ABSTRACT
Introduction: Cancer patients have been considered a high-risk population in the COVID-19 pandemic. We previously investigated risk of COVID-19 death in COVID-19 positive cancer patients during a median follow-up of 134 days, and identified the following risk factors: male sex, age >60 years, Asian ethnicity, hematological cancer type, cancer diagnosis for >2.5 years, patients presenting with fever or dyspnea, and high levels of ferritin and C-reactive protein (CRP). Here, we further investigate which factors are associated with a COVID-19 related death within 7 days of diagnosis. Methods: Using data from Guy's Cancer Centre and one of its partner trusts (King's College Hospital), we included 306 cancer patients with a confirmed COVID-19 diagnosis (February 29th-July 31st 2020). 72 patients had a COVID-19 related death (24%) of whom 35 died within 7 days (50%). Cox proportional hazards regression was used to identify which factors were associated with a COVID-19 related death <7 days of diagnosis. Results: Of the 72 cancer patients who had a COVID-19 related death, the mean age was 72 years (Standard Deviation (SD) 14). A total of 53 (74%) patients were men. 37 (52%) had a hematological cancer type, 47 (65%) had stage IV cancer, and 42 (58%) had been diagnosed with cancer more than 24 months before COVID-19 related death. In the group of patients who died within 7 days of diagnosis (n= 35), mean age was 73 years (SD 13.96), 24 (68%) were men, 20 (57%) had a hematological cancer type, 26 (74%) had stage IV cancer, and 24 (68%) had been diagnosed with cancer >24 months before COVID-19 diagnosis. Factors associated with COVID-19 related death <7 days of diagnosis were: hematological cancer (Hazard Ratio (HR): 2.74 (95% Confidence Interval (CI): 1.21-6.22)), 2-5 yrs since cancer diagnosis (HR: 4.81 (95%CI: 1.47-15.69)), and >5 yrs since cancer diagnosis (HR: 4.41 (95%CI: 1.38-14.06)). Additionally, patients who presented with dyspnea had increased risk of COVID-19 related death <7 days compared to asymptomatic patients (HR: 5.25 (95%CI 2.14-12.89)). CRP levels in the third tercile (146-528 mg/L) as compared to the first were also associated with increased risk of an early death due to COVID-19. Conclusion: From all the factors identified in our previous COVID-19 related death analysis, only hematological cancer type, a longer-established cancer diagnosis (2-5 years and more than 5 years), dyspnea at time of diagnosis and high levels of CRP were indicative of an early COVID-19 related death (within 7 days of diagnosis) in cancer patients.
ABSTRACT
Background: The Coronavirus disease 2019 (COVID-19) pandemic continues to have a significant impact on the treatment of cancer patients. Understanding the clinical course, potential risk factors for severe infection and excess mortality, is essential to improve patient outcomes. We previously presented preliminary results from 156 SARS-CoV-2 positive cancer patients from Guy's Cancer Center, which suggested that increased COVID-19 mortality was associated with a diagnosis of cancer for over 2 years, Asian ethnicity and being on palliative treatment. Herein, we present an updated analysis using data from Guy's Cancer Centre and a partner Hospital Trust (King's College Hospital), with an increased number of patients and an extended follow up. Methods: We performed an analysis of all cancer patients who had a positive RT-PCR nasal/throat swab for SARS-CoV-2 infection at our Centers between 29th February and 31st July 2020. Associations between patients' demographics, clinical characteristics, and laboratory investigations with COVID-19 severity and mortality, were assessed using Logistic regression and Cox proportional hazards models. Results: 306 SARS-CoV-2 positive cancer patients were included in the analysis with a median follow up of 134 days (IQR 32-156). 184 (60%) were male and 217 (71%) were aged over 60 (mean age: 66). The most common malignancies were haematological (38%) and urological-gynaecological (20%). 218 (71%) had mild/moderate COVID-19 and 88 (29%) had severe disease. The overall COVID-related mortality rate was 24%;19% in solid and 32% in haematological cancers. Male sex [OR: 1.84 (95%CI:1.08-3.13)], Asian ethnicity [3.86 (1.20-12.36)], haematological cancer type [2.16 (1.18-3.95)], being diagnosed with cancer for 2-5 years [3.74 (1.80-7.78)] or ≥5 years [3.06 (1.50-6.26)] and a ferritin > 1964 mcg/l [54.92 (5.90-511.33)] were all associated with a risk of developing severe COVID-19 disease. Similarly, male sex [HR:1.97 (95%CI:1.15-3.38)], Asian ethnicity [3.42 (1. 59-7.35)], haematological cancer type [2.03 (1.16-3.56)] as well as a cancer diagnosis for >2-5 years [2.81 (1.41-5.59)] or ≥5 years [2.13 (1.06-4.27)] and a ferritin > 1964 mcg/l [16.11 (3.81-68.17)] were associated with an increased risk of death from COVID-19. Age >60 [2.14 (1.15-3.98)] and a raised CRP [4.10 (1.66-10.10)] were also associated with COVID-19 death. An inverse relationship was observed between a raised albumin and COVID-19 related death [0.12 (0.03- 0.51)]. Performance status and treatment paradigm were not associated with COVID-19 severity or mortality. Conclusions: This study further substantiates the evidence for an increased risk of severe COVID-19 infection and mortality for male and Asian patients with cancer, and those with haematological malignancies or with a diagnosis of cancer for over 2 years. These risk factors should be taken into account when making clinical decisions for cancer patients during the pandemic.
ABSTRACT
Background: The provision of cancer services has been strongly impacted by the outbreak of SARS-CoV-2. Our Cancer Centre in South-East London treats about 8,800 patients annually (incl. 4,500 new diagnoses) and is one of the largest Comprehensive Cancer Centres in the UK. The first COVID-19 positive cancer patient was reported on 29 Feb 2020. Whilst we are dealing with the second wave of COVID-19, it is important to further evaluate safety of cancer treatments whilst balancing risks of COVID-19 infection and complications. Methods: Using descriptive statistics, we report on the patient/tumour characteristics as well as short-term clinical outcomes of those patients undergoing radical treatment (i.e. systemic anticancer treatment (SACT), surgery, or radiotherapy (RT)) for their cancer during the first wave as to help establish the clinical guidelines for the management of cancer patients in a SARS-CoV-2 epidemic. Results: Between March-July 2020, 1,553 patients underwent surgery, 1,125 received SACT, and 814 had RT. Compared to the same period in 2019, there was a decrease of 28% for surgery, 15% for SACT, and 10% for radiotherapy. Whilst surgery was performed on more male patients (58%), more women received SACT (75%) and RT (58%). The age distribution was similar between treatment arms, with the majority of patients aged 50 to 80 years. The most common tumour types were breast (21%), thoracic (20%), and urological (29%) for surgical treatment;breast (49%), gastrointestinal (18%), and gynaecological (10%) for SACT;and breast (40%), urology (25%), and head & neck (11%) for RT. Within SACT, 36% received combination therapy, 35% received systemic chemotherapy, 23% targeted therapy, 5% immunotherapy, and 2% biological therapy. In terms of oncological outcomes, outcomes were similar to pre-COVID-19 times;with 6 deaths at 30 days (<1%) for surgical patients and 36 readmissions (2%), 10 deaths (<1%) for SACT patients, and 52% of RT delivered with radical intent (which was the same in 2019). The COVID-19 infection rates for our patients were very low: 12 patients were positive pre-surgery (1%), 7 post-surgery (<1%), 17 SACT patients (2%) and 3 RT patients (<1%). No COVID-19 related deaths were registered for the surgical, SACT and RT patients. Conclusion: Whilst there was a decline in overall radical treatment, likely due to a delay in cancer diagnoses, those who did undergo their treatment were treated in a safe COVID-19 managed environment. Our findings highlight that cancer patients should have the confidence to attend hospitals and be reassured of the safety measurements taken.
ABSTRACT
Background: Early reports in the COVID-19 pandemic suggested higher mortality for cancer patients. The impact of potentially immunosuppressive systemic anti-cancer treatments (SACT) was unknown. This study analysed the delivery of SACT for patients with solid malignancies during the COVID-19 outbreak in 2020 compared to the same period in 2019 to inform future clinical decision-making. Methods: All patients receiving at least one SACT at Guy's comprehensive Cancer Centre during the COVID-19 outbreak for solid tumours (1st March- 31st May 2020) were compared to the same period in 2019. SARS-CoV2 infection was by positive RT-PCR test. Data collected: demographics, tumour type/stage and treatment (chemotherapy, immunotherapy (IO), biological-targeted (BT)). Results: 2125 patients received SACT in 2020, compared to 2450 in 2019 (13% decrease). Demographics were comparable with mean age of 62. 56% females in 2020 vs 54% in 2019, 85% vs 83% in the low socio-economic category, 63% vs 73% PS 0-1;30% vs 29% uro-gynaecological, 27% vs 24% breast and 20% vs 23% GI tumours. In 2020 compared to 2019, there was an increase in metastatic disease (71% vs 62%), decrease in CT (34% vs 42%), increase in IO (10% vs 6%), but similar rates of BT treatments (38% vs 37%). Treatment paradigms were similar in 2020 and 2019: neo/adjuvant (28% vs 29%), radical (4% vs 5%) and palliative (69% vs 67%). Earlier palliative treatments were prioritised in 2020 with significant increase in treatments in 1st-2nd line (72% vs 67%;p=0.02) and reduction in > 3rd line (12% vs 27%;p<0.05). 42 of 2125 patients (2%) developed SARS-CoV2 infections;38% GI, 26% breast with 69% on CT. Of 42 patients with COVID-19, 24 (57%) had severe infections and 6 (14%) resulted in COVID-related death. Conclusions: These data suggest that SACT does not put solid tumour patients at much a higher additional risk from COVID-19. Despite a 13% decline in treatment rates, radical and early palliative treatment were prioritised. There was a low frequency (2%) of SARS-CoV-2 infection;comparable to the 1.4% point prevalence rate in our cancer population. However, this was during national lockdown with limited COVID-19 testing. The next steps are to evaluate the impact of new variant strains and COVID vaccination programme. Legal entity responsible for the study: Guy's Real-World Evidence. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
ABSTRACT
Background: It is standard practice in our centre for patients to be given permanent skin marks during breastradiotherapy planning, for use as reliable landmarks in daily reproduction of their positioning for treatment. However,these permanent marks (tattoos) may have a significant psychological impact on patients (1). In recent years, therehave been technological advances in surface-guided radiotherapy techniques (SGRT) which may provide improvedset-up accuracy compared to permanent markers. Aims: 1. To evaluate if surface-guided set-up is as good, if notbetter, than set-up with permanent markers alone.2. To safely implement a permanent marker (PM) free, surface-guided set-up technique. Methods: A pilot study was conducted with tangents-only breast patients treated in freebreathing (FB). All treatments were delivered on Varian TrueBeam linear accelerators, with patients immobilised ona couch indexed breast board. The study group (n=20) were set up using PMs with adjustments guided by theAlignRT SGRT system to optimise patient positioning. Imaging (MV tangent images) was performed as perstandard protocol on fractions 1-3, 8 and 12. Additional imaging was performed if indicated. The translational androtational displacements calculated by the TrueBeam verification system for this group were compared to averagedisplacements calculated for patients set up using PMs alone (the control group, n=20). Encouraged by the resultsof the pilot study, the centre moved to safely roll-out the PM-free technique to include additional applications. Thestep-wise approach taken will be described. Results: The mean displacements calculated from the verificationimaging are shown in Table 1 below: SGRT set-up demonstrated statistically-significant improvements compared to PM set-up alone with respect tolateral, vertical and total translational displacements. Longitudinal displacements favoured PM set-up alone but thisdid not reach statistical significance. Rotational displacements favoured SGRT set-up and the results reachedstatistical significance.Given the improved set-up accuracy with SGRT, and the wish to reduce the psychologicalmorbidity of radiotherapy for our breast cancer patients, the centre moved to safely implement a PM free SGRTtechnique along agreed timelines as shown in Table 2 : Conclusions: Our pilot study demonstrated that surface-guided radiotherapy (SGRT) set-up is as good, if not better,than set-up with permanent markers (PM) alone in tangent-only free-breathing patients. Subsequent further analysisshowed improved consistency of set-up guided by PM plus SGRT for all breast set-ups (to include nodal regionsand DIBH). We have described our step-wise approach to setting up PM free radiotherapy delivery for breast cancerpatients, which has additional advantages in maintaining social distancing in the COVID19 era.