), radiation therapy (8%), or surgery (6%), of whom 39% experienced TDD. Across treatment modalities, the most commonly reported TDD reason from the clinic perspective was the patient's COVID-19 disease (∼90%). Overall, NH-Black (62%), Hispanic/Latinx (44%), and NH-Asian (42%) adults with breast cancer and SARS-CoV-2 were more likely to experience TDD versus NH-White adults (34%) (p < 0.001). In multivariable analyses, NH-Black cancer patients were more likely to experience TDD compared to NH-White patients (aOR: 3.12, 95% CI: 1.96-5.47). The data suggest Hispanic/Latinx (aOR: 1.34, 95% CI: 0.78-2.30) breast cancer patients may also experience TDD, although not statistically significant. No association was observed among NH-Asian (aOR: 1.16, 95% CI: 0.50-2.73) or NH-AI/AN (aOR: 0.64, 95% CI: 0.28-1.52) breast cancer patients with TDD. Conclusions: Black or African American breast cancer patients are more likely to experience cancer care disruptions during the pandemic. Future research should evaluate the long-term impacts of care disruptions on breast cancer outcomes among minoritized US communities.

The role of rurality in cancer treatment disruptions among patients with cancer diagnosed with SARS-CoV-2: An analysis of the ASCO Survey on COVID-19 in Oncology Registry

Background: U.S. rural cancer patients experience multifactorial barriers to cancer treatment;however, little is known about the impact of the pandemic on cancer treatment delays or discontinuations (TDD) in the rural context. Our objective was to evaluate the role of rurality at both the patient and clinic level on cancer TDD among patients living with cancer with SARS-CoV-2 infection. Methods: We used data from the ASCO Survey on COVID-19 in Oncology Registry (March 2020-July 2021), which includes cancer patients diagnosed with SARS-CoV-2 (n = 3193). Data included patient demographics, SARSCoV- 2 treatment, cancer characteristics, and modifications to cancer treatment plans. Cancer-related TDD was defined as any treatment postponed > two weeks from the original scheduled date. Rurality was defined using the USDA Rural-Urban Commuting Area schema. We compared cancer characteristics, COVID-19 outcomes, and TDD by rurality of cancer patients, and TDD by rurality of oncology practices. We computed adjusted odds ratios (aOR) using multivariable logistic regression to evaluate rurality with TDD adjusting for age, race/ethnicity, sex, comorbidities, ECOG score, cancer extent, pandemic time period based on case peaks (< 06/2020, 06-12/2020, 01-07/2021), and COVID-19 severity. Results: Rural cancer patients (n = 499, 16%) with SARS-CoV-2 were mostly over 50 years (87%), female (57%), and NH-White (81%) with solid tumors (76%). Most rural patients received oncology treatment in urban areas (65%, p < 0.001). Rural patients were less likely to receive care through telemedicine (18%) compared to urban patients (26%) (p < 0.001). At SARS-CoV-2 diagnosis, rural patients were scheduled to receive drug-based therapy (72%), radiation therapy (8%), surgery (4%), or transplant (1%). Rural versus urban cancer patients with SARS-CoV-2 were less likely to experience TDD (41% vs. 51%) (p < 0.001). Among patients treated at rural oncology clinics, urban cancer patients were more likely to experience TDD (65%) compared with rural patients (47%) (p < 0.001). Similarly, among patients treated at urban oncology clinics, urban cancer patients were also more likely to experience TDD (51%) compared with rural patients (38%) (p < 0.001). In multivariable analyses, rural cancer patients were 28% less likely to experience TDD (aOR:0.72, 95% CI: 0.55- 0.94) than urban cancer patients. Oncology practice rurality was not associated with TDD (aOR: 1.19, 95% CI: 0.81-1.76). Conclusions: Rural cancer patients were less likely to experience TDD than urban patients supporting the urban-rural paradox i.e., geographic distance to cancer care facilities is not consistently associated with treatment delivery in expected ways. Future work should focus on area-level factors of the rural cancer patient experience to disentangle potential reasons for TDD during the pandemic.

Disparities in cancer treatment delays or discontinuation among cancer patients diagnosed with SARS-CoV-2 infection: An analysis of the U.S. ASCO COVID-19 and cancer registry

Background: Due to societal factors in the US, racial/ethnic minority adults are disproportionately impacted by the COVID-19 pandemic, particularly those with existing comorbid conditions such as cancer. It is currently unknown whether disparities exist in cancer treatment delivery among racial/ethnic minority patients with cancer and SARS-CoV-2. Methods: Data were obtained from the ASCO COVID-19 and Cancer Registry (March 2020-July 2021), including data from cancer patients diagnosed with SARS-CoV-2 during their care (n=3193) at 60 practices across the US. Data included patient demographics, SARS-CoV-2 diagnosis and treatment, cancer clinical characteristics, and modifications to cancer treatment plans. Cancer treatment delay or discontinuation (TDD) was defined as any treatment postponed more than two weeks from the original scheduled date. We descriptively evaluated demographic and clinical characteristics, compared disparities in TDD by race/ethnicity and urban/rural residency, and evaluated reasons for TDD as reported by the clinics. We computed adjusted odds ratios (aOR) using multivariable logistic regression, accounting for non-independence of patients within hospitals to evaluate racial/ethnic disparities of TDD. Multivariable models were adjusted for age, sex, body mass index, number of comorbidities, cancer type, cancer extent, cancer status at SARS-CoV-2 diagnosis (progressing/stable) and SARS-CoV-2 severity (death/hospitalization/ICU admission/mechanical ventilation). Results: Cancer patients with SARS-CoV-2were mostly female (57%), urban residents (84%), and NH-White (66%);49% were 65+ years old. Most patients had solid tumors (75%). At SARS-CoV-2 diagnosis, 2403 patients (76%) were scheduled to receive drug-based therapy (69%), radiation therapy (7%), surgery (4%), or transplant (0.7%), of whom 49% experienced TDD. The most reported TDD reason from the clinic perspective was the patient's COVID-19 disease (90%). Overall, NH-Black (64%) and Hispanic (57%) with SARS-CoV-2 were more likely to experience TDD versus NH-White adults (46%) (p<0.001). This disparity was also observed across urban residing adults (p<0.001). Among rural adults, NH-AI/AN (75%) and NH-Black (61%) were more likely to experience TDD versus NH-White patients (39%). In multivariable analyses, disparities persisted, by NH-Black cancer patients with 92% (aOR:1.92, 95% CI:1.24-2.96) and Hispanic patients with 41% (aOR:1.41, 95% CI:1.03-1.91) higher odds of experiencing TDD. We observed consistent results among urban and rural subgroups. Conclusion: Racial/ethnic disparities exist in TDD among cancer patients with SARS-CoV-2 in urban and rural care settings. Future studies should evaluate the impacts of delays to cancer treatment delivery on cancer outcomes among minoritized communities in the US.

Feasibility of Smartphone-Based Physical Activity Tele-Coaching in Lung Transplant Recipients;an Interim Analysis

Purpose: The COVID-19 pandemic has increased the demand for tele-medicine, particularly for lung transplant (LTX) recipients who are immunosuppressed and often live far from transplant centres. We report the feasibility of a 3-month semi-automated tele-coaching intervention in this population. Methods: The intervention consists of a pedometer and smartphone app, allowing transmission of activity data to a platform (Linkcare v2.7) that provides feedback, activity goals, education and contact with the researcher as required. Remote assessment pre- and post-intervention included patient acceptability using a project specific questionnaire, physical activity using accelerometry (Actigraph GT3X), HADS and the SF-36 questionnaire. Results: So far, all eligible patients approached were willing to be randomised to the intervention or usual care (n=14;COPD=4, ILD=7;CF=1;PH=2). For the intervention, usage of the pedometer was excellent, with patients wearing it for 6.9±0.1 days/week and rating the pedometer and telephone contact (9±2 out of 10) as the most vital aspects. Patient feedback has been positive, with 80% of patients responding that they ‘liked’ taking part and that it ‘helped them a lot’ to increase their activity levels. Daily steps and VMU are presented in Figure 1 and SF-36 scores in Figure 2. There were no changes in HADS scores between groups. Conclusion: Tele-coaching appears feasible in LTX recipients, with patients showing excellent adherence and providing positive feedback after 3 months. This is promising, with the on-going need to develop and evaluate ways of supporting patients remotely.

Feasibility of smartphone-based physical activity tele-coaching in lung transplant recipients

S21 Figure 1Daily steps using accelerometry (Actigraph GTX3), at baseline (hospital discharge), 3 months and 6 months for lung transplant recipients assigned to the intervention group (n=5)[Figure omitted. See PDF]ConclusionTele-coaching appears feasible in lung transplant recipients, with patients wearing the pedometer and interacting well with the app over 3 months. This is promising in the current climate, with the need to develop and evaluate innovative ways of supporting patients remotely.

The impact of covid-19 shielding on levels of Physical activity and health-related quality of Life in COPD patients following pulmonary Rehabilitation

Introduction To prevent infection during the peak of the COVID-19 pandemic, COPD patients were instructed to 'shield', resulting in restrictions to usual daily activities, potentially negating health benefits attained during pulmonary rehabilitation (PR). The aim of this study was to determine the impact of a shielding period on physical activity levels and health-related quality of life (HRQoL) in COPD patients who completed a course of supervised PR before shielding in March 2020 Methods COPD patients who completed an 8-week PR course between January and March 2020 were enrolled into this single centre, observational cohort study. Physical activity was measured using accelerometry (Actigraph wGT3X) and the Clinical Visit of Proactive Physical Activity in COPD (CPPAC) instrument (that captures the domains of amount and difficulty of physical activity;Gimeno-Santos et al. ERJ 2015) in the week preceding PR, the week following completion of PR and for a week 3 months following completion of PR during the shielding period (April to July 2020). Additionally, assessment of HRQoL (COPD Assessment Test [CAT] and Clinical COPD Questionnaire [CCQ]) and psychological wellbeing (Hospital Anxiety and Depression Scale [HADS]) was undertaken. Results In ten COPD patients (FEV1: 55±23% predicted), a significant and clinically meaningful decrease in daily steps was shown from post-PR to shielding (4129±2245 versus 2508±1186 steps/day;p=0.030), as well as pre-PR to shielding (3681±2025 versus 2508±1186 steps/day;p=0.015). Likewise, there was a significant and clinically meaningful worsening in the C-PPAC score from post-PR to shielding (68 ±13 versus 59±13 points;p=0.060), but not pre-PR to shielding (61±11 versus 59±13 points;p=1.000). There were no statistically or clinically meaningful changes in HADS and CAT scores. However, the worsening in CCQ scores from post-PR to shielding did exceed clinically meaningful margins (±0.4 points) for both functional (+0.5 points) and mental domains (+0.7 points). Conclusions In COPD, the shielding period had a negative impact on physical activity levels, evidenced by reduced daily steps compared to not only post-PR, but also pre-PR. This decline below baseline values could have led to further physical deconditioning, potentially reversing some of the benefits gained during PR and worsening long term disease-related outcomes.

P239 The impact of COVID-19 shielding on levels of physical activity and health-related quality of life in COPD patients following pulmonary rehabilitation

IntroductionTo prevent infection during the peak of the COVID-19 pandemic, COPD patients were instructed to ‘shield’, resulting in restrictions to usual daily activities, potentially negating health benefits attained during pulmonary rehabilitation (PR). The aim of this study was to determine the impact of a shielding period on physical activity levels and health-related quality of life (HRQoL) in COPD patients who completed a course of supervised PR before shielding in March 2020.MethodsCOPD patients who completed an 8-week PR course between January and March 2020 were enrolled into this single centre, observational cohort study. Physical activity was measured using accelerometry (Actigraph wGT3X) and the Clinical Visit of Proactive Physical Activity in COPD (C-PPAC) instrument (that captures the domains of amount and difficulty of physical activity;Gimeno-Santos et al. ERJ 2015) in the week preceding PR, the week following completion of PR and for a week 3 months following completion of PR during the shielding period (April to July 2020). Additionally, assessment of HRQoL (COPD Assessment Test [CAT] and Clinical COPD Questionnaire [CCQ]) and psychological wellbeing (Hospital Anxiety and Depression Scale [HADS]) was undertaken.ResultsIn ten COPD patients (FEV1: 55±23% predicted), a significant and clinically meaningful decrease in daily steps was shown from post-PR to shielding (4129±2245 versus 2508±1186 steps/day;p=0.030), as well as pre-PR to shielding (3681±2025 versus 2508±1186 steps/day;p=0.015). Likewise, there was a significant and clinically meaningful worsening in the C-PPAC score from post-PR to shielding (68±13 versus 59±13 points;p=0.060), but not pre-PR to shielding (61±11 versus 59±13 points;p=1.000). There were no statistically or clinically meaningful changes in HADS and CAT scores. However, the worsening in CCQ scores from post-PR to shielding did exceed clinically meaningful margins (±0.4 points) for both functional (+0.5 points) and mental domains (+0.7 points).ConclusionsIn COPD, the shielding period had a negative impact on physical activity levels, evidenced by reduced daily steps compared to not only post-PR, but also pre-PR. This decline below baseline values could have led to further physical deconditioning, potentially reversing some of the benefits gained during PR and worsening long term disease-related outcomes.

Origin and cross-species transmission of bat coronaviruses in China.

Bats are presumed reservoirs of diverse coronaviruses (CoVs) including progenitors of Severe Acute Respiratory Syndrome (SARS)-CoV and SARS-CoV-2, the causative agent of COVID-19. However, the evolution and diversification of these coronaviruses remains poorly understood. Here we use a Bayesian statistical framework and a large sequence data set from bat-CoVs (including 630 novel CoV sequences) in China to study their macroevolution, cross-species transmission and dispersal. We find that host-switching occurs more frequently and across more distantly related host taxa in alpha- than beta-CoVs, and is more highly constrained by phylogenetic distance for beta-CoVs. We show that inter-family and -genus switching is most common in Rhinolophidae and the genus Rhinolophus. Our analyses identify the host taxa and geographic regions that define hotspots of CoV evolutionary diversity in China that could help target bat-CoV discovery for proactive zoonotic disease surveillance. Finally, we present a phylogenetic analysis suggesting a likely origin for SARS-CoV-2 in Rhinolophus spp. bats.

Origin and cross-species transmission of bat coronaviruses in China (preprint)

Bats are presumed reservoirs of diverse coronaviruses (CoVs) including progenitors of Severe Acute Respiratory Syndrome (SARS)-CoV and SARS-CoV-2, the causative agent of COVID-19. However, the evolution and diversification of these coronaviruses remains poorly understood. We used a Bayesian statistical framework and sequence data from all known bat-CoVs (including 630 novel CoV sequences) to study their macroevolution, cross-species transmission, and dispersal in China. We find that host-switching was more frequent and across more distantly related host taxa in alpha-than beta-CoVs, and more highly constrained by phylogenetic distance for beta-CoVs. We show that inter-family and -genus switching is most common in Rhinolophidae and the genus Rhinolophus. Our analyses identify the host taxa and geographic regions that define hotspots of CoV evolutionary diversity in China that could help target bat-CoV discovery for proactive zoonotic disease surveillance. Finally, we present a phylogenetic analysis suggesting a likely origin for SARS-CoV-2 in Rhinolophus spp. bats.