Facing SARS-CoV-2 outbreak in immunotherapy era

Effects of the COVID-19 pandemic on care of melanoma patients in Berlin, Germany: the Mela-COVID survey

Background

The COVID-19 pandemic imposes major challenges for care of cancer patients.

Objectives

Our aim was to assess the effects of the pandemic on treatment and appointments of patients with malignant melanoma based on a large skin cancer centre in Berlin, Germany, and identify reasons for, and impact factors associated with these changes.

Materials & Methods

Patients with melanoma treated from January 1^st 2019 received a postal survey with questions on impairment due to the pandemic, fear of COVID-19, fear of melanoma, changes in therapy and/or appointments, including reasons for the changes. Impact factors on postponed/missed appointments were examined using descriptive analyses and multivariate logistic regression.

Results

The response rate was 41.3% (n = 324; 57.4% males; mean age: 67.9 years). Among 104 participants currently receiving therapy, four (3.8%) reported treatment changes due to the pandemic. Postponements or cancellations of appointments occurred in 48 participants (14.8%), most frequently, at their own request (81.3%) due to fear of SARS-CoV-2 infection (68.8%). Current treatment was associated with a reduced chance of postponing/missing appointments (OR = 0.208, p = 0.003), whereas a high or very high level of concern for COVID-19 (OR = 6.806, p = 0.034; OR = 10.097, p = 0.038), SARS-CoV-2 infection among close acquaintances (OR = 4.251, p = 0.026), anxiety disorder (OR = 5.465, p = 0.016) and AJCC stage IV (OR = 3.108, p = 0.048) were associated with a higher likelihood of postponing/missing appointments.

Conclusion

Among our participants, treatment changes were rare and the proportion of missed/delayed appointments was rather small. The main reasons for delays/cancellations of appointments were anxiety and concern for COVID-19.

Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1684/ejd.2021.4098.

Table S1. Disease and treatment characteristics and their association with postponed/missed appointments.

Table S2. Treatment changes or postponement due to the pandemic.

Table S3. Comorbidities and their association with postponed/missed appointments.

Fig. S1. Number of new SARS-CoV-2 infections per day in Germany and Berlin between February 1^st 2020 and July 1^st 2020.

Potential protective role of the anti-PD-1 blockade against SARS-CoV-2 infection

The outbreak of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan, China, in December 2019, and its global dissemination became the coronavirus disease 2019 (COVID-19) pandemic declared by the World Health Organization (WHO) on 11 March 2020. In patients undergoing immunotherapy, the effect and path of viral infection remain uncertain. In addition, viral-infected mice and humans show T-cell exhaustion, which is identified after infection with SARS-CoV-2. Notably, they regain their T-cell competence and effectively prevent viral infection when treated with anti-PD-1 antibodies. Four clinical trials are officially open to evaluate anti-PD-1 antibody administration's effectiveness for cancer and non-cancer individuals influenced by COVID-19 based on these findings. The findings may demonstrate the hypothesis that a winning strategy to combat SARS-CoV-2 infection could be the restoration of exhausted T-cells. In this review, we outline the potential protective function of the anti-PD-1 blockade against SARS-CoV-2 infection with the aim to develop SARS-CoV-2 therapy.

Does immune checkpoint inhibitor increase the risks of poor outcomes in COVID-19-infected cancer patients? A systematic review and meta-analysis

Background

The association between immune checkpoint inhibitor (ICI) and outcomes of cancer patients with coronavirus disease 2019 (COVID-19) infection has yet to be systematically evaluated. This meta-analysis aims to investigate the effects of ICI treatment on COVID-19 prognosis, including mortality, severity, and any other prognosis-related outcomes.

Methods

Eligible studies published up to 27 February 2021 were included and assessed for risk of bias using the Quality in Prognosis Studies tool. A random-effects meta-analysis was conducted to estimate the pooled effect size along with its 95% confidence intervals. The quality of body evidence was evaluated using the modified Grading of Recommendations Assessment, Development, and Evaluation framework.

Results

Eleven studies involving a total of 2826 COVID-19-infected cancer patients were included in the systematic review. We discovered a moderate-to-high quality of evidence that ICI was not associated with a higher mortality risk, while the other outcomes yielded a very low-to-low-evidence quality. Although our findings indicated that ICI did not result in a higher risk of severity and hospitalization, further evidence is required to confirm our findings. In addition, we discovered that prior exposure to chemoimmunotherapy may be linked with a higher risk of COVID-19 severity (OR 8.19 [95% CI: 2.67–25.08]; I² = 0%), albeit with small sample size.

Conclusion

Our findings indicated that ICI treatment should not be adjourned nor terminated during the current pandemic. Rather, COVID-19 vigilance should be increased in such patients. Further studies with larger cohorts and higher quality of evidence are required to substantiate our findings.

Trial registration number

This project has been prospectively registered at PROSPERO (registration ID: CRD42020202142) on 4 August 2020.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00262-021-02990-9.

Humoral Immune Response of SARS-CoV-2-Infected Patients with Cancer: Influencing Factors and Mechanisms

Background

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)–infected patients with cancer show worse outcomes compared with patients without cancer. The humoral immune response (HIR) of patients with cancer against SARS‐CoV‐2 is not well characterized. To better understand it, we conducted a serological study of hospitalized patients with cancer infected with SARS‐CoV‐2.

Materials and Methods

This was a unicentric, retrospective study enrolling adult patients with SARS‐CoV‐2 admitted to a central hospital from March 15 to June 17, 2020, whose serum samples were quantified for anti–SARS‐CoV‐2 receptor‐binding domain or spike protein IgM, IgG, and IgA antibodies. The aims of the study were to assess the HIR to SARS‐CoV‐2; correlate it with different cancer types, stages, and treatments; clarify the interplay between the HIR and clinical outcomes of patients with cancer; and compare the HIR of SARS‐CoV‐2–infected patients with and without cancer.

Results

We included 72 SARS‐CoV‐2–positive subjects (19 with cancer, 53 controls). About 90% of controls revealed a robust serological response. Among patients with cancer, a strong response was verified in 57.9%, with 42.1% showing a persistently weak response. Treatment with chemotherapy within 14 days before positivity was the only factor statistically shown to be associated with persistently weak serological responses among patients with cancer. No significant differences in outcomes were observed between patients with strong and weak responses. All IgG, IgM, IgA, and total Ig antibody titers were significantly lower in patients with cancer compared with those without.

Conclusion

A significant portion of patients with cancer develop a proper HIR. Recent chemotherapy treatment may be associated with weak serological responses among patients with cancer. Patients with cancer have a weaker SARS‐CoV‐2 antibody response compared with those without cancer.

Implications for Practice

These results place the spotlight on patients with cancer, particularly those actively treated with chemotherapy. These patients may potentially be more vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection, so it is important to provide oncologists further theoretical support (with concrete examples and respective mechanistic correlations) for the decision of starting, maintaining, or stopping antineoplastic treatments (particularly chemotherapy) not only on noninfected but also on infected patients with cancer in accordance with cancer type, stage and prognosis, treatment agents, treatment setting, and SARS‐CoV‐2 infection risks.

To better understand the anti‐viral immune response in the context of cancer, this serological study of hospitalized cancer patients infected with SARS‐CoV‐2 was conducted.

Impact of COVID-19 on cancer patients: A review

To inform about the impact of COVID-19 on cancer patients, a literature review was carried out, using the descriptors "COVID-19," "SARS-CoV-2," "Oncology," and "Coronavirus," in the Pubmed, Sciencedirect, and Scifinder databases. Fifty-three articles were included after analyzing the inclusion and exclusion criteria, being divided into five sessions: Epidemiological aspects of COVID-19; Pathophysiology of COVID-19; Clinical aspects of cancer patients; Risks to cancer patients infected with COVID-19; and Care for cancer patients amid a pandemic. The cancer patient has a weakened immune system, due to characteristics specific to the development of cancer or even chemotherapy, leaving these patients more susceptible to infections by COVID-19. Thus, the development of protection plans for cancer patients should be encouraged, reducing the exposure of these patients to the SARS-CoV-2 virus, contributing to the maintenance of the health of the cancer patient, and avoiding possible therapeutic complications that can lead the patient to death.

COVID-19 and cancer: From basic mechanisms to vaccine development using nanotechnology

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Shows updated understanding of SARS-CoV-2, including the interaction between ACE 2 and the viral spike protein.

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More effective vaccines are required for immunocompromised cancer patients.

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Cancer alters the immune system through different levels of D-Dimer, albumin, prothrombin, and neutrophils.

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Nanomaterials assist vaccine delivery, including viral vector and mRNA vaccines with lipid nanoparticles.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global pandemic which has induced unprecedented ramifications, severely affecting our society due to the long incubation time, unpredictably high prevalence and lack of effective vaccines. One of the interesting notions is that there is an association between COVID-19 and cancer. Cancer patients seem to exhibit exacerbated conditions and a higher mortality rate when exposed to the virus. Therefore, vaccines are the promising solution to minimise the problem amongst cancer patients threatened by the new viral strains. However, there are still limitations to be considered, including the efficacy of COVID vaccines for immunocompromised individuals, possible interactions between the vaccine and cancer, and personalised medicine. Not only to eradicate the pandemic, but also to make it more effective for immunocompromised patients who are suffering from cancer, a successful vaccine platform is required through the implementation of nanotechnology which can also enable scalable manufacturing and worldwide distribution along with its faster and precise delivery. In this review, we summarise the current understanding of COVID-19 with clinical perspectives, highlighting the association between COVID-19 and cancer, followed by a vaccine development for this association using nanotechnology. We suggest different administration methods for the COVID-19 vaccine formulation options. This study will contribute to paving the way towards the prevention and treatment of COVID-19, especially for the immunocompromised individuals.

Cancer and Immune Checkpoint Inhibitor Treatment in the Era of SARS-CoV-2 Infection

Simple Summary

The introduction of immune checkpoint inhibitors (ICI) in 2011 revolutionized the management of many solid cancers and hematological malignancies. However, there are concerns regarding the use of ICI in the era of COVID-19. We present currently available information on the pros and cons of using ICI in cancer patients with respect to the risk of acquiring an infection by SARS-CoV2 and mortality from COVID-19. By means of the present paper, clinicians and researchers may update their knowledge on a highly topical clinical question—is the use of ICI in cancer patients with SARS-CoV2 infection harmful with respect to COVID-19 outcome?

Abstract

Whether cancer patients receiving immune checkpoint inhibitors (ICI) are at an increased risk of severe infection and mortality during the corona pandemic is a hotly debated topic that will continue to evolve. Here, we summarize and discuss current studies regarding COVID-19 and anti-cancer treatment with an emphasis on ICI. Importantly, several lines of evidence suggest that patients currently treated with ICI do not display an increased vulnerability to infection with SARS-CoV-2. Data regarding morbidity and mortality associated with COVID-19 in cancer patients receiving ICI are less clear and often conflicting. Although mostly based on experimental data, it is possible that ICI can promote the exacerbated immune response associated with adverse outcome in COVID-19 patients. On the other hand, mounting evidence suggests that ICI might even be useful in the treatment of viral infections by preventing or ameliorating T cell exhaustion. In this context, the right timing of treatment might be essential. Nevertheless, some cancer patients treated with ICI experience autoimmune-related side effects that require the use of immunosuppressive therapies, which in turn may promote a severe course of infection with SARS-CoV-2. Although there is clear evidence that withholding ICI will have more serious consequences, further studies are urgently needed in to better evaluate the effects of ICI in patients with COVID-19 and the use of ICI during the corona pandemic in general.

Immune Checkpoints in Viral Infections

As evidence has mounted that virus-infected cells, such as cancer cells, negatively regulate the function of T-cells via immune checkpoints, it has become increasingly clear that viral infections similarly exploit immune checkpoints as an immune system escape mechanism. Although immune checkpoint therapy has been successfully used in cancer treatment, numerous studies have suggested that such therapy may also be highly relevant for treating viral infection, especially chronic viral infections. However, it has not yet been applied in this manner. Here, we reviewed recent findings regarding immune checkpoints in viral infections, including COVID-19, and discussed the role of immune checkpoints in different viral infections, as well as the potential for applying immune checkpoint blockades as antiviral therapy.