Ensuring equity in the management of patients, over 70 years of age, on immunotherapy during the COVID-19 pandemic

ABSTRACT

Background: Immunotherapy (IO) has transformed the landscape for melanoma. Checkpoint inhibitors (CPI) are now routinely given to older patients. The impact of performance status (PS) and age on the immune response remains unclear. During the COVID-19 pandemic, most older patients elected to continue their cancer therapy. Meta-analysis from trial data thus far has not demonstrated any association with cancer immunotherapy survival. This abstract reports on real -world experience of older patients with melanoma treated during the global pandemic. Methods: Real world data of all patients over 70 years of age receiving IO for melanoma, was collated at a tertiary cancer centre from Oct 2019 - Dec 2020. The objective was to see how these older patients tolerated CPI, in both the adjuvant and palliative settings, during a global pandemic. Information on demographics including age at diagnosis, intention, sites of metastases, PS, co-morbidities, toxicity, impact of COVID-19 and the patient outcomes were collected. During the pandemic the majority of patients on CPI treatment were assessed and followed up by telephone call rather than face to face. Results: Fifty-six patients over 70 years,were identified to have received CPI during the time period. There were 36 male and 22 female patients. Median age was 74 (range 70-88 years). Sixteen patients (29%) were treated with adjuvant intent;the remaining 40 patients (71%) were treated with palliative intent. Most patients with metastatic disease had 1-3 sites. All patients were PS0-1, except for one patient who was PS2. There were 19 patients (34%) who developed significant grade toxicities. No patients were treated on a clinical trial during the pandemic. Three patients (5%) elected to stop treatment during the pandemic. Calls to triage were taken as normal and the majority of patients had toxicity managed as an outpatient. No patients received the vaccine by the end of the study period. Conclusions: Real-world data explored the use of CPI in older patients and the impact of the COVID-19 pandemic on their management. Older patients were able to continue on CPI during the pandemic and it was given safely in adjuvant and palliative settings. Comprehensive geriatric assessments are planned to be integrated however the current demands on medical colleagues has delayed the introduction. However clinicians working in partnership with patients ensured the safe delivery and no patients died from toxicity of therapy or COVID-19 during this time. These findings suggest that shared decision-making during a pandemic with older patients is essential to support patients and optimise outcomes. We suggest cancer therapies should not be restricted to patients based on age and IO can be given safely if precautions are taken during a global pandemic. Patients have now received first COVID-19 vaccinations and ongoing assessement of the impact of the vaccination is in progress.