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Severity of COVID-19 in Lung Cancer Patients

Findings from the MSKCC series
18 Jun 2020

In a study conducted among 102 patients with lung cancer and COVID-19, the researchers of the Memorial Sloan Kettering Cancer Center (MSKCC) in New York, US examined the course of disease, impact of antitumour treatment and determinants of COVID-19 severity/recovery. They identified several important implications.

Severity of COVID-19 is high in lung cancer patients with 62% of patients being hospitalised and 25% who died, but determinants of severity are rather patient-specific, including smoking status and chronic obstructive pulmonary disease (COPD), than tumour-specific characteristics or treatments. Although severe, COVID-19 accounted for a minority of overall lung cancer deaths in the MSKCC during the pandemic (11%). The study findings are published on 16 June 2020 in the Annals of Oncology.

The authors explained in the study background that patients with cancer, especially those with lung cancer have increased severity of COVID-19. However, it is unknown if lung cancer itself or age, genetic variation in immunity, smoking history, cardiopulmonary disease, and/or antitumour treatment predisposes to significant symptoms of infection. The study team previously explored the impact of anti-PD-1 therapy on COVID-19 severity and did not find a clinically meaningful relation.

The study population included 102 patients with lung cancer treated at MSKCC who had positive COVID-19 test by RT-PCR between the first case identified on 12 March 2020 through 6 May 2020. Outcomes of interest included dates of hospitalisation, admission to intensive care unit (ICU), intubation and invasive mechanical ventilation, transition to Do not intubate (specifically in place of otherwise urgent intensification of care and/or intervention such as intubation for treatment of hypoxic respiratory failure), death (at home or inpatient), and recovery. Recovery was defined as more than 14 days from COVID-19 positive test and more than 3 days since symptom resolution.

Median age was 68 years (range, 31 to 91 years). Most patients had metastatic or active lung cancer (72%). Median pack-year smoking history was 23.5 (range, 0 to 120 pack-years). Common chronic conditions included hypertension (56%) and COPD (24%).

The patients who died from confirmed COVID-19 during the follow-up period represented 11% of all deaths among patients with lung cancer at MSKCC. The peak of deaths related to COVID-19 was approximately 20% in April 2020. Most deaths occurred within a week of COVID-19 diagnosis.

Although symptoms such as cough (70%) and fever (59%) were common, the constellation of symptoms within a given patient at presentation were variable. Of 102 patients, 62% required hospital admission and 25% died. Of the patients who required ICU level of care (21%), 14% recovered and 72% died.

Determinants of COVID-19 severity were largely patient-specific features, including smoking status and COPD (odds ratios for severe COVID-19 2.9, 95% confidence interval [CI] 1.07-9.44 comparing the median [23.5 pack-years] to never and 3.87, 95% CI 1.35-9.68, respectively). Other baseline clinical features that were associated with increased risk of COVID-19 severity were age, hypertension and congestive heart failure.

Tumour-specific characteristics, such as presence of active/metastatic lung cancer or history of prior thoracic radiation or thoracic surgery did not appear to impact severity of COVID-19. Histology, presence of targetable oncogenes, or PD-L1 immunohistochemistry expression also did not impact severity.

HLA supertypes were generally similar in mild or severe cases of COVID-19 compared to non-COVID-19 controls.

Recent anti-PD-1 treatment with or without chemotherapy did not associate with increased severity of COVID-19. The authors did not observe a consistent impact of severity in patients who recently received chemotherapy or tyrosine kinase inhibitors.

Most patients recovered from COVID-19, including 25% patients who initially required intubation.

Among hospitalised patients, hydroxychloroquine did not improve COVID-19 outcomes.

A limitation of this study is the sample size, which impacts the ability to perform adjustments for multiple potential confounders with smaller effect sizes. Larger sample sizes and cohorts are needed to confirm the generalisability of these results. Still, the results characterise COVID-19 in patients with lung cancers, highlighting their vulnerability during the pandemic. 

Reference

Luo J, Rizvi H, Preeshagul I, et al. COVID-19 in patients with lung cancer. Annals of Oncology; Published online 16 June 2020. DOI: https://doi.org/10.1016/j.annonc.2020.06.007 

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