CCC19 is a grassroots consortium that was founded by the five founding institutions. It started with a social media tweet and it has snowballed into a global phenomenon. We have more than a hundred cancer centres and institutions who are participating right now. It’s one of the first registries that has started collecting data on our patients with cancer and COVID-19 and now it’s the largest registry with a global reach.
This was conceived and developed within less than a month and we have more than 2,000 cases of COVID-19 in our patients with cancer.
What were your methods?
This is the first publically released analysis of our cohort within the first month of data lock. We have reported patients’ clinical course and outcomes in more than 1,000 patients who were infected with the SARS-CoV-2 virus. We looked at thirty day mortality and also a secondary endpoint of severe disease. We examined pre-specified clinical variables which have had a significant impact on cancer outcomes and understand how those risk factors affect the disease course of COVID-19 in our patients.
What were the main findings?
One of the main findings of our studies is that we identified a 13% mortality rate in our patients. This is more than double than what was reported as the global death rate by John Hopkins Group. This, again, is not uniformly distributed – certain subgroups have 0% mortality, especially those who are younger fit patients with no comorbidities and greater ECOG performance status. However, those who have poor ECOG performance status, that is 2 or more, and probably who required mechanical ventilation, they had mortality rates as high as 85%. So there’s a wide range of mortality in different groups of cancer patients and not everyone is affected equally.
Now, with regards to the risk factors, after a partial adjustment what we identified is older age, male sex, being a former smoker and having two or more comorbidities or chronic conditions which required active treatment were associated with high mortality rates. With regards to cancer specifically we identified that, again, ECOG performance status of 2 or more and also having active cancer which is progressing or even stable had a higher mortality rate compared to if the cancer was in remission. We identified that the drug combination of hydroxychloroquine and azithromycin had a higher death rate. This could not be confirmed, it could not be ruled out by indication of prescribing these drugs and also the severity of disease when it was prescribed or administered. What we did find is different variables that have been reported by other studies, such as race, ethnicity, obesity specifically and also receipt of chemotherapy or surgery within the past four weeks was not associated with death. So these are some of the main findings of our study.
What is the significance of these findings?
First of all, the most important take home point is that cancer patients are significantly affected with COVID-19, so much more than the general population. So these are highly vulnerable patients and we need to be very mindful about the elevated risk of mortality in these patients. Having said that, not everyone has the same risk so identifying patients who have a higher risk such as a poorer performance status is important, or age, male sex or comorbidities is important.
Now, what everyone had on their minds with regards to the impact of COVID-19 and how this would affect the cancer care, all of our physicians, patients, caregivers, they wanted to know or are interested to know how COVID-19 would affect the cancer care.
Taken together these study findings suggest that fit cancer patients who have few comorbidities can and should proceed with lifesaving anticancer treatment. Patients who do have poor performance status or active cancer need to have a very thoughtful considerable discussion with their care providers about the risk versus benefit of their treatment.
Was the data obtained from US centres only or was it also obtained globally?
The majority of our patients were based in the US although we did have almost 11% of our cases reported from Argentina, Spain and Canada, but largely it is based in the US. We have a collaboration with ESMO in Europe so in the next studies we would definitely like to compare the US versus the Europe experience.
Do you have any follow up studies planned?
Definitely. This is the first reported analysis after our data lock within the first month of starting the consortium. Definitely longer follow up and larger sample size is being accumulated in the CCC19 database. We would like to continue the follow-up and to give us a more in-depth analysis opportunity to understand how COVID-19 affects long term outcomes. Having said that, we would also like to look at different treatment strategies, different types of cancer and also how COVID-19 related therapies have an impact on these outcomes. So there are many studies on the way and we should be able to share those with you very soon.
The general precautions of staying home, hand hygiene, social distancing, all of these are applicable because cancer patients do have an elevated risk. This does not mean that they should miss out on their screenings, on their active cancer treatment or surgeries because these are life-saving. If they are able and if they are fit to have these surgeries we do not want them to miss out on those treatments which may have deleterious effects on their health. So everything needs to be weighed with regards to pros and cons and hopefully this study and our findings will be helpful to clinicians as well as the patient community to understand those risks versus benefits.