COVID-19 infection among patients with cancer in Australia from 2020 to 2022: a national multicentre cohort study

Background

The global COVID-19 pandemic disproportionately affected certain populations and its management differed between countries. This national study describes characteristics and outcomes of COVID-19 in patients with cancer in Australia.

Methods

We performed a multicentre cohort study of patients with cancer and COVID-19 from March 2020 to April 2022. Data were analysed to determine varying characteristics between cancer types and changes in outcomes over time. Multivariable analysis was performed to determine risk factors associated with oxygen requirement.

Findings

620 patients with cancer from 15 hospitals had confirmed COVID-19. There were 314/620 (50.6%) male patients, median age 63.5 years (IQR 50-72) and majority had solid organ tumours (392/620, 63.2%). The rate of COVID-19 vaccination (≥1 dose) was 73.4% (455/620). Time from symptom onset to diagnosis was median 1 day (IQR 0-3), patients with haematological malignancy had a longer duration of test positivity. Over the study period, there was a significant decline in COVID-19 severity. Risk factors associated with oxygen requirement included male sex (OR 2.34, 95% CI 1.30-4.20, p = 0.004), age (OR 1.03, 95% CI 1.01-1.06, p = 0.005); not receiving early outpatient therapy (OR 2.78, 95% CI 1.41-5.50, p = 0.003). Diagnosis during the omicron wave was associated with lower odds of oxygen requirement (OR 0.24, 95% CI 0.13-0.43, p < 0.0001).

Interpretation

Outcomes from COVID-19 in patients with cancer in Australia over the pandemic have improved, potentially related to changing viral strain and outpatient therapies.

Funding

This study was supported by research funding from MSD.

Final overall survival analysis and organ-specific target lesion assessments with two-year follow-up in CheckMate 9ER: Nivolumab plus cabozantinib versus sunitinib for patients with advanced renal cell carcinoma

350

Background: First-line nivolumab plus cabozantinib (N+C) demonstrated superiority over sunitinib (SUN) in the primary disclosure of the phase 3 CheckMate 9ER trial (NCT03141177; 10.6 months minimum follow-up; Choueiri TK et al. N Engl J Med 2021) in patients (pts) with advanced renal cell carcinoma (aRCC). Here, we report the preplanned final overall survival (OS) analysis with updated efficacy and safety in intent-to-treat (ITT) pts, and an exploratory assessment of target lesions by organ site after extended follow-up. Methods: Pts with aRCC (clear cell component) were randomized to N 240 mg every 2 weeks + C 40 mg once daily vs SUN 50 mg once daily (4 weeks of 6-week cycles). The primary endpoint was RECIST v1.1–defined progression-free survival (PFS) by blinded independent central review (BICR) in ITT pts; secondary endpoints included OS, objective response rate (ORR) by BICR, and safety. The preplanned final OS analysis was set to occur after observing 254 events. Maximal reduction of target lung, lymph node, kidney, and liver lesions were evaluated per BICR via post hoc exploratory analyses. Results: After 25.4 months minimum follow-up (median, 32.9 months) for OS in ITT pts, a total of 271 OS events occurred, and N+C continued to demonstrate OS improvement vs SUN (N = 323 vs 328; median 37.7 vs 34.3 months; HR 0.70 [95% CI 0.55–0.90]). PFS (median 16.6 vs 8.3 months; HR 0.56 [95% CI 0.46–0.68]) and ORR (55.7% [95% CI 50.1–61.2] vs 28.4% [95% CI 23.5–33.6]) benefits were maintained with N+C vs SUN, and 12.4% (N+C) vs 5.2% (SUN) of pts had a complete response. Median duration of response was 23.1 months with N+C vs 15.1 months with SUN. A higher percentage of pts experienced any reduction and ≥30% reduction from baseline with N+C vs SUN in target lesions at all organ sites assessed (Table). Among all treated pts, 97.2% (N+C; N = 320) vs 93.1% (SUN; N = 320) had a treatment-related adverse event (TRAE) of any grade (65.0% vs 54.1% had a grade ≥ 3 TRAE). Conclusions: N+C continued to provide survival improvement vs SUN among ITT pts in the final OS analysis, additionally PFS and ORR benefits with N+C were sustained with minimum 2-year follow-up. A higher proportion of pts experienced tumor shrinkage benefit with N+C vs SUN across all 4 organ sites assessed. No new safety signals emerged with extended follow-up in either arm. These results highlight N+C as a first-line treatment for pts with aRCC. Clinical trial information: NCT03141177. [Table: see text]

The effects of unintentional drowsiness on the velocity of eyelid movements during spontaneous blinks

OBJECTIVE

Unintentional drowsiness, when we should be alert, as for example when driving a vehicle, can be very dangerous. In this investigation we examined the effects of unintentional drowsiness on the relative velocities of eyelid closing and reopening movements during spontaneous blinks.

APPROACH

Twenty-four young adults volunteered to take part in this experiment, and 18 were finally accepted. They performed a 15 min visual reaction-time test at the same time of day and under the same environmental conditions with and without overnight sleep deprivation, one week apart. Their eyelid movements during blinks were monitored by a system of infrared reflectance blepharometry during each test.

MAIN RESULTS

Very close relationships between the amplitude and maximum velocity of eyelid closing and reopening movements were confirmed. Frequency histograms of amplitude-velocity ratios (AVRs) for eyelid closing and reopening movements showed significant differences between alert and drowsy conditions. With drowsiness, eyelid movements became slower and AVRs increased for many but not all blinks. We also described a time-on-task effect on the relative velocities of eyelid movements which was more apparent in the drowsy condition. Eyelid movements became progressively slower during the first half of the test. This was presumably due to a short-lived alerting effect of starting the test.

SIGNIFICANCE

The relative velocity of eyelid closing and reopening movements during spontaneous blinks decreases with unintentional drowsiness but is sensitive to the brief alerting stimulus of starting a reaction-time test.

Comparable survival outcome of metastatic colorectal cancer in Indigenous and non-Indigenous patients: Retrospective analysis of the South Australian metastatic colorectal cancer registry

OBJECTIVE

This study aims to investigate disparities in demographics, disease characteristics, treatment and overall survival between South Australian (SA) Indigenous and non-Indigenous patients with metastatic colorectal cancer (mCRC).

DESIGN

This employs a retrospective population study using the SA mCRC registry.

SETTING

The SA mCRC registry identifies mCRC patients from hospital encounters, histopathology reports, medical oncology letters, clinician notification, attendances at multidisciplinary meetings and death audits by the SA Cancer Registry.

PARTICIPANTS

A total of 2865 adult mCRC patients including 14 Indigenous patients were identified through the SA mCRC registry between February 2006 and August 2013. Patients were linked to the SA Cancer Registry to obtain Indigenous status.

MAIN OUTCOME MEASURES

Demographic, disease and treatment characteristics were compared using Chi-squared test and t-test; while overall survival defined as time to any cause of death was analysed using Cox regression.

RESULTS

No difference was observed for clinical characteristics, except for a higher proportion of Indigenous patients receiving chemotherapy (85.7% versus 58.5%; P = 0.04). The rate of liver surgery was similar across the two groups (21.0% versus 15.1%; P = 0.40). The median overall survivals were equivalent (11.9 months versus 15.1 months; hazard ratio = 1.00; 95% confidence interval for hazard ratio, 0.54-1.86).

CONCLUSIONS

Clinical characteristics and survival outcomes were similar between Indigenous and non-Indigenous patients captured on the SA mCRC registry, and outcome of those who have an access to comprehensive cancer care appeared independent of Indigenous status and in line with large clinical trials. Underestimation of Indigenous cases due to their lower utilisation of cancer service could not be excluded and ultimately the accurate reporting of these patients is crucial.

Equivalence of outcomes for rural and metropolitan patients with metastatic colorectal cancer in South Australia

OBJECTIVE

To compare the management and outcome of rural and metropolitan patients with metastatic colorectal cancer (mCRC) in South Australia.

DESIGN, SETTING AND PATIENTS

Retrospective cohort study of patients with mCRC submitted to the South Australian mCRC registry between 2 February 2006 and a cut-off date of 28 May 2012.

MAIN OUTCOME MEASURES

Differences in oncological and surgical management and overall survival (calculated using the Kaplan-Meier method) between city and rural patients.

RESULTS

Of 2289 patients, 624 (27.3%) were rural. There was a higher proportion of male patients in the rural cohort, but other patient characteristics did not significantly differ between the cohorts. Equivalent rates of chemotherapy administration between city and rural patients were observed across each line of treatment (first line: 56.0% v 58.3%, P = 0.32; second line: 23.3% v 22.5%, P = 0.78; and third line: 10.1% v 9.3%, P = 0.69). A higher proportion of city patients received combination chemotherapy in the first-line setting (67.4% v 59.9%; P = 0.01). When an oxaliplatin combination was prescribed, oral capecitabine was used more frequently in rural patients (22.9% v 8.4%; P < 0.001). No significant difference was seen in rates of hepatic resection or other non-chemotherapy treatments between cohorts. Median overall survival was equivalent between city and rural patients (14.6 v 14.9 months, P = 0.18).

CONCLUSION

Patterns of chemotherapy and surgical management of rural patients with mCRC in SA are equivalent to their metropolitan counterparts and lead to comparable overall survival. The centralised model of oncological care in SA may ensure rural patients gain access to optimal care.

Predictive biomarkers of response to anti-EGF receptor monoclonal antibody therapies

SUMMARY 

The EGF receptor (EGFR) pathway plays an important role in the progression of several carcinomas, including colorectal cancer (CRC). The EGFR has emerged as a candidate for targeted therapy for CRC. Two monoclonal antibodies used to inhibit the EGFR signaling pathway are cetuximab and panitumumab. Both these monoclonal antibodies inhibit tumor-promoting activities, such as tumor cell proliferation, survival, angiogenesis and metastasis. However, only a subpopulation of metastatic CRC patients responds to such therapy. Constitutive activation within the pathway gives rise to other aberrantly expressed biomarkers that are able to circumvent the anti-EGFR treatment and confer resistance. Mechanisms of resistance and the value of these emerging predictive biomarkers in the clinical setting are discussed in this review.

A new perspective on family involvement in chronic pain management programmes

OBJECTIVES

The aim of this study was to investigate how those with pain, and their significant others, perceive the involvement of significant others in a multidisciplinary chronic pain management programme.

METHODS

Semi-structured telephone interviews were conducted with eight people who had attended a Family Day as part of a three-week multidisciplinary chronic pain management programme in Auckland, New Zealand. Four of the participants had pain and four were significant others. Follow-up interviews were conducted with seven of the participants up to one year after their initial interview. Conventional content analysis was used to analyse collected data.

RESULTS

Participants viewed the involvement of significant others to be important because managing pain necessitates 'being on the same page' and significant others also needed an opportunity to access support and information.

CONCLUSION

The involvement of significant others in programmes is perceived to be important but must be a balance between what is feasible for significant others and beneficial for all. Further research into when and how significant others are included within programmes is urgently required.

Can we accurately report PTEN status in advanced colorectal cancer?

BACKGROUND

Loss of phosphatase and tensin homologue (PTEN) function evaluated by loss of PTEN protein expression on immunohistochemistry (IHC) has been reported as both prognostic in metastatic colorectal cancer and predictive of response to anti-EGFR monoclonal antibodies although results remain uncertain. Difficulties in the methodological assessment of PTEN are likely to be a major contributor to recent conflicting results.

METHODS

We assessed loss of PTEN function in 51 colorectal cancer specimens using Taqman® copy number variation (CNV) and IHC. Two blinded pathologists performed independent IHC assessment on each specimen and inter-observer variability of IHC assessment and concordance of IHC versus Taqman® CNV was assessed.

RESULTS

Concordance between pathologists (PTEN loss vs no loss) on IHC assessment was 37/51 (73%). In specimens with concordant IHC assessment, concordance between IHC and Taqman® copy number in PTEN loss assessment was 25/37 (68%).

CONCLUSION

Assessment PTEN loss in colorectal cancer is limited by the inter-observer variability of IHC, and discordance of CNV with loss of protein expression. An understanding of the genetic mechanisms of PTEN loss and implementation of improved and standardized methodologies of PTEN assessment are required to clarify the role of PTEN as a biomarker in colorectal cancer.

Proangiogenic tumor proteins as potential predictive or prognostic biomarkers for bevacizumab therapy in metastatic colorectal cancer

Tumor biomarkers to more accurately predict a patient's response to a given therapy are much needed in oncology practice. For metastatic colorectal cancer the anti-vascular endothelial growth factor (VEGF) monoclonal antibody bevacizumab is now commonly included in first-line therapy regimens and has led to modest but significant improvements in patient outcomes compared with chemotherapy. Given the modest gains there is a pressing need for predictive biomarkers to better identify patients who would benefit from this targeted therapy. We used a multiplex protein assay to determine the tumor expression levels of the proangiogenic proteins IL-6, IL-8, bFGF, PDGF-BB and VEGF-A in formalin-fixed paraffin-embedded tumors from the MAX clinical trial patients with available tissue samples. Patients were dichotomized into "low" vs. "high" expression subgroups based on median baseline levels to correlate with objective response rate (ORR), progression-free survival (PFS) and overall survival (OS). "Low" tumor VEGF-A level was predictive of better ORR for bevacizumab [ORR (low) 53% vs. (high) 19%, interaction p = 0.03] but not for PFS [hazard ratio, HR (low) 0.73 vs. (high) 0.62, interaction p = 0.68] in the comparison of capecitabine (C) versus C and bevacizumab (CB) and CB plus mitomycin (M). When analyzed as a dichotomized variable, "high" VEGF-A was prognostic for shorter PFS (unadjusted HR 1.34, p = 0.06; adjusted HR 1.55, p = 0.008). The other four proteins were neither predictive of bevacizumab benefits nor prognostic for ORR, PFS or OS. "Low" tumor VEGF-A was associated with longer PFS after adjustment for other baseline factors. Proangiogenic proteins were not predictive of benefit with bevacizumab for PFS.

Right (R) or left (L) primary site of colorectal cancer and outcomes for metastatic colorectal cancer (mCRC): Results from the south Australian registry of mCRC

596

Background: Previous reports have described differences in biology and outcome based on whether the primary is R or L sided. Possible differences in response to biological agents have also been reported based on side of primary lesion (SY Brule et al., JCO31, 2013 (supp #3528). Methods: We explored the SA mCRC registry to assess if there were any differences in patient characteristics, treatment received and outcomes based on whether the primary was R (caecum to transverse colon) or L (splenic flexure to rectum) sided (JA Bufill, Ann Int Med. 113, 1990, 779-788). KM was used for survival outcomes and Cox proportional hazards regression modeling was used to assess defined prognostic markers. Results: 2,877 patients were analysed. 33% had R sided primary. Major differences between R and L respectively are as follows; Female 51.3% vs. 37.9% (p = <0.0001), Med age 75.8 yrs vs. 70.5yrs (p = <0.0001), poorly differentiated pathology 34.3% vs. 20.8% (p = <0.0001), KRAS mutation 48% vs. 37% (p = 0.023), and liver surgery 10.5% vs. 16.3% (p = <0.0001). Analysis of chemotherapy (defined as either cytotoxic and/or molecular-targeted) revealed similar rates of first-line therapy, but differences in rates of therapy beyond first-line R vs. L respectively; second-line 46% vs. 60.4%, third-line 17% vs. 30%, fourth-line 7% vs. 13%. There was however no difference in single agent vs. combination first-line therapy. The median overall survival (mOS) for the entire group R vs. L was 9.6 vs. 20.3 months (p <0.0001). For the group who had active therapy defined as chemotherapy (+/- metastasis resection), mOS was R 18.2 months vs. L 29.4 months (p <0.0001). For those (n = 123) who underwent liver resection (+/- chemotherapy) mOS was 6.2 years for both R and L (p = 0.32). Patients who were treated with only chemotherapy, the mOS was 10.7 mths vs. 15.3 mths for R v L (p = 0.0005). Conclusions: Patients with R sided primary have more negative prognostic factors and indeed have inferior outcomes when compared with those with a L sided primary. This did not appear to be the case for patients who were suitable for hepatic surgery.

Evaluation of cognitive performance in the heat by functional brain imaging and psychometric testing

Military operations in tropical environments have imposed a significant challenge to the Australian Defence Forces (ADF). The hot and humid conditions are known to cause debilitating effects on soldiers deployed to northern regions of Australia, with the consequence that the effectiveness and efficiency of operations are severely compromised. While the adverse effects of thermal stress on soldiers' physiological capability are well established, this has not been confirmed for cognitive performance. A select range of psychometric tests were administered and functional brain electrical activity imaging was performed to investigate the impact of thermal stress on cognitive performance. The brain electrical activity of subjects was measured while undertaking a range of cognitive tasks. Steady State Probe Topography (SSPT), a novel brain imaging technology, was employed to monitor the changes in regional brain activity and neural processing speed of subjects under thermal stress. The psychometric test batteries included the following tasks; Rey Auditory Verbal Learning Test; Inspection Time; Digit Span test; a spatial working memory task; and the AX-continuous performance task. These tasks measure a range of cognitive processes including attention, memory, verbal learning, information processing and concentration. The functional brain imaging provided topographical information, which showed changes in electrical activity in response to thermal stress during cognitive performance. These changes in brain electrical activity and neural speed induced by thermal stress may help to identify the type of cognitive functions that are likely to be impaired under operational conditions. Results indicated that subjects experienced increasing cardiovascular strain through thermally neutral to thermally straining conditions. The results from the psychometric test battery showed some promising effects given the small sample size including deficits in working memory, in information retention and in information processing. There was also marked differences in the electrical responses of the brain when subjects were thermally strained. The Steady-State Visual Evoked Potential recordings showed an increase in amplitude and a decrease in latency, suggesting an increase in the utilisation of neural resources or effort by subjects to maintain the same level of performance as under thermally neutral conditions. The data are suggestive of the high sensitivity of brain imaging techniques with high temporal resolution to identify important decrements in cognitive performance in hostile environments.

Reflections on a renaissance of occupation

At the close of the 20th century, there is a renaissance of occupation in occupational therapy and occupational science. Kielhofner (1992) offers an intraprofessional explanation that the growing interest in occupation recaptures occupational therapy's lost identity. An extraprofessional explanation is that postmodern ideas and social practices have helped to create a societal context in which a renaissance of occupation is welcome. Postmodernism raises questions and awareness of power, diversity, temporality, and situatedness in which normative ideas of occupation as paid work can be challenged. Since occupation is of primary concern to occupational therapy and occupational science, the authors reflect on postmodernism and its influence on a renaissance of occupation in these two fields. These reflections consider what such a renaissance means for occupational therapists and occupational scientists in the 21st century.

Sensitivity of Shah, Vanclay and Cooper's modified Barthel Index

OBJECTIVE

To investigate whether Shah, Vanclay and Cooper's modification of the Barthel Index improved its sensitivity to change.

DESIGN

Correlational study.

SETTING

School of Occupational Therapy at Auckland Institute of Technology, Auckland, New Zealand.

SUBJECTS

One hundred subjects requiring rehabilitation following a stroke.

MAIN OUTCOME MEASURES

Change in function which was measured using Shah, Vanclay and Cooper's (1989) modified Barthel Index and walking speed over 10 metres.

RESULTS

Five statistical analyses were undertaken, none of which demonstrated clear superiority of one measure over the other.

CONCLUSIONS

The study did not indicate the modified Barthel Index to be more sensitive to change than the 20-point Barthel Index for this population. The statistical analysis strategies utilized are recommended for similar studies.

Shared responsibility for ongoing rehabilitation: a new approach to home-based therapy after stroke

OBJECTIVE

To assess the efficacy of a programme of continuing self-directed exercises for people discharged home after a stroke, supervised once a week by therapists.

DESIGN

A randomized controlled trial of 100 patients discharged from hospital after a stroke, requiring ongoing therapy. The control group received outpatient or day hospital therapy; the experimental group were visited once a week by an occupational and/or physiotherapist who prescribed a programme of exercises and activities for the following week. Subjects were studied for the first three months after discharge from hospital.

SETTING

A district general hospital, or the homes of subjects randomized to the experimental group, in New Zealand.

MAIN OUTCOME MEASURES

(1) Characteristics of the groups, (2) gait speed, limb function, activities of daily living, (3) time with therapists, (4) mood of both subjects and caregivers, (5) anticipation of outcome at entry, compared with perceived outcome at exit.

RESULTS

No statistical differences between the control and experimental groups in characteristics, or in any outcomes measured, except that the contact time period, but not the number of visits, was longer in the experimental group (p = 0.003).

CONCLUSIONS

A supervised home-based programme is as effective as outpatient or day hospital therapy.