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Background: Whilst patients (pts) with cancer are at increased risk of adverse outcome from Coronavirus disease 2019 (COVID-19), no evidence exists as to the natural history of the SARS-CoV-2 B.1.1.529 (Omicron) variant in this population. Methods: Capitalizing on OnCovid study data (NCT04393974), a European registry that collects data on consecutive patients with cancer and COVID-19, we analysed COVID-19 morbidity and case fatality rates at 14 days (CFR14) across 3 phases defined following the evolution of the pandemic in Europe, according to date of COVID-19 diagnosis: “Pre-vaccination” phase (27/02/2020-30/ 11/2020), “Alpha-Delta variant” phase (01/12/2020-14/12/2021), “Omicron variant” phase (15/12/2020-31/01/2022). Results: By the data lock of 04/02/2022, 3820 consecutive pts were enrolled, 3473 of whom were eligible for this analysis. Among them, 2033 (58.6%), 1075 (30.9%) and 365 (10.5%) were diagnosed during the Pre-vaccination, Alpha-Delta and Omicron phases. Pts diagnosed in the Omicron phase were more likely aged < 65 years (48.6% vs 42.5%, 39.4% p = 0.01), had < 2 comorbidities (61.9% vs 55.6%, 52.1% p = 0.01). They had more advanced-stage tumours (62.1% vs 53.3%, 49.0%, p < 0.01) and were more likely receiving systemic anticancer therapy (SACT) at COVID-19 diagnosis (54.9% vs 43.9%, 39.6%, p < 0.01). Proportions of fully vaccinated/boosted pts were higher in the Omicron phase (33.9%-48.1%) compared to the Alpha-Delta phase (16.6%-2.3%, p < 0.01). Pts diagnosed in the Omicron phase had improved CFR14 (9.0% vs 13.9%, 23.1%, p < 0.01) lower hospitalization rates due to COVID-19 (24.4% vs 41.4%, 56.6%, p < 0.01), lower complications rates (15.3% vs 33.6%, 39.4%, p < 0.01) and reduced need for COVID-19 specific therapy (22.4% vs 43.0%, 65.7% p < 0.01) compared to the Alpha-Delta and pre-vaccinal phase. After adjusting for country of origin, sex, age, comorbidities, tumour stage, status and receipt of SACT at COVID-19, patients diagnosed in the Omicron phase displayed the lowest risk of death at 14 days compared to earlier phases. Similarly, rates of hospitalization and complicated COVID-19 were lowest for Omicron phase. Conclusions: This is the first study to portray the evolution of the SARS-CoV-2 Omicron outbreak in Europe, documenting an improvement in all COVID-19 outcomes compared to earlier phases of the pandemic. Enhanced healthcare capacity, improved disease management, immunization campaigns alongside differential virulence of viral strains are likely contributing to improved outcomes across phases.
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Purpose: The COVID-19 pandemic transformed cancer care, with oncologists trying to balance the benefits of SACT against the risk of COVID-19 infection and mortality. Our study compares the demographic and treatment characteristics of BC patients treated at Guy’s Cancer Centre during the first wave of the pandemic with the same period in 2019. Methods: We conducted a retrospective analysis of all BC patients who received SACT from 1 March 2020 until 31 May 2020 and compared the demographic (age, ethnicity, socioeconomic and performance status), cancer (stage) and SACT characteristics (type, intent and line of treatment) with those from the same period in 2019. Results: In 2020, 571 BC patients received SACT during the study period, compared with 595 in 2019. Demographic characteristics were equally balanced between both years. The cancer stage, type of treatment and treatment paradigm were also similar (stage I–III: 49.8% versus 50.9%;chemotherapy: 29.8% versus 30.8%;palliative treatment: 49.9% versus 46.6%, in 2020 and 2019, respectively). However, a larger proportion of patients received first-line palliative treatment in 2020 compared with 2019 (38.6% versus 14.8%). The overall mortality rate was 3.15% in 2020 versus 4.36% in 2019. 11 BC patients were diagnosed with COVID-19 in 2020. From these patients, 10 were receiving chemotherapy and 7 were treated with palliative intent. 9 patients developed severe pneumonia and there was 1 COVID-19-related death. Conclusion: Our study shows that there were no significant differences in patient characteristics during the first wave of the pandemic, compared with a similar period in 2019, although numerically fewer patients were treated in 2020 and there was a focus on first-line palliative treatment, rather than subsequent lines. Moreover, it demonstrated that SACT during the pandemic was relatively safe. However, this study might not reflect the decrease in the number of new referrals owing to the pandemic.
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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.
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Background It is widely accepted that advancing age is associated with worse COVID-19 outcomes. However, there is insufficient data analyzing the impact of COVID-19 in the older cancer population. The aim of the study is to establish if age has an influence on severity and mortality of COVID-19 in cancer patients. Methods We reviewed 306 oncology patients with PCR-confirmed COVID-19 from Guy's Cancer Centre and its partner Trust King's College Hospital, between 29 February - 31 July 2020. Demographic and tumor characteristics in relation to COVID-19 severity and death were assessed with logistic and Cox proportional hazards regression models, stratified by age (≤65 and >65 years). Severity of COVID-19 was classified by World Health Organization (WHO) grading. Results A total of 135 patients were aged ≤65 years (44%) and 171 aged >65 (56%). Severe COVID-19 presentation was seen in 27% of those aged ≤65 and 30% of those aged >65. The COVID-19 mortality rate was 19% in those aged ≤65 and 27% in those aged >65. In the older cohort, there was an increased incidence of severe disease in Caucasian ethnicity compared to the younger cohort (55% vs 43%) and compared to severe disease in Black and Asian ethnicities. There were increased co-morbidities in the older cohort including hypertension (54% vs 32%), diabetes (30% vs 12%) with increased rate of poly-pharmacy (62% vs 40%) compared to the younger cohort. In terms of cancer characteristics in the older cohort, there was a higher rate of patients with cancer for more than 2 years (53% vs 32%) and performance status of 3 (22% vs 6%). In terms of severity, Asian ethnicity [OR: 3.1 (95% CI: 0.88-10.96) p=0.64] had greater association with increasing COVID-19 severity in those aged >65. Interestingly, there were no positive associations between number of co-morbidities, treatment paradigm or performance status with severity of disease in the older group. The risk of mortality was greater in the elderly cohort with hematological cancer types [HR: 2.69 (1.31-5.53) p=0.85] and having cancer for more than 2 years [2.20 (1.09-4.42) p=0.28] compared to the younger cohort. Conclusions In our study we demonstrate that severity and mortality of COVID-19 did not significantly differ between the two age cohorts except in regards to Asian ethnicity, hematological malignancies and having cancer for more than 2 years. As expected, the older population had more co-morbidities and polypharmacy. Despite this, the incidence of severe COVID-19 was similar regardless of age. Further analyses for other geriatric presentations are ongoing to understand their interaction with COVID-19 in the cancer population.
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Background: To understand the impact of the COVID-19 pandemic on National Health Services (NHS) cancer service delivery, care and patients, we examined the impact of changes in cancer service delivery, treatment intensity and delay by evaluating oncological outcomes of genitourinary (GU) cancer patients receiving systemic anticancer treatment (SACT) during 1st March and 8th July 2020. Methods: We used data from patients with GU cancers (i.e. prostate, urothelial, kidney and testicular) treated with SACT at Guy's Cancer Centre during the first wave of the COVID-19 pandemic in the UK: demographics (sex, age, ethnicity, ECOG performance status (PS), comorbidities, smoking history, socio-economic status (SES)) and disease characteristics (stage, treatment type and setting, lines of treatment), as well as results from SARS-CoV-2 PCR testing. Classification of COVID-19 severity was based on the World Health Organisation (WHO) guidelines. Results: A total of 457 GU cancer patients received SACT during the study period: 68% prostate cancer, 23% renal cancer, 7% urothelial cancer, 2% testicular cancer. Mean age was 69 years (SD: 11.2). 91% were males, 82% were classified as low SES and out of the 291 patients we had ethnicity data on 199 (68%) were White British. The majority of patients had a PS of 1 and 95% of all patients had stage IV disease and hence received palliative SACT, with 58% being in the second line setting. Half of the patients received hormone therapy, 17% received chemotherapy, 20% received targeted therapy, 13% received immunotherapy (IO) and 1% received combination IO and targeted treatment. Only 5 (1%) patients tested SARS-CoV-2 positive: 2 had prostate cancer, 2 renal and 1 bladder cancer. Mean age was 66 years (SD: 5.6). They were all male, 2 White British, 1 Black African and 2 of unknown ethnicity and were all classified as low SES. Average PS was 2. Of these 5 patients 3 had at least two comorbidities (i.ehypertension, diabetes mellitus, renal impairment, frailty) and were receiving multiple medications. All had stage IV disease and received palliative SACT. 3 were on hormone therapy alone and 2 on chemotherapy. 2 of the patients presented symptoms within less than 7 days from PCR diagnosis, 1 within 7 to 14 days and 1 after 14 days. All 5 COVID-19 positive patients required hospitalization, 4 suffered severe pneumonia, 1 died from COVID-19 and 2 died from cancer related causes. In comparison, the mortality rate for the COVID-19 negative patients was 3.3%. Conclusion: Despite the impact of COVID-19 in health provision, a large number of our GU patients at Guy's Cancer Centre safely received SACT. Our results suggest that the continuation of SACT during the COVID-19 pandemic did not increase the risk of COVID-19 in our patient cohort (SARS-CoV-2 infection rate: 1%). Of note, the infection rate was lower than observed in a similar study in our centre for gastrointestinal cancer patients (SARS-CoV-2 infection rate: 3.4%). In light of the above, decisions against SACT or SACT intensity should carefully be evaluated.
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We sought to determine parameters of the acute phase response, a feature of innate immunity activated by infectious noxae and cancer, deranged by Covid-19 and establish oncological indices' prognostic potential for patients with concomitant cancer and Covid-19. Between 27/02 and 23/06/2020, OnCovid retrospectively accrued 1,318 consecutive referrals of patients with cancer and Covid-19 aged 18 from the U.K., Spain, Italy, Belgium, and Germany. Patients with myeloma, leukemia, or insufficient data were excluded. The neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), prognostic nutritional index (PNI), modified Glasgow prognostic score (mGPS), and prognostic index (PI) were evaluated for their prognostic potential, with the NLR, PLR, and PNI risk stratifications dichotomized around median values and the pre-established risk categorizations from literature utilized for the mGPS and PI. 1,071 eligible patients were randomly assorted into a training set (TS, n=529) and validation set (VS, n=542) matched for age (67.9±13.3 TS, 68.5±13.5 VS), presence of 1 comorbidity (52.1% TS, 49.8% VS), development of 1 Covid-19 complication (27% TS, 25.9% VS), and active malignancy at Covid-19 diagnosis (66.7% TS, 61.6% VS). Among all 1,071 patients, deceased patients tended to categorize into poor risk groups for the NLR, PNI, mGPS, and PI (P<0.0001) with a return to pre-Covid-19 diagnosis NLR, PNI, and mGPS categorizations following recovery (P<0.01). In the TS, higher mortality rates were associated with NLR>6 (44.6% vs 28%, P<0.0001), PNI<40 (46.6% vs 20.9%, P<0.0001), mGPS (50.6% for mGPS2 vs 30.4% and 11.4% for mGPS1 and 0, P<0.0001), and PI (50% for PI2 vs 40% for PI1 and 9.1% for PI0, P<0.0001). Findings were confirmed in the VS (P<0.001 for all comparisons). Patients in poor risk categories had shorter median overall survival [OS], (NLR>6 30 days 95%CI 1-63, PNI<40 23 days 95%CI 10-35, mGPS2 20 days 95%CI 8-32, PI2 23 days 95%CI 1-56) compared to patients in good risk categories, for whom median OS was not reached (P<0.001 for all comparisons). The PLR was not associated with survival. Analyses of survival in the VS confirmed the NLR (P<0.0001), PNI (P<0.0001), PI (P<0.01), and mGPS (P<0.001) as predictors of survival. In a multivariable Cox regression model including all inflammatory indices and pre-established prognostic factors for severe Covid-19 including sex, age, comorbid burden, malignancy status, and receipt of anti-cancer therapy at Covid-19 diagnosis, the PNI was the only factor to emerge with a significant hazard ratio [HR] in both TS and VS analysis (TS HR 1.97, 95%CI 1.19-3.26, P=0.008;VS HR 2.48, 95%CI 1.47- 4.20, P=0.001). We conclude that systemic inflammation drives mortality from Covid-19 through hypoalbuminemia and lymphocytopenia as measured by the PNI and propose the PNI as the OnCovid Inflammatory Score (OIS) in this context.
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Introduction: The COVID-19 pandemic has had profound effects on healthcare systems worldwide. It has also had global economic impacts that will continue to be felt for years. The effects have implications for how cancer research is conducted and funded. The REPRISE project aims to learn from the COVID-19 pandemic to provide opportunities to redefine cancer research priorities in low- to middle-income countries (LMICs). We aim to characterize the nature of these practical and economic impacts and use this information to redefine research priorities in a changed world moving forward. Methods: As a first step, we conducted a snapshot survey of members of the 'Cancer and COVID-19 Global Task Force', which consists of experienced cancer researchers across the world. We asked about the extent to which the COVID-19 outbreak and resulting public health measures had affected cancer research in their centers. Results: We received 57 responses to our questionnaire. The respondents worked in 22 countries, representing all Word Health Organization (WHO) regions. 67% of respondents worked in either an academic/university setting, or in a public teaching hospital. The specialities of medical oncology, radiation oncology, surgery, and epidemiology were each represented by >25% of all respondents, which also included those with backgrounds in nursing, palliative care, survivorship, psychology, pathology, and prevention. Respondents in 17/22 countries reported that some (n=10) or all (n=7) cancer research studies were suspended at their center following the outbreak of COVID-19. Respondents in 5 countries reported that suspension of these studies had lasted >6 months. Respondents in 8/22 countries reported that staff redeployment, furlough, or restriction from clinical areas had had a 'large impact' on the conduct of research they were involved with. Respondents in 4 further countries reported that these factors had had a 'moderate impact'. Respondents also reported local impacts on cancer research from in-center outbreaks of COVID-19 (14 countries);government-imposed 'lockdowns' (20 countries);compliance with COVID-19 safety (18 countries);decreases in participant accrual (11 countries);and decreased patient access to diagnostics or treatment (19 countries). Nine countries yielded reports of funding cuts in their center. Twenty countries yielded reports of concerns about future funding cuts. Fifteen countries yielded reports of issues from delays to postgraduate education. Additionally, respondents were concerned about future impacts on cancer research from COVID-19 safety measures, funding cuts, and decreased patient access to diagnostics or treatments. Conclusion: The COVID-19 pandemic has profoundly impacted on the conduct of cancer research in many different countries and in several different ways. The process of redefining cancer research priorities throughout the REPRISE project will ensure that the impacts we have documented here are mitigated as far as possible and that moving forward, we can begin to address global disparities in cancer research.
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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.
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Background: The COVID-19 pandemic has influenced treatment decisions in cancer patients. There is increasing evidence that not all oncology patients are at increased risk of COVID-19 infection or death. This study aimed to look at rate of SARS-CoV-2 infection and mortality in patients with skin malignancies receiving systemic anti-cancer therapy (SACT) during the pandemic in Guy's Cancer Centre. Methods: All patients with skin cancer receiving SACT at Guy's Cancer Centre between March 1st and May 31st 2020 were included. Demographic data: sex, age, socio-economic status (SES), ethnicity, comorbidities, medications and smoking history were collected along with cancer characteristics: cancer type, stage, treatment paradigm, modality and line. COVID-19 infection was confirmed by PCR and severity defined by the World Health Organisation classification. Patients with radiological or clinical diagnoses alone were excluded. Results: Of 116 skin cancer patients on SACT over the 3-month period, 89% had Melanoma, 5% Kaposi's Sarcoma (KS), 3% Squamous Cell, 2% Merkel Cell, 1% Basal Cell Carcinoma and 1% Angiosarcoma. 53% were male and 78% were of low SES. 62% were being treated with palliative intent and 70% of these were on first line palliative treatment. The median age was 57.6 years in COVID-19 positive patients (n=3) compared to 60.3 years in the negative group (n=113). 58.6% received immunotherapy, 28.4% targeted therapy, 7.8% chemotherapy and 4.3% combined treatment. Of the 3 patients (2.6%) with confirmed COVID-19 infection, the two patients with KS were receiving liposomal doxorubicin hydrochloride and the other paclitaxel chemotherapy and the patient with Melanoma was receiving encorafenib and binimetinib. All COVID-19 positive patients were of low SES, 2 females and 1 male. There was a low rate of co-morbidities with hypertension in 1 COVID-19 positive patient and none in the negative group. All 3 confirmed COVID-19 patients developed severe pneumonia and were diagnosed within 7 days of the onset of symptoms. There were no COVID related deaths and one disease-related death in the negative cohort. Conclusion: There was a low rate of COVID-19 infection in the 116 skin cancer patients on SACT (2.6%) with 60% of patients on immunotherapy. All 3 confirmed cases had severe pneumonia with no COVID-19 related deaths (0%);2 were receiving chemotherapy and 1 on targeted therapy. Patients on treatment were encouraged to shield between hospital attendances during this period which may account for the reduced rate of SARS-CoV-2 infection. This data supports the emerging observations that immunotherapy does not confer an increased risk of severe COVID-19 infection in cancer patients. This observation is confounded by the relatively young age and low co-morbidity rates in the cohort which may have contributed to the low infection and mortality rate.
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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.
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Introduction: A better understanding of the reality for cancer patients during COVID-19 will help us readapt current predication models. To further inform future clinical guidelines, we need a deep dive into rich data sources from apex Cancer Centres. We report on the outcomes of cancer patients receiving radical surgery between March-September 2020 (as well as 2019) in the European Institute of Oncology (EIO) in Milan and the South East London Cancer Alliance (SELCA). Methods: IEO is one of the largest cancer hospitals in Italy. SELCA includes 3 major hospital trust, treating about 8,000 new cancer patients per annum. Both institutions implemented a COVID-19 minimal pathway, whereby patients were required to shield for 14 days prior to admission and were swabbed for COVID-19 within 3 days of surgery. Positive patients had surgery deferred until a negative swab. Surgical outcomes assessed were: ASA grade, surgery time, theatre time, ICU stay>24h, pneumonia, length of stay (LOS), and admissions. For COVID-19, we focused on infection rate and mortality. Results: At IEO the number of radical surgeries (270 for gynaecological, 339 for head and neck, 377 for thoracic, and 491 for urological cancers) declined by 6% as compared to the same period in 2019 (n=1477 vs 1560). The main decline was observed for thoracic surgery (377 vs 460, i.e. -18%). Age, sex, SES, ethnicity, comorbidities, and performance status were all comparable between both periods (e.g. 58% male, 38% aged 70+, 48% high SES, 15% with existing cardiovascular diseases). Readmissions were required for 39%, and <1% (n=9) developed COVID-19, of which only 1 had severe disease and died. 11 died of other causes during follow-up (1%). At SELCA, the number of radical surgeries (321 for breast, 129 for colorectal, 114 for gynaecological, 152 for head and neck, 92 for liver, 56 for plastics/skin, 305 for thoracic, 72 for upper gastrointestinal, and 312 for urology) declined by 29% (n=1553 vs 2182). Even though a different geographical setting, characteristics were fairly comparable with the IEO: 58% males, 30% aged 70+, 34% high SES, 16% with existing cardiovascular diseases. Readmissions were required for 22%, <1% (n=7) developed COVID-19, and none died from it. 19 died of other causes within 30 days (1%). Conclusion: Milan and London were both at the epicentre of the first COVID-19 wave. Whilst a decline in number of surgeries was observed, the implemented COVID-19 minimal pathways have shown to be safe for cancer patients requiring radical treatment, with limited complications and almost no COVID-19 infections.
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Background: At the Rapid Access Diagnostic Unit at Guy's Hospital London, we review patients with vague symptoms that are concerning for malignancy. As part of our response to the COVID-19 pandemic, we developed a virtual triage pathway with the aim to reduce face-to-face appointments and prioritise resources towards patients with an underlying cancer diagnosis. Methods: Patients were triaged by clinicians based on a telephone consultation with the patient and history and blood tests provided in the referral. Those triaged as high risk were either directly booked for investigation ("straight-to-test") or booked for a face-to-face consultation for further history and examination. Low risk patients were either put on a watch-and-wait pathway with a telephone follow-up in 3-4 weeks or discharged back to the GP with a robust plan on symptom management. The patient outcomes were tracked and compared to the outcomes from the face-to-face assessment service used prior to the COVID-19 pandemic (Dec 2016-Feb 2020). Patients triaged as low risk and discharged were tracked to monitor for any subsequent cancer diagnoses. Results: There were 804 referrals triaged between March 2020-January 2021. 75% were triaged to a face-to-face assessment and 18% triaged straight-to-test. 4% were placed on the watch-and-wait pathway and 3% were returned to the GP with advice. In those triaged as high risk, 8.2% were diagnosed with cancer, 54% were diagnosed with a serious-benign condition and 38% with a non-serious or no condition. In the patients triaged as low risk and placed on the watch-and-wait pathway, 14% were brought in for a face-to-face assessment based on their follow-up telephone assessment. None of the patients on the watch-and-wait pathway were found to have a cancer diagnosis, 11% were diagnosed with a seriousbenign condition, and 89% were diagnosed with a non-serious or no condition. There was an overall cancer diagnosis rate of 7.6% compared with a pre-COVID-19 diagnosis rate of 6.6%. Conclusions: The virtual triage pathway effectively risk-assessed patients, with those triaged as high risk having an 8.2% cancer diagnosis rate compared to a 0% cancer diagnosis rate in those triaged as low risk. Furthermore, the virtual triage service had a higher cancer diagnosis rate compared to the pre-COVID-19 face-to-face assessment service. Therefore the virtual triage service provides an efficient pathway for cancer diagnosis in patients presenting with vague symptoms, reducing the number of face-to-face appointments and supporting management of low risk patients in the community.
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Background: The COVID-19 pandemic was declared in the UK in February 2020, impacting significantly on healthcare. Delivery of systemic anti-cancer treatment (SACT) rapidly adapted to minimize patient exposure to SARS-CoV-2. The risks of SACT and concomitant COVID-19 infection are unknown. Here we report the patient/tumour characteristics of pts with any GYN cancer undergoing SACT during the first wave to understand risks of SACT and establish clinical guidelines for safe management in the ongoing SARS-CoV2 pandemic. Methods: Demographic and clinical characteristics of GYN cancer pts receiving at least one SACT between 1st March- 31st May 2020 (first wave COVID-19) were compared to the same three month timeframe in 2019. SARS-CoV2 infection was defined as a positive RT-PCR test for COVID-19. Pts with symptoms or radiological changes alone were not considered SARS-COV2 positive. As part of the Guy's Cancer Cohort we collected information on age, ethnicity, performance status (PS), cancer type, stage (Stg), treatment (SACT, surgery, radiotherapy) and COVID-19 infection. Results: There were no COVID-19 related deaths. 1 pt (0.5%) had SACT delay due to confirmed SARS-CoV-2 infection. Overall mortality at 6 months in each timeframe was 6.9% in 2020 and 8.1% in 2019. In the comparative 3-month intervals, similar numbers of GYN cancer pts received SACT in 2020 compared to 2019: 170 patients (126 ovarian;44 non-ovarian) in 2020, 184 (131 ovarian;53 nonovarian) in 2019. Median age was 61y in both groups and BAME ethnicity was balanced. In 2020, more pts had Stg III/IV disease (93%) than 2019 (84%) and fewer had Stg I/II disease (7%) compared to 2019 (16%). PS was: 0-1 in 92% of patients in 2020 vs 85% in 2019. The average number of cycles of SACT delivered in each time frame was 3. In 2020 9% received neoadjuvant SACT of which 69% proceeded to planned surgery and 31% were deemed unfit. Comparatively, in 2019 7% received neoadjuvant SACT of whom 75% proceeded to surgery and 25% were deemed unfit. In 2020, 3 pt received chemoradiation compared to 8 in 2019. 40 of 170 pts (24%) had 1-5 week treatment delays in 2020 due to any aetiology with. In 2019 there were treatment delays in 63 of 184 pts (34%). The use of GCSF in support of all SACT regimens was 52% in 2020 vs 11% in 2019. Conclusions: There was no increase in mortality associated with SACT during the first wave of the COVID-19 pandemic in GYN cancer pts. 0.5% of pts had confirmed SARS-COV2 infection. We were able to maintain full SACT delivery for all GYN cancer pts with average cycle number unchanged between 2019 and 2020. There was no significant reduction in surgical debulking rates. In contrast, there was a reduction in GYN cancer pts receiving chemoradiation. More pts presented with Stg III/IV disease in 2020. Increased use of GSCF may have contributed to the reduced chemotherapy delays in 2020. Further research will explore the impact of vaccination.
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 approximately 8,800 patients annually and is one of the largest Comprehensive Cancer Centres in the UK. When dealing with the second wave of COVID-19, it is important to further evaluate the safety of cancer treatments whilst balancing the risks of COVID-19 infection and complications. Here, we report on the patient/tumour characteristics of those patients undergoing SACT for a urological cancer diagnosis during the first wave, so as to help establish clinical guidelines for the management of these patients in a SARS-CoV-2 epidemic. Methods: All urological cancer patients receiving at least one SACT between 1st March- 31st May 2020 (COVID-19 period) were compared to the same timeframe in 2019. SARSCoV2 infection was defined as a positive RT-PCR test;patients with symptoms or radiological changes alone were excluded. As part of Guy's Cancer Cohort, we collected information on demographics, and cancer type, stage, and treatment. Results: A total of 455 patients (305 prostate, 102 renal, 38 bladder, and 10 testicular) received SACT in 2020 as compared to 535 (353 prostate, 129 renal, 37 bladder, and 15 testicular) in 2019 (15% overall decline). Patient characteristics in terms of demographics were fairly comparable, with 10% female patients in 2019 and 9% in 2020;49% aged 70+ vs 45%;and 77% in the low socioeconomic category vs 78%. There was an increase in patients with stage 4 (89% vs 95% in 2020) and a slight change in distribution of SACT types (2019 vs 2020): chemotherapy (18% vs 14%), immunotherapy (7% vs 10%), biological or targeted (63% vs 66%), combination of biological/targeted (6% vs 5%), other combinations (5% vs 5%). The proportion of SACT delivered as part of radical treatment declined from 3% to 0.2% in 2020. A total of 5 patients (1%) developed COVID-19 (2 prostate, 2 renal, and 1 bladder). All were male and aged 60+;three had 2+ comorbidities. One patient was on immunotherapy and four on biological or targeted treatment. Four patients had severe pneumonia and one died of their COVID-19 (bladder cancer). Conclusions: Whilst there was a decline of number of patients receiving SACT during COVID-19, we were still able to provide a safe high-quality urological cancer SACT pathway during the peak of the COVID-19 pandemic, with very few COVID-19 positive patients. In a next step we will evaluate oncological outcomes at 6 months follow-up.
ABSTRACT
Introduction: ReIMAGINE aims to improve current PSA/biopsy risk stratification for prostate cancer (PCa) and develop a new image-based method for diagnosing high/low risk PCa. Here, we describe how active involvement/ engagement with patients and the general public from study inception led to impactful evidence-based clinical research outputs for ReIMAGINE. Patients & Methods: We began with a series of discussion groups, whereby patients and their family members, as well as men without PCa (i.e. the general public) provided insight into participant preferences with respect to study design and management, data collection and analysis, and dissemination of findings. Results: Our consultation phase confirmed research need for less invasive PCa diagnostic strategies and generated study design recommendations. In addition to various outreach activities, our Twitter account (@reimagine-pca) is at the heart of our engagement strategy as it allows us to participate in many other relevant PPI activities. Most recently, our PPI-Subcommittee has worked collaboratively with our Trials team to reopen consortium studies following a pause in recruitment because of COVID-19. They developed information videos in which members played the parts of patients providing a "walk-through" of COVIDsecure clinical pathways encountered by study participants. Conclusion: ReIMAGINE has incorporated structures and funding for inclusion and engagement of the patient and public voice in the study design, monitoring and ongoing processes. The appointment of a funded PPI co-ordinator and a patient chair of the PPI sub-committee has led to further work outside the study remit, particularly in the establishment of a BAME PPI committee for prostate cancer.
ABSTRACT
Background: The Covid-19 pandemic is a healthcare emergency with a significant impact on cancer services provision. In March 2020, our institution adopted the ESMO expert consensus guidelines for radiotherapy management of rectal cancer during the pandemic. Here we present short-term oncological outcomes of this approach compared to the same period in 2018. Methods: Patients who underwent neoadjuvant (chemo) radiotherapy for rectal cancer between 1st March 2020 and 31 May 2020 were identified from a research ethics committee (REC)-approved research database for cancer patients (Guy’s Cancer Cohort). Patient demographics and treatment characteristics were extracted and compared with a control cohort treated in the same period in 2018. The definition of local response was based on identification of downstaging on re-staging Magnetic Resonance Imaging (MRI) post neoadjuvant treatment (mrT3c/d-4 to mrT0-2 and mrT2 to mrT0-1) and classified in a binary format (response vs no response). In addition, in patients who underwent total mesorectal excision (TME), neoadjuvant rectal (NAR) score was calculated, as described previously, and classified into low (<8), intermediate (>=8<=16) and high (>16). The frequency of MRI and pathological response was compared using non-parametric Fisher exact test. Results: Thirty patients were treated in the three-month period in 2020 as compared with 21 in 2018 (43% increase). No statistically significant differences were observed in baseline tumour characteristics. The use of neoadjuvant short-course radiotherapy (SCRT) treatment increased significantly from 19% of cases in 2018 to 50% during the pandemic, which was reflected in reduced radiotherapy-related hospital footfall (median 15 appointments in 2020 vs 25 appointments in 2018). While the use of concomitant fluoropyrimidines was lower (47 vs 71%), the use of induction chemotherapy was higher (30 vs 19%) in 2020 compared to 2018, which may reflect more prevalent use of total neoadjuvant treatment. There was no difference in the proportion of MRI responders between cohorts (52% in 2020 vs 38% in 2018). In patients who underwent TME, there was no difference in the proportion of R1 resection (0 in 2020 vs 9% in 2018), median NAR scores (8 (1-30) in 2020 v 15 (range 4-50) in 2018) or NAR score categories (22% good responders, 64% intermediate and 14% non-responders during Covid-19 vs 9% good responders, 55% intermediate and 36% non-responders in 2018). Conclusions: Changes in radiotherapy treatment of rectal cancer during Covid-19 pandemic, including more frequent use of SCRT (often in combination with neoadjuvant chemotherapy), did not seem to have negatively impacted short-term oncological outcomes, as measured by MRI downstaging rates and NAR scores following TME. The effect of the pandemic on medium and long-term oncological outcomes is still awaited. Legal entity responsible for the study: The author. Funding: We acknowledge funding support from King’s Health Partners Research and Development Challenge Fund and Biomedical Research Centres (BRC) at Guy's and St Thomas' NHS Foundation Trust. Disclosure: All authors have declared no conflicts of interest.
ABSTRACT
Background: Current precautionary management decisions being made for cancer patients are based onassumptions supported by limited evidence, based on small case series from China and Italy and larger series fromNew York and a recent consortium of 900 patients from over 85 hospitals in the USA, Canada, and Spain. Hence, there is insufficient evidence to support clinical decision-making for cancer patients diagnosed with COVID-19 dueto the lack of large studies. Methods: We used data from a single large UK Cancer Centre to assess demographic/clinical characteristics of 156cancer patients with a confirmed COVID-19 diagnosis between 29 February-12 May 2020. Logistic/Cox proportionalhazards models were used to identify which demographic and/or clinical characteristics were associated withCOVID-19 severity/death. Results: 128 (82%) presented with mild/moderate COVID-19 and 28 (18%) with severe disease. Initial diagnosis ofcancer >24m before COVID-19 (OR:1.74 (95%CI: 0.71-4.26)), presenting with fever (6.21 (1.76-21.99)), dyspnea(2.60 (1.00-6.76)), gastrointestinal symptoms (7.38 (2.71-20.16)), or higher levels of CRP (9.43 (0.73-121.12)) werelinked with greater COVID-19 severity. During median follow-up of 47d, 34 patients had died of COVID-19 (22%).Asian ethnicity (3.73 (1.28-10.91), palliative treatment (5.74 (1.15-28.79), initial diagnosis of cancer >24m before(2.14 (1.04-4.44), dyspnea (4.94 (1.99-12.25), and increased CRP levels (10.35 (1.05-52.21)) were positivelyassociated with COVID-19 death. An inverse association was observed with increased levels of albumin (0.04 (0.01-0.04). Conclusions: Our analysis of one of the largest single-center series of COVID-19-positive cancer patients to dateconfirms a similar distribution of age, sex, and comorbidities as reported for other populations. With respect tocancer-specific observations, patients who have lived longer with their cancer were found to be more susceptible toa greater infection severity, possibly reflecting the effect of more advanced malignant disease, as almost half of thesevere cohort were on third-line metastatic treatment, or the impact of this infection. The latter was also found to beassociated with COVID-19 death in cancer patients, as were Asian ethnicity and palliative treatment. Furthervalidation will be provided from other large case series, as well as from those including longer follow-up, to providemore definite guidance for oncologic care.