Cancer and COVID-19

Board-certified Medical Oncologist David Chism, MD helps us understand what impact COVID-19 has on cancer patients. 

Does COVID-19 impact cancer patients differently?

We have discovered that cancer patients with metastatic disease (stage IV) and active cancer do worse with COVID-19.  Kuderer, N.M. et.al published on behalf of the COVID-19 and Cancer Consortium (CCC-19) in June 2020, that patients with active cancer had an increased 30-day mortality versus those whose cancers were in remission.¹ In addition, Kuderer reported that cancer patients had increased mortality with age, male sex, smoking status, 2 or more comorbidities and poor functional status. 

Mengyuan Dai et al added that patients with hematological cancer, lung cancer or with metastatic cancer (Stage IV) had the highest frequency of severe events occurring as determined by a multicenter study of 105 patient with cancer and 536 non-cancer patients with COVID-19. ² 

Worse outcomes associated with active hematologic or lung malignancies were confirmed in a study at Memorial Sloan Kettering Cancer Center.³    Similarly, patients with hematological malignancies did worse than those with solid tumors according to a retrospective study of 205 cancer patients from Hubei, China collected from January 13, to March 18, 2020. ⁴

Additionally, a prospective observational study that analyzed 800 patients with active cancer in the United Kingdom from March 18 to April 26, 2020 produced the following findings:

• Four-hundred and twelve patients had mild COVID-19;
• 226 patients died and risk of death was associated, like the CCC19 data with advanced age, being male and presence of comorbidities including hypertension and cardiovascular disease. 
• Chemotherapy in the past 4 weeks did not have significant effect on mortality.
• There was no significant effect on mortality for patients with immunotherapy, hormonal therapy, targeted therapy, radiotherapy use within the past 4 weeks. ⁵

Do certain types of chemotherapy or immunotherapies make patients more susceptible to the effects of COVID-19?

Patients with cancer treated with cytotoxic chemotherapy did not have an increased risk of worse COVID-19 course.  However as noted above, persons with a hematological malignancy, lung cancer, low lymphocyte count at diagnosis, and/or low neutrophils had higher rates of severe/critical illness.  ³

Do certain types of chemotherapy or immunotherapies make patients more likely to catch COVID-19?

Robilotti et al published in Nature Medicine that, of the 423 cancer patients with symptomatic COVID-19 diagnosed at MSKCC from March 10 to April 7 2020, 40% were hospitalized for COVID-19, 20% developed severe respiratory illness (9% requiring mechanical ventilation), and 12% died within 30 days. 

They found age older than 65 years and treatment with immune checkpoint inhibitors (ICIs) were predictors for hospitalization and severe disease.  Like Justin Lee et al., Robilotti et al determined that the receipt of chemotherapy did not predict hospitalization and severe disease.  They caution that until further evidence on the role of ICIs and COVID-19, not to alter treatment decisions but did suggest increased vigilance with SARS CoV-2 testing patients on ICIs.⁶

On the contrary, ICIs did not have a significant effect on mortality in a study done at United Kingdom.⁵

Do cancer patients currently in radiation therapy have different risk factors than patients going through other treatments?

There was no significant effect on mortality for patients with radiotherapy use within the past 4 weeks.⁵ A study out of Wuhan, China involving 209 cancer patients on radiotherapy from January 20 to March 5 2020 demonstrated that 53.5% were not able to return for radiotherapy due to lockdown and only 1 case of confirmed severe acute respiratory syndrome Coronavirus 2 infection was reported out of 67 a patients receiving radiotherapy treatment. ⁷ Additional research regarding radiation therapy patients with COVID-19 are needed as well.

Are long-term cancer survivors at any greater vulnerability to COVID-19?

As detailed above, patients with active malignancy  do worse when they develop COVID-19. However, long-term data on vulnerabilities of COVID-19 for cancer survivors are needed and currently unknown. 

Is there a certain timeframe after cancers when concern/risk decreases (such as 12 months after last chemo or 5 years in remission)?

Individuals with active care or with active, recent (less than 6 months) or planned cancer treatment, hold the highest priority for vaccination and therefore are at highest risk.  Patients in remission will require additional studies to determine effect of COVID-19.   

 Are there any prevention steps cancer patients or cancer survivors can take to avoid getting or decrease the impact of COVID-19?

Obtain vaccination as soon as available based on age, or co-morbidities which may support a higher risk of adverse outcomes.  Cancer patients and cancer survivors should continue to follow CDC guidelines regarding social distancing, wearing masks over your nose and mouth, hand hygiene, avoiding crowds and poorly ventilated spaces.  Encourage vaccination for caretakers of patients with cancers and practice COVID-19 prevention guidelines. 

Does cancer have a long term impact on the immune system?

Certainly, cancer in general may have significant impact on the immune system, especially if bone involvement exits.  Therefore, various cancers impact the immune system to different degrees.  Advanced cancers have more impact on the immune system than localized cancers. 

Furthermore, the treatments for cancer can have some impact on the immune system as well.  Hematological malignancies in general may have a broader effect than solid tumors due to effects on cell counts including neutrophils or lymphocytes. 

Should patients in active treatment for cancer try to get the COVID-19 vaccine?

According to NCCN: Cancer and COVID-19 Vaccination, Version 1.0 published on 1/22/2021, patients with cancer are prioritized for vaccination (CDC priority group 1 b/c) and should be immunized when vaccination is available to them.  Optimal timing of vaccination in relation to cycles of chemotherapy is unknown.  Vaccine efficacy in this population is unknown.

Have any of the COVID-19 vaccines been tested in populations of cancer patients or cancer survivors?

There is limited prospective data related to vaccination use in active malignancy and so recommendations are based on the expert opinion of the National Comprehensive Cancer Network group.  The Pfizer and Moderna trials excluded this population. 

Should patients delay any of their treatments until they receive the COVID-19 vaccine or the number of cases begin to fall?

No. Treatment for cancer is recommended with the above precautions, including receipt of the COVID-19 vaccine as soon as possible. 

Do you have any other general advice for cancer patients during this time of pandemic?

In addition to receiving any of the available vaccines against COVID-19, patients should also follow CDC guidelines, including:

• maintain social distancing
• avoid touching the eyes, nose, and mouth
• wear masks over the nose and mouth
• maintain proper hand hygiene – wash hands with soap and water for at least 20 seconds
• avoid crowds and poorly ventilated spaces. 

There has also been a rise in depression and anxiety due to the pandemic, so patients are encouraged to discuss these issues with their healthcare provider. 

Some follow-up visits that are routine may be conducted via telemedicine rather than in-person.

Where can patients and their families find reliable information about COVID-19?

• The Centers For Disease Control and Prevention
• The National Cancer Institute
• The American Society for Clinical Oncology

References: 

• Kuderer, N.M., et al. Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study. Lancet. 395:1907-18.
• Dai, Mengyan, et al. Patients with Cancer appear more vulnerable to SARS-CoV-2: A multicenter Study during the COVID-19 Outbreak. Cancer Discov. 10(6): 783-791.)
• Jee, Justin, et al. Chemotherapy and COVID-19 Outcomes in patients with cancer. Journal of Clinical Oncology. 38:3538-3546. 
• Yang, K., et al. Clinical characteristics, outcomes, and risk factors for mortality in patients with cancer and COVID-19 in Hubei, China: a multicenter, retrospective, cohort study. Lancet Oncology. 2020 Jul. 21(7):904-913. 
• Lee, Lennard Yw, et al. COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective
• cohort study. Lancet. 2020 06 20; 395(10241):1919-1926. Robilotti, EV et al. Determinants of COVID-19 disease severity in patients with cancer. Nature Medicine. Volume 26, August 2020; pages 1218-1223.
• Conghua, Xie, et al., Outcomes in Radiotherapy-Treated patients with cancer during the Covid-19 Outbreak in Wuhan, China, JAMA Oncol. 2020 Sep; 6(9): 1457-1459.
• Reference: NCCN: Cancer and COVID-19 Vaccination, Version 1.0 published on 1/22/2021