Data Sharing, Vigilance Pivotal in Maintaining Patient Safety While Treating Cancer Amid the COVID-19 Pandemic

As the COVID-19 pandemic continues to negatively impact the care of patients with metastatic renal cell carcinoma (mRCC) and other cancers, oncologists and other health care professionals are working together to make the best treatment decisions for their patients by pooling their data with tools like the COVID-19 and Cancer Consortium (CCC19), says Dr. Toni K. Choueiri.

In an interview with CURE®’s sister publication, OncLive®, Choueiri, director of the Lank Center for Genitourinary Oncology and director of the Kidney Cancer Center at Dana-Farber Cancer Institute, spoke about the current mRCC treatment landscape and how the pandemic is impacting patients.

Additionally, Choueiri, who is also the Jerome and Nancy Kohlberg Chair and professor of medicine at Harvard Medical School, went into greater detail about how tools like the CCC19, a multi-institutional registry that is collecting data on patients with cancer who have either suspected or confirmed COVID-19 infection, are helping those in health care identify and understand any trends that might potentially impact treatment decisions.

Currently, the mRCC treatment landscape is entering an era of combination therapies, said Choueiri. “We have (had several) FDA-approved regimens in the past couple of years, such as nivolumab (Opdivo) and ipilimumab (Yervoy), but also axitinib (Inlyta) in combination with the PD-1 inhibitor pembrolizumab (Keytruda), or the PD-L1 inhibitor avelumab (Bavencio).”

However, Choueiri noted, the paradigm is still evolving, with some trials just recently having finished accrual and results soon to be released.

But as for how the pandemic has impacted the diagnosis and treatment of this patient population, Choueiri explained, many factors come into play, mostly around the physical need for in-person treatment or the administration of therapies that could cause side effects that require emergency treatment.

“For example, we debate treatment for (those with) small kidney masses. We are carefully delaying therapies over surgery,” said Choueiri. “Situations also exist where we give cytotoxic chemotherapy, but not necessarily where we're pushing more growth factor (use), because we cannot afford (patients developing) neutropenic fever and being admitted to the hospital in this situation.” Choueiri went on to say that some clinical trials have also been reconsidered.

To better guide their treatment choices, Choueiri said, he and his colleagues from the Lank Center for Genitourinary Cancer, Brigham and Women's Hospital, and Dana-Farber Cancer Institute have all created a dynamic document of recommendations on what to do during the pandemic. Contributors from each institution go into the document and offer their input on cancer management depending on the number of cases being seen.

“For example, a patient with testicular cancer may need chemotherapy (and we will give them) chemotherapy; these are (treatments with) curative intent,” Choueiri said. “However, if a patient with RCC is on their fourth, fifth, or sixth line of treatment, with limited therapies (available), perhaps we can discuss other options, such as adjuvant therapy. Would they be eligible for sunitinib (Sutent) or other (options)? This is how we try to provide the best care with the best evidence available for minimizing exposure (to COVID-19).”

COVID-19 and Cancer Consortium

Similar to this working document, Choueiri went on to discuss the CCC19, which he’s on the steering committee for.

The product of a group of curious investigators who met online through social media at the beginning of the pandemic, the CCC19 is a collection of clinical data and outcomes on patients with cancer who also have COVID-19.

“To date, we have over 100 sites that are entering patient data with regard to mortality, intensive care unit admission, and other variables,” Choueiri explained. “It's an important database that now has information for thousands of patients. With the pandemic continuing to progress, we'll have more data coming out of CCC19 in the future.”

From the data collected thus far, researchers were able to identify some “interesting observations” which were then presented during the 2020 ASCO Virtual Scientific Program and published in the Lancet and Cancer Discovery journals. Of note, the team has found that hydroxychloroquine combined with any other agent was linked with increased mortality versus other COVID-19 therapies, and that treatment with Veklury (remdesivir) was found to result in reduced mortality versus untreated controls, although that was not determined to be statistically significant.

It is worth noting, Choueiri added, that this data is all observational. “(These studies) are limited by potential unmeasured confounding, but they add in aggregate to the emerging understanding of the pattern of care for patients with cancer and COVID-19.”

COVID-19 and Cancer Care Challenges

As for what challenges exist regarding COVID-19 and cancer care, Choueiri said, many questions remain. “This isn't specific to patients with kidney cancer, but if a patient with cancer has active COVID-19, (the question arises as to whether) steroids will be associated with worse mortality. The data are all over the place.”

Overall, Choueiri concluded, some of the changes that were first implemented at the start of the pandemic have since been relaxed, but officials remain vigilant and ready to enact more restrictions if COVID-19 cases rise. Essentially, the virus is the number one factor that determines how treatment evolves from day to day.

“We're not in control. My message here is that the only thing in control (right now) is the virus. We are reactive. The virus dictates treatment,” he said.

“If we experience a second wave or a surge tomorrow, we will need to escalate to more aggressive measures. If suddenly, things get better and we (develop) a vaccine, we're going to go back (to normal) gradually. We'll see how the virus (progresses). That's why I follow the cases of COVID-19 in our hospital, in our county, and in our state on a daily basis.”

A version of this story originally appeared on OncLive as “RCC Care Continues to Evolve as the COVID-19 Crisis Rages On”