Living with COVID-19 and cancer: the need for observational research in the post-pandemic world

In this issue of The Lancet Regional Health – Western Pacific, Victoria G. Hall and colleagues report that severe COVID-19 outcomes in a cohort of people with a recent cancer diagnosis largely mirrored those of the wider community in Australia and lessened over the course of the pandemic as the omicron strain became endemic in Australia.1Hall V. Sim B. Lim C. et al.COVID-19 infection among patients with cancer in Australia from 2020-2022: a national multicentre cohort study.Lancet Reg Health West Pac. 2023; https://doi.org/10.1016/j.lanwpc.2023.100824Summary Full Text Full Text PDF PubMed Google Scholar Older age and male sex were significant predictors of the need for supplemental oxygen treatment2Australian Government Department of Health and Aged Care Risk factors for more serious illness Canberra 2022.https://www.health.gov.au/health-alerts/covid-19/advice-for-groups-at-risk/risk-factors-for-more-serious-illnessGoogle Scholar; while diagnosis during the omicron outbreak (late 2021 into 2022) was associated reduced odds of needing oxygen, reflecting the reduced severity of the omicron strain.3Ward I.L. Bermingham C. Ayoubkhani D. et al.Risk of covid-19 related deaths for SARS-CoV-2 omicron (B.1.1.529) compared with delta (B.1.617.2): retrospective cohort study.BMJ. 2022; 378e070695Google Scholar These results are reassuring as many of the actions taken to mitigate COVID-19 risks in cancer care during the pandemic have been guided by reports from the general population. All-cause mortality reported by Hall and colleagues (10.6%) was significantly lower than that from earlier studies of patients with cancer and COVID-19 (30–38%), which may be due to most cases being diagnosed after the lower-severity omicron strain was established as well as improvements in COVID-19 management during the later years of the pandemic. Unlike many other countries, Australia was able to delay widespread COVID-19 infection in the community, including amongst people with cancer, using stringent border closures and movement restrictions (i.e., “lockdowns”) until vaccinations and COVID-19 therapeutics became available. The low mortality rate among people with cancer in this study is arguably a testament to the effectiveness of public health measures to postpone COVID-19 in a vulnerable population to a time when they more are likely survive an infection. Hall and colleagues’ finding that patients who were unable to receive early COVID-19 treatments, such as antiviral and monoclonal antibody therapy, were more likely to require supplemental oxygen therapy highlights the importance of the real-world, observational research facilitated by the large, multicentre data collection used in their study. Clinical trials showing the efficacy of early COVID-19 treatments were published in the midst of the pandemic,4The RECOVERY Collaborative GroupDexamethasone in hospitalized patients with Covid-19.N Engl J Med. 2020; 384: 693-704Crossref PubMed Scopus (5982) Google Scholar,5Jayk Bernal A. Gomes da Silva M.M. Musungaie D.B. et al.Molnupiravir for oral treatment of Covid-19 in nonhospitalized patients.N Engl J Med. 2021; 386: 509-520Crossref PubMed Scopus (718) Google Scholar however, the effectiveness of these agents in cancer populations, as well as potential issues around their use alongside active cancer therapy, remain largely unknown. Trial evidence addressing these concerns is unlikely to be forthcoming and studies such as this one—based on large patient samples with rich clinical data—are essential to guiding practice as Australia and other nations transition to a post-pandemic world. Interestingly, disease factors, receipt of anti-cancer treatment, and patient comorbidities were not associated with severe COVID-19 outcomes in this potentially immunosuppressed cohort. While relatively large for a clinical cohort, the modest sample size could account for the lack of significant association between comorbidities and oxygen requirement in contrast with other studies; and rates of diabetes mellitus, chronic lung disease, renal impairment and coronary artery disease were higher in patients requiring oxygen compared to those did not. Hall and colleague's work also highlights the need for data collections with detailed clinical information to inform clinical practice. Due to its universal healthcare system, Australia routinely collects a wealth of administrative health data that are increasingly used in various areas of population health research.6de Oliveira Costa J. Bruno C. Schaffer A.L. et al.The changing face of Australian data reforms: impact on pharmacoepidemiology research.Int J Popul Data Sci. 2021; 6: 1418PubMed Google Scholar During the pandemic, these data were used to highlight the impacts of paused cancer screening programs on cancer notifications,7Te Marvelde L. Wolfe R. McArthur G. et al.Decline in cancer pathology notifications during the 2020 COVID-19-related restrictions in Victoria.Med J Aust. 2021; 214: 281-283Crossref PubMed Scopus (23) Google Scholar reductions in cancer-related services across Australia,8Cancer AustraliaThe impact of COVID-19 on cancer-related medical services and procedures in Australia in 2020: examination of MBS claims data for 2020, nationally and by jurisdiction. Cancer Australia, Surry Hills, NSW2021Google Scholar and the impacts of lockdowns on systemic therapy.9Tang M. Daniels B. Aslam M. et al.Changes in systemic cancer therapy in Australia during the COVID-19 pandemic: a population-based study.Lancet Reg Health West Pac. 2021; 14100226Google Scholar These population-level analyses are crucial to our understandings of real-world health outcomes and the impacts of public health policies, however, these administrative data collections typically lack patient and disease information so important for investigating many risks and outcomes in cancer. Large and detailed clinical data resources, such as that assembled by Hall and colleagues, are needed to further our understandings around cancer treatment and outcomes as COVID-19 becomes a routine part of the public health landscape. For instance, these collections will be a tremendous resource for investigating the impact of COVID-19 vaccinations in people diagnosed with, being treated for, and surviving cancer. The present study provides the first evidence around the use of early COVID-19 treatments but more research is needed to understand how these treatments might be integrated with current cancer treatment paradigms and these data will facilitate that important work. Ongoing clinical data collections will also better prepare us to rapidly support clinical decision making should we face similar public health crises in the future. The pandemic may be over but COVID-19 remains with us. While omicron has been a milder strain, it has also been a more infectious one, and the absolute number of COVID-related deaths remained higher throughout 2022 than at any point during the pandemic.10Australian Bureau of Statistics COVID-19 Mortality by wave 2022.https://www.abs.gov.au/articles/covid-19-mortality-waveGoogle Scholar While Hall and colleagues have shown the severity of/mortality from COVID-19 in people with cancer is decreasing, people with cancer still have worse outcomes compared to the general population. Hall and colleagues’ work highlights the essential role that robust, timely observational studies will play in ensuring the best cancer outcomes in our post-pandemic world. BD, MT, and MA were responsible for the writing of the commentary. BD is supported by an Early Career Fellowship from Cancer Institute NSW (ID: ECF13) and NHMRC Medicines Intelligence Centre of Research Excellence (payments to institution), unrelated to this commentary. The rest of the authors declare no conflicts of interest. COVID-19 infection among patients with cancer in Australia from 2020 to 2022: a national multicentre cohort studyOutcomes from COVID-19 in patients with cancer in Australia over the pandemic have improved, potentially related to changing viral strain and outpatient therapies. Full-Text PDF Open Access