Many thanks for this opportunity to present the highlights of the SIOG COVID-19 working group which were presented at the SIOG 20th Annual Conference back on 1st October 2020. Like with most annual conferences this year, it was also held online and it was well received and well attended by various professions from several countries who were passionate about the care of older adults with cancer.
I guess I’ll start off with a bit of background. The SIOG COVID-19 working group was conceptualised back in March this year when emerging results from epidemiological data indicated negative outcomes in older patients who were affected with COVID-19 because of their age, comorbidities or other geriatric factors. The working group has several pioneers, including myself and Dr Battisti as the chairs, and the panel consisted of various international experts from different continents. Our aim is to develop consensus and recommendations on the implications of the pandemic on several aspects of cancer care in the older population because at the time it was already clear that COVID-19 poses a threat to equal and evidence-based management of cancer in older adults.
So we published our first recommendation in the Journal of Geriatric Oncology in July 2020. These recommendations were previously discussed here by Dr Battisti and as the data on COVID-19 in older patients with cancer are still limited and rapidly evolving, our recommendations could also change and we intend to update this as more data becomes available.
So geriatric oncology is best managed in a multidisciplinary setting and our recommendations were presented like so in the annual conference. So I’ll start off with updates on geriatrics and this was presented by Dr Lisa Cooper, a geriatrician from Brigham and Women’s Hospital, Harvard Medical School, USA. She emphasised that even though the pandemic has negatively impacted the patients and their families, we still have to continue in advocating great quality multidisciplinary goal concordant care. Older adults are at higher risk of morbidity and mortality and patients in long-term facilities such as age care facilities are at higher risk, especially those who have multiple comorbidities including cancers. So as she discussed the aetiology of the aging immune system and described inflammaging, which is a result of accumulation of cellular damage in aging, and the pathophysiology is deemed to be closely similar to that of cancer and aging. This could lead to chronic inflammation characterised by high baseline cytokine levels such as IL-6 that have been implicated to developing atherosclerosis, osteoporosis, sarcopenia, functional decline, disability, frailty and death.Frailty in itself amplifies inflammaging, causing a vicious cycle.
Inflammaging is also connected to the pathophysiology of delirium which is a state of acute brain failure following a specific stressor such as hospitalisation for a medical condition or surgery. It has been stated as a silent epidemic within the pandemic. We already know that patients with COVID-19 have an accelerated risk for delirium, occurring in up to 60-70% of patients with COVID-19. Not only that, hospital settings, the use of PPE, the need for social distancing, physical inactivity, restrictions of visitors, these were all identified as deliriogenic factors, emphasising the need for stratifying the risk of developing delirium, preferably in the outpatient setting prior to administering any anti-cancer treatment and then plan for preventative measures.
Assessment of frailty is a better predictor of toxicity and mortality. It can help guide the decision making, especially when there is a high competing risk such as cancer, COVID-19, frailty and even social disparity. Geriatric assessment could help us recognise frailty, sarcopenia, mood changes, malnutrition, social needs and plan for appropriate personalised interventions accordingly. During the pandemic geriatric assessment could still be performed via telemedicine; there are limitations from using this and this includes the access to technology and other resources, a difficulty for some patients with hearing or visual or even cognitive impairments. But this could be mitigated by family and healthcare workers being present and providing support during the assessment.
Next, I will discuss the update on cancer surgery during the pandemic as presented by Professor Michael Jaklitsch, also from the Harvard Medical School, USA. We already know that surgery is essential in several aspects of the cancer journey from diagnosis and staging to providing curative resection or even palliation of symptoms. However, inadequate diagnosis and staging or work-up, as well as delay of cancer treatment is inevitable in the pandemic era, especially when the resources are reprioritised and infection prevalence is extremely high. The COVID surge collaborative study showed a high 30 day mortality and long complications when surgery was conducted in COVID-19 patients. They concluded that the thresholds for surgery during the COVID-19 pandemic should be higher than usual, particularly in men aged 70 years or older, and consideration should be given for postponing the procedure. Yet, emergency surgery is still required for palliation of symptoms such as in the event of bowel or airway obstruction or when used for short procedures needing local anaesthetics.
When surgery is deferred we need to balance the risk of exposure as well as the risk of altered hospital routine against the risk of upstaging the cancer and therefore losing the opportunity to treat them accordingly. Telemedicine again provides a good strategy to assess and support patients in the safety of their own home. It provides opportunity for education; it can bring multispecialty professionals together and it can be adapted for screening programmes and perhaps the best avenue for the provision of care during the pandemic.
Thirdly, I will then discuss radiotherapy updates as delivered by Associate Professor Anita O’Donovan from Trinity College, Dublin, Ireland. She again emphasised the many factors to consider when deciding treatment of older people with cancer during the pandemic by using geriatric assessment and focussing on a personalised approach based on the risk-benefits of treatment and patient preferences.
The SIOG COVID-19 working group recommends prioritising urgent clinical needs versus delaying versus omission and the radiation fractionation schedule is extremely important during the pandemic to minimise the number of travels and hospital visits. A systematic review on the radiation fractionation schedules published during the COVID-19 pandemic by Thomson et al was discussed. A stereotactic, ultra-hyperfractionation provides a more precise and a much smaller treatment volume and is therefore less toxic than conventional radiotherapy and may be a reasonable alternative to surgery for selected patients. Radiotherapy has been underutilised pre-COVID but now it becomes an attractive and effective treatment option for older patients, especially where other options such as surgery or systemic therapy are too high a risk to consider.
Then, finally, I gave updates on systemic therapy. Patients with COVID-19 and cancer are known to have a poorer prognosis with an increased risk of death, as highlighted by several published and presented collaborative studies from the Cancer Board the COVID-19 and Cancer Consortium Group, and the UK Coronavirus Cancer Monitoring Project. All three associated older age, comorbidities, cancer and poor performance status as negative predictive factors for worse outcomes. Anti-cancer therapy in the past four weeks had no significant effect on mortality.
An update on the correlation between the timing of anti-cancer treatment and COVID-19 complications was presented in ESMO this year by the CCC19 group and the risk of death was highest among patients with progressive disease, those treated one to three months prior to COVID-19 diagnosis and those who received active systemic therapy. Equally, the ISARIC COVID-19 group reported that patients aged more than 70 years are less likely to be admitted to ICU while those aged 80 years or more are less likely to be offered mechanical ventilation. It is still unclear if this was due to age bias, institutional policy or patient or family preferences. Notably, the hazard ratio for death was highest with increasing age, regardless of the cancer diagnosis or treatment received, highlighting the significant risk of mortality in the older population.
So, SIOG had recommended guidelines for adapting systemic therapy for older patients during the COVID-19 pandemic by categorising the need to clinical priority delay, the escalation or omission of treatment, examples of which are available in the recommendations published in The Journal of Geriatric Oncology. So cancer and COVID-19 mortality are principally driven by advancing age, comorbidities and performance status. When we contemplate systemic therapy we need to take into account the likelihood of the patient’s response to treatment and survival against the risk of dying from COVID-19, the severity of their comorbidities, their independent prognosis and their effect on cancer and COVID-19 and the likelihood of long-term patient survival with an attempt to assess both the quality and potential quantity of life. So performing geriatric assessment becomes even more imperative during the COVID-19 pandemic. Early discussions about the goals of care, patient and family preferences and the realistic feasibility of care on improving survival outcomes should be conducted early and periodically. If possible we should engage a multidisciplinary approach to get a consensus on optimal management or seek advice from other relevant experts.
What does the future of geriatric patients look like during the pandemic?
There remain a number of challenges that are being faced, specifically by any older patients, especially those with cancer during the pandemic such as the travel restrictions. They continue to impact both hospital and home support care for these patients. Teleconsultations, although they are very useful at this point in time, especially during the pandemic, they may not necessarily be truly accessible to everyone and everywhere due to the digital divide. There will always be a delay in access to healthcare, either deliberately due to patients’ fear of exposure or incidentally due to lack of transport or lack of care or intended due to reprioritisation of available resources.
So, as such, we intend to bring resources and people together to tackle several challenges by using the SIOG COVID-19 working group as a platform for discussions, information dissemination, training, education and support. It remains critical to work on an international collaborative evidence-based set of recommendations for addressing the urgent capacity building and community needs for older cancer patients. SIOG is committed to improving the care of older adults with cancer, especially during the pandemic.