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Aakash Desai, MD, MPH. provides additional insight into his research on COVID-19 risk and patients with cancer and sheds light on how institutions are taking action against the virus.
Aakash Desai, MD, MPH
The COVID-19 pandemic has drastically changed the healthcare industry, especially when it comes to the care of patients with cancer, according to Aakash Desai, MD, MPH, who added that reports from China indicate that those who are at higher risk—those on active chemotherapy, those undergoing bone marrow transplant, those with hematologic malignancies—should be especially cautious.
A meta-analysis was conducted using random-effects models to analyze the pooled prevalence of cancer among patients with COVID-19. The overall pooled prevalence of cancer in patients with the virus in these studies was 2.0% (95% CI, 2.0%-3.0%; I2 = 83.2%).1 On further subgroup analysis, based on sample size, a slightly higher prevalence was observed in studies with a sample size of <100, at 3.0% (95% CI, 1.0%-6.0%). In larger studies, with a sample size >100, a lower overall prevalence of 2.0% was observed (95% CI, 1.0%-3.0%).
This paper was based on a previously published article from China that set out to establish a prospective cohort to monitor COVID-19 cases throughout the country. As of the data cut off, which was January 31, 2020, investigators collected and analyzed 2007 cases from 575 hospitals in 31 provincial administrative regions; 417 cases were excluded because of insufficient records of previous disease history.
Of 1590 COVID-19 cases, 18 patients had a history of cancer, which appeared to be higher than the incidence of cancer in the overall Chinese population, according to the investigators (1%; 95% CI, 0.61-1.65).2 Lung cancer was the most frequent tumor type, at 28% (n = 5). Furthermore, 25% of patients with cancer and COVID-19 (n = 4) had received chemotherapy or surgery within the past month. The other 25% of patients (n = 12) were cancer survivors who were in routine follow-up after primary resection.
"We wanted to answer our question on the relationship between cancer and COVID-19 based on the data that are out there. We looked at those data and found that they were inadequate due to the sample size," said Desai. "We thought that if we still found an increased signal for these patients with cancer and COVID-19 [in our work], we should impress that upon not just the oncology community, but the medical community overall. This is something that oncologists and primary care physicians will all see in the future. Patients with cancer are a special subset who should be given more attention during this pandemic and now, we have robust data from this study to indicate that."
In an interview with OncLive, Desai, vice-chair of the Resident Fellow Section of the Connecticut State Medical Society, and resident physician at the University of Connecticut Health Center, provided additional insight into his research on COVID-19 risk and patients with cancer and shed light on how institutions are taking action against the virus.
OncLive: How is COVID-19 impacting your practice in Connecticut? Have you seen a surge in cases?
Desai: COVID-19 has definitely impacted our practice of medicine and etiquette; it has ranged from restructuring hospital floors to making more intensive care unit (ICU) beds [available]. There has been an increase in the geographical distribution of patients within the hospital [in light of the pandemic]. We're trying to minimize the spread of the virus, especially to patients with cancer and those who are immunocompromised. [Institutions have] been setting up tents outside of emergency services to increase the availability of beds. Obviously, the virus is also affecting the patient discharge. We’ve heard stories about nursing homes experiencing a surge in cases. In Connecticut, we are also seeing a surge of COVID-19 cases, similar to other states. Given our proximity to New York, we have still done fairly well; however, cases have been reported all over Connecticut.
Could you expand on some of the measures that have been put into place at your institution to prevent the spread of the virus?
We've made changes at various levels. I have seen that the ICU units have been split into a COVID-19 unit and a non-COVID unit to minimize spread. We’ve also seen an increase in mechanical ventilator devices; in fact, the ICUs have also ordered more non-invasive ventilating devices. At the level of medical floors, we have designated COVID-19 floors in our hospital and a designated COVID-19 team. Patients who do not require an ICU level of care are admitted to the medical floors. We've seen patients being moved geographically to ensure they are away from the chemotherapy floors or any other floors where there is a high risk of transmission.
Every patient with a symptom complex related to clinical features of COVID-19 is swabbed and isolated. Usually, we preemptively start them on treatment after a discussion with an infectious disease expert. Although we don't have a lot of robust data on [the virus yet], when you're treating these patients clinically, you have to be able to do something more.
You were the first author on a pooled meta-analysis examining COVID-19 and cancer. Could you discuss the objective of this study and how you selected which studies/data to include?
The very early reports that came out of China about COVID-19 and cancer came from 1 paper published in the Lancet Oncology, which reported a cancer prevalence of 1% among 1590 cases of COVID-19; this was reportedly higher than the overall cancer incidence in China. A plethora of studies from China have analyzed and reported on clinical features, morbidities, and outcomes [with the virus]. However, this paper was the first to examine this from a cancer perspective, so we wanted to know whether this was an anomaly or a consistent finding. Should we be concerned more for patients with cancer as related to COVID-19?
The objective of our study was to do a pooled prevalence analysis of patients with cancer and COVID-19 from these studies. We searched databases, such as PubMed, using the search terms of "COVID-19," "malignancy," or "cancer." We found about 276 articles and 266 of them were either reviews or [included] non-reported patient populations. We had to narrow [these articles] down to the 11 studies that we included in the paper, which look at patients with COVID-19 and identify the those who had cancer. Using these studies, we wanted to find the pooled prevalence to get a better idea of COVID-19 risk and how that’s related to cancer.
What were your findings?
We found that the overall prevalence of cancer in patients with COVID-19 was about 2%. If we relate back to the Chinese population, that is more than the 0.3% incidence that they reported. We also wanted to do a subgroup analysis based on the sample size because that was one of the limitations of the prior studies. We found that even in a patient population with COVID-19 of less than 100, [the prevalence] was 3%. In a sample size of more than 100, it was, overall, 2%. As such, they regressed to the findings of these larger studies.
This then convinced us that the prevalence of cancer in these studies is higher than the incidence of cancer in the Chinese population. All these studies are coming out of China, which gives us uniform results. These studies only reported prevalence; we do not know how many of these patients had a history of cancer or had active cancer at the time of analysis. We also have no granular data on the type of cancer or treatment they were receiving. However, this study does tell us [more about] the risk of COVID-19 in our patients [with cancer].
Could you discuss the subsets of patients who require more intensive attention? How are you providing that attention in practice?
Some of the previously discussed studies have shown that patients with cancer have a high risk of severe events, which include being admitted to the ICU and requiring ventilative support, or even death, compared with patients without cancer. Studies have shown that patients who are undergoing chemotherapy or surgery in the past month have a higher risk of 75% versus somewhere in the 40% range [for those who were not undergoing that treatment].
Also, a recent pre-print observation study just came out after our paper. This paper showed that when you're looking at a subset of cancer populations, patients with lung cancer or hematological malignancies have the highest mortality with [regard to] ICU admission rates. This study also confirmed the increased severity of symptoms in the need for mechanical ventilation. We have to be very cognizant of the fact that this is an at-risk population. Patients with lung cancer, those who are undergoing active chemotherapy, are neutropenic, have hematological malignancies, are undergoing stem cell or bone marrow transplant, deserve special attention—not only from oncologists, but from their primary physicians at the hospital because they have poor outcomes.
In practice, changes have been made. We are conducting more telehealth appointments, especially for patients with cancer or those who are immunocompromised and are worried about being exposed to the virus at the hospital or clinic. In the oncology space, there has been a lot of talk about switching over from intravenous regimens to oral regimens in an attempt to allow these patients to stay away from the hospitals when they can. We are risk stratifying patients to ensure that we don't expose them to the virus.
What are some of the questions that arise for patients who underwent chemotherapy or surgery in the past month?
Again, some of the answers to these questions that arise are unknown. We don't know whether or not we should be giving chemotherapy actively or delaying chemotherapy or surgery. There has been some comment about what different societies and institutions are implementing, but there is a lot of unknowns and variables; this is a case-by-case evaluation.
How do you decide when adjuvant chemotherapy or elective surgery should be postponed? What do some of these discussions look like in your practice?
These are risk-benefit discussions that all of us have with patients in many fields, but especially in oncology. Several efforts are being made to objectively assess what needs to be done and what can wait. However, that being said, things are constantly changing and we're getting new data every day so we don't have a fixed [recommendation] at this point. Institution-specific guidelines [have been released] and then there are emerging consensus among oncologists and the community. The thought process that is useful for this is one that was recently reported: Think about these at different levels of benefit. We have to stratify these patients into patients we can potentially cure. We must treat them because their cancer-related mortality is higher than their COVID-related mortality.
Then, there's another subset of patients [who are on] therapies that have a moderate effect on their quality of life (QOL) and overall survival (OS). We're trying to lower infection risks by warning these patients about their risk of infection. We're doing more stringent neutropenia monitoring and treatment. There are the other subsets of patients in which [therapies] have a marginal effect on their QOL and OS. That's a discussion where you have a patient with metastatic cancer who [has progressed on their] third line of therapy and you need to determine whether or not it's worth putting them at risk of infection. You're not going to get much mileage from a fourth line of therapy in that case. Lastly, the minimal risk is where you have patients who are cancer survivors or for whom you're performing cancer surveillance; that’s where we are hitting them with at-home care delivery and avoiding seeing them unless absolutely necessary.
In your meta-analysis, you mention that no evidence currently indicates an increased risk of pneumonitis in those receiving immunotherapy or radiotherapy. However, this has obviously been an area of concern. What are your thoughts?
This is a legitimate concern, especially given the mechanism and biological plausibility behind it. However, not much data exist to comment on that. It's too early to know, and there's still a lot to be discovered with regard to COVID-19 and cancer. I hope we see emerging data on these clinical questions that are applicable to practice.
What COVID-19—related challenges are you experiencing in practice that we haven’t discussed yet?
Other challenges include personal challenges for physicians and the healthcare industry. It's a stressful time, a difficult time for physicians and their families. Many of us are separating ourselves from our families by sleeping in the basement and working longer hours. It's a remarkable effort for the healthcare system.
Are there any ongoing research efforts that you’re particularly excited about?
I'm honored to be a part of the COVID-19 and Cancer Consortium. It's fascinating that the effort started with a few tweets among colleagues and within 1 month we're now a consortium of over 80 cancer centers and organizations that have come together to collect data about patients with cancer who have been infected with COVID-19. Our hope is to understand the demographic patterns and clinical characteristics. The pace with which this effort is moving is tremendous, so I'm very excited about that.
Many similar efforts are being made. Societies, such as the American Society of Clinical Oncology and the American Society of Hematology, are also doing something similar and they have collected similar data. Additionally, there is also a thoracic cancer-specific registry. More crowdsourcing applications are coming to the oncology field to examine the data.
Being a trainee in the middle of a pandemic, and learning about [the virus], evaluating the clinical characteristics of patients, and [studying] new treatments coming through makes it an exciting time academically and a challenging time clinically.
What do you feel is most needed to quell the pandemic?
Solidarity. We need collaborations among foundations, clinicians, and scientists. We're seeing this with [the unified effort being made with] social distancing. We're seeing glimpses of it every day and, hopefully this union will provide us with the right answers to the right questions.