In the Cancer and COVID-19 CME event hosted by Penn Medicine and featuring Dr. Anthony Fauci, Dr. Charu Aggarwal, MD, elaborates on the risk factors associated with cancer and COVID-19, treatment of cancer patients during COVID-19, and the futures challenges for cancer care during the coronavirus pandemic. She discusses the mortality rates amongst cancer patients with COVID-19, and the variable effects of different treatment options of cancer and COVID-19 patients.
Twitter @PennMDForum Dr. Aggarwal’s physician profile Thank you so much, Bob, on behalf off my co chairs and the faculty. I would like to officially welcome you to our Conference on Covert 19 and cancer today to begin the conference. I would like to discuss the impact off over 19 on the cancer patient. Mhm. Some of the data in my talk has only been presented as abstract form and therefore should be considered preliminary infections with sorrow. School over two and subsequent covert 19 disease was initially identified in Wuhan, China, in 2019 and subsequently was declared a pandemic. In early 2020. Initial reports off increased mortality were reported in older adults and in those with high or more calmer abilities. The curve on the right is all too familiar for many off us. As the number of daily confirmed coronavirus cases have increased, so has our understanding off the impact off over 19 and cancer. In fact, over the last six months, we've had an exponential increase in our understanding off the risk factors for cancer patients. We've grown together as a global community and identifying solutions and practical management ideas that have been innovative, and we've really implemented this adapting to a rapidly changing environment around us. Much of the data that we know today has come from shared experiences on information from global registries that have spent not just the United States but international boundaries. One of these is the C C C 19 registry, which is the Covert 19 and Cancer Consortium, an international collaboration that really began as a grassroots effort on social media, with the clinical question off finding the impact off covert 19 on patients, specifically cancer patients. In their initial report at the ASCO meeting in 2020 the first reported data on 928 patients with cancer infected with Kovar 19 and reported a mortality rate of 13%. Factors associated with high mortality were high. Were older age male sex smoking, worst performance status and higher number of co morbidity is as well as presence of active malignancy. Interestingly, type off anti cancer therapy was not found to be associated with mortality. In addition, terrible was parallel Lee, looking at other, um, other data specifically in patients with harass IQ malignancies. In an international consortium that spent 26 countries patients with harassing malignancies with either a confirmed SARS cov to test or those with clinical features either clinical or radiographic suspicion for Kobe. 19 were included and it s co We heard data on 400 patients, which was subsequently published in Lancet oncology. In lung cancer cations, there was a significantly higher rate of mortality that was seen at 33.3% and there were some commonalities older, age above the age of 65. And worse performance status at Peacock PS, off one or above, was found to be significantly associated with worst outcomes. They went a step further and looked at outcomes related to treatments. Chemotherapy alone or in combination with either targeted therapy or immunotherapy was found to be a significant factor for mortality steroids given before treatment or for the duration off the infection with SARS. CoV to was not found to be a significant factor related toe outcomes or to mortality on this analysis. Now, lung cancer patients represent a very highly vulnerable population. Anyway. They often are older. They have multiple co more abilities and often compromise pulmonary function status. So it's no surprise that these patients that higher mortality, But what about patients with other solid tumors or he malignancies. Where is the data on those we saw recently of data on 1000 patients reported from the United Kingdom, where they looked at outcomes in patients by cancer type. In this figure, in this heat map off sorts, the tumor types are represented in each role. On the columns are age categories or sex categories in the right hand, in the right handed columns at even in first blush, you can see that the pinkish and reddish columns, which represent the highest rates of case fatality, seemed to be congregating in the first two rows. These are patients that had either leukemia or multiple myeloma, and you can see that older patients above the age of 70 seemed to have the highest mortality. And in fact, this mortality was highest in patients that had received recent treatments. Six months into the pandemic, we now see a pattern. In March. We see that patients with cancer are highly susceptible, they tend to have high mortality, and this is data that has been corroborated by various reports that spans multiple regions on multiple countries across the world, mortality rates off 11 to 33% have been reported in many of these studies, but we still don't know the effects of treatment, since those have been variable across these many reports. At this year's EHSMOH meeting, we saw data on the two largest cohorts off patients with Covert 19 presented to date. The first one of them was data from the Ice Eric Consortium, which is the international severe acute respiratory and emerging infectious consortium. They presented data on about 7000 patients with cancer and compared it to 60,000 patients without cancer in their cohort. About 10% of the patients admitted to the hospital had a history of cancer, and we see pretty much what we've come to expect that outcomes of patients with cancer were much worse. But it's sobering to see that in such a large Siri's, the mortality for cancer patients was very high at 40%. This included patients that had been on active treatment. When we look at this data a little bit more clearly, two things are very striking. Firstly, patients all under the age of 80 had the worst absolute outcomes. Their mortality was 46.8%. But what was really interesting was that patients younger than the age of 50 had a much higher rate of death compared to their counterparts that were young and had no history of cancer. Here you can see the hazard ratio for these young patients to die from Kovar 19 was 4.9 leading to the worst relative outcome in these adult patients. Now, is this related to the biology of cancer in these young patients? Or is it related to the delivery of supportive care or critical care services? I guess these air intriguing questions, but the authors sought to answer the latter. They looked at the rates of critical care delivery for these patients, and what they found was that patients with cancer were less likely to receive critical care at rates that were half those of patients without cancer. And in fact, the rates off invasive mechanical ventilation for 4.1% compared to 8.9% in patients without cancer. Suggesting to us that differential delivery off supportive care and critical care services me perhaps lead to differential outcomes in patients with cancer, and I'm not even talking about other disparities in care delivery. I'm simply talking about critical care support. We also saw updated data from the C C C 19 registry at Ehsmoh here. They talked about more than 3000 patients with Co vid and Kovar 19 and cancer with an angle on. Looking at the relationship between the timing off anti cancer treatment and Kovar 19 related mortality and risk off death, they categorized more than 3000 patients into different categories, such as chemotherapy, immuno, mono therapy or combination chemo immunotherapy. They also categories patients into targeted therapy and endocrine therapy. And what they found was that the majority of their patients, about 1000 or so, had received treatment within the two weeks preceding their diagnosis of Kovar 19. Very interesting trends have emerged from this analysis. Firstly, chemo immunotherapy was associated with the highest risk of 30 day mortality coming in at 30% with a hazard ratio of 2.13 I will caution you that these are very small numbers, and only 27 patients in this data set received chemo immunotherapy on. I will also stress that chemo immunotherapy is often currently used a standard of care and patients that have incurable malignancies and tumors such as lung cancer, but perhaps have a higher rate of death anyway. But still, this is intriguing data that needs to be validated. They also reported that mortality for patients receiving targeted therapy a targeting B cells such as anti CD 20 therapies were associated with significant increase in the hazard ratio for mortality. Again the numbers of very small only 17 patients. But it is sobering to see that these patients were being treated with curative intent. Therapy on the mortality rates upwards of 40% are striking. Over the last six months, the scientific community has really worked at a four went face to develop Therapeutics Fork over 19, and they have been evaluated in cancer patients. A swell. These therapeutics range from vaccines to steroids, tow anti virals as well as the use of hydroxy Flora Quinn either alone or in combination with other agents. Updates from the c c C 19 registry. Yet again, looking at these covert 19 specific treatments and cancer patients revealed that Ram Diesel, where was the only agent that was associated with benefits hydroxy claure Quinn, either alone or in combination with any other agents such as azithromycin, was actually associated with the worst outcome with an increased risk of mortality within adjusted odds ratio off 2.91 especially in patients with active disease. Does hydroxy clerk will have a role in prevention for off over 19, perhaps in healthcare workers? We'll hear more about this during our conference today from a study that was conducted and pen by Dr Amra Body and Dr Abella. Cancer and Cove in 19 really represent a dilemma in modern medicine there the Skylar and corrupt US off Greek mythology. For many of you who may not be aware of Skylar and Caribbeans in Greek mythology, Skylar was a six headed monster that lived on a rock and across the narrow strait. Corrupt us was a whirlpool. Ships and sailors would have to cross this narrow, straight and face one or the other before meeting their fate. Cancer and covert really represents Skyland Caribbeans. It represents being between a rock and a hard place for us as well as our patients. And many questions remain. Which patients can we safely treat during the covert pandemic? Which patients can be watch? Where can we afford to take the risk? With many of these questions in mind, we at Penn Medicine over the last six months have published national guidelines for cancer Care during the Cove in 19 Pandemic. Following key principles off risk mitigation we have been able to safely delivered therapy not just for solid tumors but also for him malignancies. Our cancer care at Home program has grown tremendously during the pandemic. Over a seven week period, we increased our home infusions by 700% again delivering care safely. We also created institutional protocols for testing, monitoring and delivering chemotherapy as well a cellular therapy. And you'll hear much more about this during our conference today. So in summary, patients with cancer and covert 19 have exceptionally high mortality, which has been corroborated by many national and international studies. Older age receipt of chemotherapy, either alone or in combination with immuno therapies, seem to increase. This risk risk benefit ratio should be carefully considered so that we can manage our patients and safely deliver timely care for cancer for our patients. With that, I would like to thank you for your attention