An Insight into Covid-19 & Cancer in Edinburgh
This year has been a worrying one for us all, but patients with cancer have been living with huge additional uncertainties. Early evidence suggested that patients with cancer had a two-fold higher mortality rate from COVID-19 than the general population. Experience from previous SARS, MERS and Influenza outbreaks suggested patients with cancer, and particularly those on chemotherapy, would be at higher risk. Cancer care inherently has side effects that can require hospital care, and healthcare capacity was already going to be stretched by COVID-19.
In the UK, cancer services responded accordingly – patients were advised to shield, cancer teams switched to remote out-patient care where possible, treatment strategies were rationalised in discussion with patients and treatments were changed to those considered ‘lower risk’. In Edinburgh, like in many centres, ‘hot’ and ‘cold’ zones were created to separate COVID-19 and non-COVID-19 patients.
But early on, we started to worry about the risk to patients with cancer in the short and long term. In Edinburgh, we looked at the first patients with COVID-19 in our cancer patients, and noticed that our data didn’t entirely back up what the early studies from China and Italy said. The ‘two-fold risk’ had come from studies with very small patient numbers, a hugely diverse interpretation of the definition of ‘cancer’ and often few patients on active treatment. In our patients, we noticed that it was high cancer burden, with inflammatory markers to match, that marked out vulnerable patients, and recent chemotherapy didn’t necessarily lead to a poor outcome. Charities such as Action Radiotherapy shared the concern that more evidence was needed to avoid
the mortality from cancer exceeding that from COVID-19. Coupled with this was the reported drop in cancer diagnoses due to a combination of delayed patient presentation and reduced access to diagnostic services.
The cancer community has worked hard to understand more about COVID-19 and cancer. One project has been a UK-wide registry of cases of COVID-19 in patients with cancer, the UK Coronavirus Cancer Monitoring Project (UKCCMP). Cancer centres all over the UK have been reporting information about each case of COVID-19 in patients with cancer or on cancer treatment to a central database. The resulting information has allowed rapid analysis of large numbers of patients to better understand the risk posed to patients with cancer. Early data suggested that male gender, increasing age and comorbidities were associated with increased mortality, and, importantly, that once these were accounted for, chemotherapy was not. This has been mirrored in two other studies – one from the USA, another from Europe. A subsequent analysis from the UKCCMP showed that not everyone with cancer carries the same level of risk of a poor outcome – which will hopefully allow cancer teams and patients to discuss the risk as relevant to them in more nuanced terms. It has also highlighted that patients with haematological cancers may be at higher risk from severe COVID-19 infection and death than other cancer groups.
The mortality rate of COVID-19 in patients with cancer remains high in most of these studies – in the region of 30%. However, it’s important to remember what the national testing strategy has been for much of the
pandemic. Until recently, people were only tested if they were
symptomatic. Therefore it’s likely the UKCCMP cases as a whole represent a more symptomatic population who needed to go to hospital for assessment. It’s also important to remember it’s not been ‘business as usual’ – patients with cancer have been shielding and outpatient reviews have been done remotely where possible.
It’s clear that cancer doesn’t know there’s a pandemic on, and we need to find ways of continuing as safely as we can to avoid a rise in cancer-related harm.