Cancer and Covid-19: The case of Cyprus during the first wave of the pandemic
Katodrytis N 1 , Drakos P 1 , Vasiliou B 1 , Pittaka M 1 , Konstantinidou A 1
1 Oncologist, Board Member of the Cyprus Oncology Society (OEK)
Summary
Introduction: Traditionally and for many reasons, cancer patients are considered susceptible to infections. Therefore, during the Covid-19 pandemic, patients diagnosed with cancer were treated in Cyprus, as worldwide, as a vulnerable group.
Purpose and method: The purpose is to evaluate the available data of patients with Covid-19 – with a pre-existing diagnosis of cancer in Cyprus. The data were obtained from the National Report of the Ministry of Health of the Republic of Cyprus and compared with the international bibliography.
Results: As of 25 August 2020, 1,442 cases of Covid-19 and 27 deaths had been recorded. Information on underlying diseases, including cancer, was available for 1,370 cases (90.6%). A cancer diagnosis was reported by 29 individuals (2.2%), of whom 4 died (13.8%) with only one having a confirmed cause of death as Covid-19.
Conclusion: Despite the small number of cases involving cancer patients, all available epidemiological data are consistent with international reports.
Import
Due to the nature of cancer, its occurrence mainly in the elderly, the immunosuppression caused by both the malignancy itself and the treatments with which it is combated, and due to frequent hospital visits, cancer patients have traditionally been considered susceptible to infections, which was also true in the case of the Covid-19 pandemic. [1-6] A study from China showed that cancer patients, due to frequent hospital visits, had a 2.31-fold higher risk of being infected with the SARS-COV-2 coronavirus. [1] Therefore, during the Covid-19 pandemic, patients diagnosed with cancer were treated worldwide as a vulnerable group.
In Cyprus, the measures taken by the state to protect the population were deemed satisfactory by the oncology community for the protection of, among others, the group of cancer patients. [7] At the same time, it was clarified by the competent scientific society that not all cancer patients are vulnerable to infections, but especially those who are receiving immunosuppressive treatment or have completed it a few months earlier, a position that is consistent with the positions of national and international organizations, such as the Hellenic Society of Oncologists (ESMO) and the European Society for Medical Oncology (ESMO) and which is confirmed by recent studies. [2, 8] At the same time and in addition to the state guidelines, international recommendations were adopted (ESMO, ASCO, NHS) and guidelines were issued for doctors for the management of cancer patients in the midst of the pandemic. [9]
The “one size fits all” model was adopted by the state and implemented in Cyprus, as it is worldwide, since the individualized treatment of cases was, firstly, not justified by the scientific data in force before the pandemic and, secondly, it entails risks for patients.
Purpose and method
The aim of the study is to evaluate the available data of patients with Covid-19 – with a pre-existing diagnosis of cancer in Cyprus. The data were obtained from the National Report of the Ministry of Health of the Republic of Cyprus.
Through a review of international literature, an attempt was made to compare Cyprus’ data with those observed internationally.
Results: Pandemic data in relation to cancer in Cyprus
Based on data published on 27 August 2020, as of 25 August 2020, 1,442 Covid-19 cases and 27 deaths were recorded in Cyprus (fatality rate of diagnosed Covid-19 cases: 1.9%). 51.4% of Covid-19 cases were male and 48.6% female. The median age was 39 years (Interquartile range: 27-56 years). [10]
Information on underlying diseases, including cancer, was available for 1,370 cases (90.6%), of which 448 (34.2%) reported at least one pre-existing disease. A cancer diagnosis was reported by 29 individuals, corresponding to a rate of 2.2%, while in the general population it is estimated at 0.43% (423 individuals/100,000 inhabitants, 2017 data). [10, 11]
Of the 29 patients diagnosed with cancer who developed Covid-19, 4 died (13.8%). These were 4 men, with one of them having a confirmed cause of death of Covid-19. The median age was 81 years (Interquartile range: 67.5-88). The 4 cancer patients who died represent 14.8% of all Covid-19 cases that died. [10]
Since the interquartile range of time to death for all Covid-19 patients (n=27) was 4 to 30 days (median time between sampling and death was 12 days), it is concluded that 50% of deaths in cancer patients occurred within 30 days of the sampling date. [10]
Discussion
Although studies show that patients with cancer are more likely to be infected with the SARS-COV-2 coronavirus [1, 12], some attribute the increased incidence to the older age of the patients, poor clinical condition, gender, and comorbidities they usually present.[2-4, 6] Some even conclude that it is not clear from the new scientific data that the increased incidence of infections is due to the underlying malignancy.[2] It is also interesting to note that several studies do not associate receiving chemotherapy or other anticancer treatment within the last 4 weeks before the diagnosis of Covid-19 with increased mortality [3, 4, 13] while there are also those, such as those by Yang et al (2020) from Wuhan, that report receiving chemotherapy 4 weeks before the onset of symptoms as a factor in increased risk of death. [14] Additional studies have shown that cancer patients are at a much higher risk of serious complications after infection with SARS-COV-2 than patients without cancer. [6, 15] The most comprehensive study is that of Singh et al (2020), who reported a relative risk of 2.48 (95% CI 1.46-4.19) after analyzing 18 studies. [16] Desai et al (2020) state that no conclusions can be drawn from the evidence so far regarding the suspension or delay of anticancer treatments and emphasize that special attention should be paid to cancer patients considering that they are at higher risk. [17] At the same time, researchers emphasize that published data should be treated with caution and may overturn existing recommendations and tactics. [18]
Qiang Su et al (2020) in a meta-analysis of 32 studies with 21,248 patients between December 2019 and May 3, 2020, showed that the cancer rate among Covid-19 patients was 3.97%, much higher than the overall cancer rate in China (0.29%). Further analysis revealed that the overall cancer rate in Covid-19 patients in China was 2.59%, specifically in Wuhan 3.79% and in other regions of the country outside Wuhan 2.31%. [19]
Other review studies have shown rates between 0.92% and 3.4%. [17, 20, 21] Higher rates of cancer in patients with Covid-19 have been reported in individual studies, such as that by M. Montopoli et al (2020), who reported that of 9,280 patients with Covid-19 hospitalized in 68 hospitals in Veneto, Italy, 8.5% had a pre-existing diagnosis of cancer.[22] A rate of 7.2% was reported in a review of 138 hospitalized patients at Zhongnan Hospital, China. [2]
As can be seen, the percentage of cancer patients among Covid-19 patients in Cyprus (2.2%) appears lower than those reported in areas that were hit hard by the pandemic, while it fluctuates at satisfactory levels and within the percentages reported in the literature, in relation to areas with a good epidemiological profile.
Regarding cancer deaths among patients with Covid-19, the literature reports rates between 5.6% and 28%.[2, 3, 5, 13, 23] Based on the recent update as presented in the “COVID-19 and Cancer Consortium (CCC-19)”, the average mortality rate is estimated at 16%.[5] The 13.8% observed in Cyprus is within the range of international reports and below the average (16%).
During the presentation of the results of a database with 2,749 patients at the “2020 AACR Virtual Meeting on COVID-19 and Cancer”, it was reported that patients with ECOG performance status level 0 and no comorbidities have a mortality rate of only 4%.[5] This confirms the report of several studies that an increased mortality rate is observed in elderly cancer patients with poor clinical status level >2 on the ECOG scale and advanced stage. [5, 13, 15] Apart from the reference to the median age which with 81 years (Interquartile range: 67.5-88) is consistent with the bibliographic reports, data on the clinical status of the patients are not available for Cyprus. [10]
Studying the mortality in relation to the type of cancer in the above research (n= 2749) it is evident that the highest percentage with 26% (n=61/237) concerns lung cancer, with prostate cancer (n=39/392), and bowel cancer (n=36/186) at 18% and 19% respectively, while breast cancer (n=502) presents a mortality of 8%. [5] Unfortunately, a similar comparison cannot be made with the available data for Cyprus.
The increased risk of death in men with cancer observed in Cyprus was confirmed both during the proceedings of the “2020 AACR Virtual Meeting on COVID-19 and Cancer” and by other studies. [5, 14]
In a presentation by Jeremy L. Warner during the 2020 ASCO Virtual Scientific Program, it was reported that patients with progressive cancer had a 5.2-fold higher risk of dying within 30 days of the date of Covid-19 diagnosis compared to patients in remission or without evidence of cancer. [5] Cancer type and treatment received did not increase the risk of death within 30 days of Covid-19 diagnosis. [23] In Cyprus, at least 50% of cancer patients (n=4/29) who died died within 30 days of Covid-19 diagnosis [10], which is consistent with international reports. Data on cancer type and treatment received are not available in Cyprus.
Conclusion
As can be seen, the percentage of cancer patients among Covid-19 patients in Cyprus is lower than the percentages reported in areas that were hit hard by the pandemic, while it fluctuates at satisfactory levels and within the percentages reported in the literature, in relation to areas with a good epidemiological profile. This is likely due to the correct guidance that Cypriot cancer patients received and the discipline that the patients themselves demonstrated in implementing the instructions of the state and their treating doctors.
The “one size fits all” model seems to have worked in the case of Cyprus. New scientific data that may lead to a change in the policy of treating cancer patients in the midst of a pandemic should be studied carefully.
Despite the small number of cases involving cancer patients, all available epidemiological data (age, gender, time to death from the day of diagnosis with Covid-19) are consistent with international reports.
The result demonstrates that the management of the pandemic was timely and effective. The experience gained may prove useful, both at the political and medical level, in dealing with a possible second wave of the pandemic.
Thanks:
Thanks to George Nikolopoulos, member of the Advisory Scientific Committee of the Ministry of Health for addressing the Covid-19 pandemic, for the exchange of scientific opinions on epidemiology issues.
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