Higher fatality from COVID-19 in patients with cancer in the UK than in Europe

Abstract

Echoing concerns expressed by oncologists early in the COVID-19 pandemic, a study led by researchers from Imperial College London (London, UK) has reported that the survival of patients with cancer after infection with SARS-CoV-2 seems to be disparate between the UK and countries in continental Europe, with apparently more detrimental outcomes for patients in the UK compared with their European counterparts. In the retrospective study, David Pinato (Imperial College London) and colleagues analysed the risk of death from all causes at 30 days and 6 months following a diagnosis of COVID-19, in 468 patients with cancer from the UK and 924 patients with cancer from Italy, Spain, France, Belgium, and Germany. The data were obtained from the OnCovid study database, a European registry of patients with cancer consecutively diagnosed with COVID-19 in 27 centres between Feb 27 and Sept 10, 2020. Notably, compared with the continental Europe cohort, the UK cohort had a lower proportion of patients with breast cancer (12·39% vs 23·70%) and a higher proportion of patients with gynaecological or genito-urinary cancers (31·20% vs 14·29%). Even after adjusting for key clinicopathological factors, including age, comorbidities, and tumour stage and status (although the authors noted that their analyses could be affected by unmeasured bias, such as of SARS-CoV-2 viral load), patients in the UK had a significantly higher case-fatality rate at 30 days after a COVID-19 diagnosis than did those in Europe (40·38% vs 26·5%; p<0·0001). This difference in case-fatality rate persisted at 6 months after a COVID-19 diagnosis (47·64% in the UK vs 33·33% in Europe; p<0·0001). Similarly, the risk of death at 30 days after a COVID-19 diagnosis was 1·52-times higher for UK patients than for their European counterparts; at 6 months, this risk of death remained elevated at 1·41-times higher in the UK versus Europe. The authors also reported that UK patients diagnosed with COVID-19 were less likely to be receiving either COVID-19-specific therapies (eg, corticosteroids or antiviral drugs) or to have received active anti-cancer treatment within the previous 4 weeks, compared with those in Europe. In multivariable analyses, exposure to any COVID-19 treatment was associated with a reduced risk of death at both 30 days and at 6 months, whereas receipt of anticancer therapy exerted a protective effect on the risk of death at the 6 month timepoint only. Study author Mieke Van Hemelrijck (King's College London, London, UK) told The Lancet Oncology, “the difference observed between the UK and Europe highlights the need to carefully continue cancer screening, diagnosis, and treatment during the pandemic. Whilst these numbers are disturbing, we have to be careful when drawing conclusions as the analyses of this observational study cannot account for all the variety in cancer patients registered into the study in Europe and the UK. It is never easy to handle all heterogeneity in these analyses, and hence these results could be considered as a first important indicator for the urgent need of further evaluations of cancer care in the pandemic.” Ajay Aggarwal (London School of Hygiene & Tropical Medicine, London, UK), who was not involved in the study, noted: “These estimates need to be considered cautiously, as the study looks at only five hospitals, concentrated in London, out of the 160–70 hospitals providing cancer care in the UK National Health Service. There are also challenges with merging varying-size patient cohorts from hospitals across European countries to create a representative cohort for comparison. Furthermore, there is a likely underestimation of the true prevalence of COVID-19 in the study among hospitalised and community-based cancer patients with active malignancy or in remission, and therefore we would expect the case fatality rate to be lower than presented.” Pasquale Rescigno (Candiolo Cancer Institute, Turin, Italy) added that “the authors cautiously interpret their results trying to identify reasons for this unbalance. UK patients were less likely to receive any kind of anti-COVID-19 treatments, [including drugs] like hydroxychloroquine, that proved ineffective; and others, like steroids, anti-interleukin-6, and remdesevir, which showed benefit depending on disease severity, but it is worth pointing out that the European cohort of this study was enriched for patients with breast cancer, who were, overall, the ones showing a decreased risk of death”. The authors conclude by stressing the importance of vaccinating and of giving anti-COVID-19 therapy to infected patients with cancer. Finally, and as also emphasised by Rescigno, “the effort of the vaccination campaign in the UK might revert this imbalance, since the number of vaccinated citizens in the UK has so far vastly exceeded that of other European countries”.