OUP accepted manuscript

Background

The risks associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated illness, coronavirus disease 2019 (COVID-19), among patients with a cancer diagnosis have not been fully characterized. This study leverages data from a multi-institutional cohort study, the University of California Cancer COVID Consortium, to evaluate outcomes associated with SARS-CoV-2 infection among patients with cancer.

Methods

Clinical data were collected from March to November 2020 and included patient demographics, cancer history and treatment, SARS-CoV-2 exposure and testing, and COVID-19 clinical management and outcomes. Multivariate ordinal logistic regression permitting unequal slopes was used to evaluate the impact of demographic, disease, and treatment factors on SARS-CoV-2 related hospitalization, intensive care unit (ICU) admission, and mortality.

Findings

Among all evaluated patients (n = 303), 147 (48%) were male, 118 (29%) were older adults (≥65 years old), and 104 (34%) were non-Hispanic white. A subset (n = 63, 21%) had hematologic malignancies and the remaining had solid tumors. Patients were hospitalized for acute care (n = 79, 26%), ICU-level care (n = 28, 9%), or died (n = 21, 7%) due to COVID-19. Patients with ≥2 comorbidities were more likely to require acute care (odds ratio [OR] 2.09 [95% confidence interval (CI), 1.23-3.55]). Cough was identified as a significant predictor of ICU hospitalization (OR 2.16 [95% CI, 1.03-4.57]). Importantly, mortality was associated with an active cancer diagnosis (OR 3.64 [95% CI, 1.40-9.5]) or advanced age (OR 3.86 [95% CI, 1.2-12.44]).

Interpretation

This study observed that patients with active cancer or advanced age are at an increased risk of death from COVID-19. These study observations can inform risk counseling related to COVID-19 for patients with a cancer diagnosis.

Examining reporting and representation of patients with cancer in COVID-19 clinical trials

BACKGROUND

Patients with cancer are particularly vulnerable in the current COVID-19 pandemic. Emerging evidence suggests that patients with a cancer diagnosis are three times more likely to die from COVID-19 compared to non-cancer patients. Due to these observed risks, it is critical that emerging COVID-19 therapies demonstrate safety and efficacy among patients with cancer.

AIM

This study sought to examine reporting and representation of patients with cancer among published COVID-19 treatment-related research studies.

METHODS AND RESULTS

All published COVID-19 treatment-related clinical research studies published from March 1 to August 20, 2020 recruiting from North America and Europe were identified. The date published, study design, therapeutics studied, and study population were evaluated. Of the 343 studies identified through initial search and researcher knowledge, 55 (16%) reported on COVID-19 treatments. Twenty-one COVID-19 therapeutic studies (n = 15, prospective; n = 6, retrospective) that recruited from the United States and Europe were identified. Among these studies, eight (38%) reported on the number of trial participants with a cancer diagnosis in the publication and two (10%) specified tumor type. Four of the studies (19%) did not collect cancer history. Among studies where cancer history was available, patients with a cancer diagnosis participated at a proportion higher than overall cancer prevalence and greater than the known proportion of COVID-19 patients with cancer.

CONCLUSION

This study observed that cancer history was not uniformly collected or reported among published COVID-19 therapeutic studies. Among reported publications, we observed that patients with a cancer diagnosis were generally overrepresented. However, patients with a cancer diagnosis were notably underrepresented in outpatient COVID-19 therapeutic studies.

Abstract P1-11-18: Measuring severe anxiety in patients with metastatic breast cancer: Living up to the PROMIS

Purpose/Objective(s):

Symptom burden in the advanced cancer patient can be substantial. PROMIS (Patient Reported Outcome Measurement Information System) is a powerful PRO symptom assessment tool that is increasingly being utilized at the point of care through patient-facing electronic health record (EHR) systems. However, the PROMIS threshold (T-score) for detecting severe anxiety has not been previously validated for patients with advanced breast cancer. The sensitivity/specificity of current expert derive threshold T-score of >/=75 in this specific population is not known. In this study, we compared PROMIS scores with the PRO-CTCAE anxiety instrument—a standard PRO tool used in the setting of clinical trials that assesses anxiety frequency, severity, and interference with usual activities—to examine the best T-score to use for PROMIS to guide management in advanced breast cancer care.

Materials/Methods:

A total of 84 unique visits of 74 English speaking patients on active cancer treatment for metastatic breast cancer were assessed using electronic PROMIS CAT (Computer Adaptive Test) and PRO-CTCAE at the UCSF Carol Buck Breast Cancer Center. Assessment forms were displayed on a touch screen tablet and completed by the patient at check-in for weekly treatment visits. PRO-CTCAE anxiety questions were graded on a scale of 1 (none) to 5 (disabling). Any score of grade >/=4 (severe to disabling) for frequency, severity or interference was defined as severe anxiety.

Results:

There was a strong correlation of PROMIS T-score and maximum PRO-CTCAE grade (highest grade of frequency, severity, or interference); Spearman correlation coefficient = 0.77 (P= <0.001). No patients reached the expert derived severe threshold of PROMIS T-score 75. Highest PROMIS T-score was 69 (range, 33-69). 11 patients reported severe or disabling anxiety by PRO-CTCAE at one visit. Area under the ROC analysis identified a cutoff that maximizes Youden's index at 55.05—sensitivity = 100% (95% CI) and specificity = 63% (95% CI).

Conclusion:

Electronic systems with integrated patient reported outcomes (PROs) along with validated thresholds to identify severe anxiety will allow for systematic identification of symptoms at point of care and the opportunity to respond rapidly to those symptoms most distressing to patients.

Citation Format: Marquez C, Li Y, Huang C-Y, Rugo H, Rabow M, Melisko M, Esserman L. Measuring severe anxiety in patients with metastatic breast cancer: Living up to the PROMIS [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-18.

The value of embedding: integrated palliative care for patients with metastatic breast cancer

PURPOSE

The American Society of Clinical Oncology recommends concurrent palliative care (PC) for patients with metastatic cancer. Recent data show benefits of early PC (at least 90 days before death). However, little is known about PC among patients who die from metastatic breast cancer.

METHODS

Patients with metastatic breast cancer at a comprehensive cancer center. Analysis of medical records and clinician and patient surveys. Assess referral patterns and value to patients at the end of life (EOL) of a specialty PC service embedded in a breast oncology program; compare to a prior period of stand-alone PC.

RESULTS

In the 18-month study period, oncologists referred for palliative care 105 of their 515 (20.4%) patients; 59 (11.5%) patients were seen by the PC physician. Of the 38 referred patients who died, 23 (60.5%) were seen by embedded PC and all 23 received PC within 90 days of death; 0 of 18 decedents with data available for analysis had ICU stays within 30 days of death. In an earlier 24-month period of stand-alone PC, 43 patients died after receiving PC, but only 11 (25.5%) received PC within 90 days of death (p < 0.01) and 7 of 43 had ICU stays within 30 days of death (p = 0.074).

CONCLUSIONS

Embedded PC was well-received by patients and oncologists, increased early PC referrals, and improved EOL care. Avoidable, unnecessary health care utilization at the end of life, such as ICU stays in the last month of life, represent an important potential reduction in patient suffering and system costs.