Journal Article Annotations
2020, 4th Quarter

Psychooncology

Annotations by Elie Isenberg-Grzeda, MD, Carlos Fernandez-Robles, MD
December, 2020

COVID-19 Severity and Outcomes in Patients With Cancer: A Matched Cohort Study.
A systematic review of the factors associated with regret post-cancer treatment.
Perceptions of cancer as a death sentence: Tracking trends in public perceptions from 2008 to 2017.

- Chemotherapy and COVID-19 Outcomes in Patients With Cancer.

PUBLICATION #1 — Psychooncology

COVID-19 Severity and Outcomes in Patients With Cancer: A Matched Cohort Study.

Gagandeep Brar, Laura C Pinheiro, Michael Shusterman, Brandon Swed, Evgeniya Reshetnyak, Orysya Soroka, Frank Chen, Samuel Yamshon, John Vaughn, Peter Martin, Doru Paul, Manuel Hidalgo, Manish A Shah

Abstract: J Clin Oncol. 2020 Nov 20;38(33):3914-3924. doi: 10.1200/JCO.20.01580. Epub 2020 Sep 28.

Purpose:
SARS-CoV-2 (COVID-19) is a systemic infection. Patients with cancer are immunocompromised and may be vulnerable to COVID-related morbidity and mortality. The objectives of this study were to determine if patients with cancer have worse outcomes compared with patients without cancer and to identify demographic and clinical predictors of morbidity and mortality among patients with cancer.

Methods:
We used data from adult patients who tested positive for COVID-19 and were admitted to two New York-Presbyterian hospitals between March 3 and May 15, 2020. Patients with cancer were matched 1:4 to controls without cancer in terms of age, sex, and number of comorbidities. Using Kaplan-Meier curves and the log-rank test, we compared morbidity (intensive care unit admission and intubation) and mortality outcomes between patients with cancer and controls. Among those with cancer, we identified demographic and clinical predictors of worse outcomes using Cox proportional hazard models.

Results:
We included 585 patients who were COVID-19 positive, of whom 117 had active malignancy, defined as those receiving cancer-directed therapy or under active surveillance within 6 months of admission. Presenting symptoms and in-hospital complications were similar between the cancer and noncancer groups. Nearly one half of patients with cancer were receiving therapy, and 45% of patients received cytotoxic or immunosuppressive treatment within 90 days of admission. There were no statistically significant differences in morbidity or mortality (P = .894) between patients with and without cancer.

Conclusion:
We observed that patients with COVID-19 and cancer had similar outcomes compared with matched patients without cancer. This finding suggests that a diagnosis of active cancer alone and recent anticancer therapy do not predict worse COVID-19 outcomes and therefore, recommendations to limit cancer-directed therapy must be considered carefully in relation to cancer-specific outcomes and death.

Annotation

The finding:
COVID-19 hospitalized patients with active malignancies have comparable morbidity and mortality to COVID-19 hospitalized patients without cancer, including similar rates of ICU admission, intubation, and death. Furthermore, the study found that older age is the strongest predictor of poorer outcomes.

Strength and weaknesses:
This study is a well-designed cohort study. The authors considered co-variables for both cancer and control patients, which helped removed confounding factors and strengthened the findings. The design’s observational nature prevents authors from concluding causality; the heterogeneous cancer cohort limited conclusions regarding specific cancers. The study was done solely on inpatients, which limits applicability to outpatient settings. Finally, socio-economic factors that impact COVID-19 infection outcomes were not accounted for in the study.

Relevance:
Psycho-oncology practitioners are well aware of the emotional impact of COVID-19 among patients with active cancer and cancer survivors. Fear of complications leads to myriad complications including anxiety, depression, and substance use disorders. Furthermore, concerns for increased mortality risk may impact decisions regarding receiving cancer treatments.

Type of study (EBM guide):
Cohort study

PUBLICATION #2 — Psychooncology

A systematic review of the factors associated with regret post-cancer treatment.

Aleksandra Karolina Szproch, Rebecca Maguire

Abstract: J Psychosoc Oncol. 2020 Nov 16;1-25. doi: 10.1080/07347332.2020.1844846. Online ahead of print.

Problem identification:
Expanding on previous work in specific cancer populations, this review aimed to explore factors associated with decisional regret following treatment for a range of cancer types.

Literature search:
A systematic search of four databases identified 1747 studies, using search terms relating to cancer survivors and decisional regret. Following quality appraisal, correlates of regret were abstracted and analyzed using narrative synthesis.

Data evaluation/synthesis:
Seventy-two studies met the inclusion criteria. Factors associated with treatment regret were categorized as being either modifiable or less modifiable. Regret was associated with various sociodemographic factors, physical health, treatment type, an unsatisfactory decision-making process, poorer mental health and lack of social support.

Conclusion:
Results highlight the complex nature of regret and illustrate how this can be experienced following a range of cancer treatments. As regret can be an obstacle to full-recovery from cancer, this review suggests some ways in which the emergence of regret may be mitigated.

Keywords:
cancer patients; decision-making; oncology; regret; survivors; treatment.

Annotation

The finding:
This study did not find one clear pattern of factors associated with regret over cancer treatment decisions. A wide range of factors impacts the occurrence of regret. Among the individual factors, socio-demographic factors included single-status, low education level, non-Caucasian race, lower-income, and post-treatment financial hardship. Lower health-related quality of life, secondary malignancies, and decreased cognitive abilities were clinical factors associated with higher regret. Findings concerning treatment type were heterogeneous, but a longer interval since treatment and prolonged post-treatment hospital stay increased the risk of regret.
Among modifiable factors, the study found a negative correlation between regret and the amount of information provided about diagnosis and treatments and receiving too many treatment options. Higher levels of regret occurred in patients with low perceived preparation for decision-making, decision uncertainty, and difficulties communicating with providers and establishing a shared decision-making framework. Finally, higher regret was also associated with anxiety, depression, and distress, and with those with lower social support.

Strength and weaknesses:
This extensive review included 72 studies and provided a broader overview of all cancer patients, as much of the work done in this area is limited to specific cancer types. The main limitation is that most of the studies included have a cross-sectional design, limiting conclusions regarding causality.

Relevance:
Regret about previous treatment-related decisions has been found to impact cancer patients negatively. Such can be an obstacle to full-recovery, and currently, little work has been done in developing tools to help mitigate its occurrence. This study provides individual risk factors that can help providers identify those at risk and highlights areas where targeted interventions can be developed and implemented to reduce the occurrence of regret in vulnerable individuals.

Type of study (EBM guide):
Systematic review or meta-analysis

PUBLICATION #3 — Psychooncology

Perceptions of cancer as a death sentence: Tracking trends in public perceptions from 2008 to 2017.

Richard P Moser, Jamie Arndt, Tyler Jimenez, Benmei Liu, Bradford W Hesse

Abstract: J Clin Oncol. 2020 Oct 20;38(30):3538-3546. doi: 10.1200/JCO.20.01307. Epub 2020 Aug 14.

Objective:
There has been steady progress in reducing cancer mortality in the United States; however, this progress hasn’t been evenly distributed across regions. This paper assesses trends in cancer mortality salience (CMS), that is, agreeing that getting cancer is a death sentence, over time in the United States and examines correlates of CMS. Methods: Data from three administrations of the Health Information National Trends Survey (HINTS), gathered in 2008, 2013, and 2017, were merged, resulting in a total sample of 10,063 respondents. Trends in changes in CMS over time were examined as well as maps of the distribution of CMS in the United States. A logistic regression model was conducted, regressing CMS on a set of sociodemographic, psychological, health‐related, and environmental predictors.

Results:
The aggregated percentage of US adults who agreed with the CMS statement changed over time and was modified by age. Geographic distribution of agreement with CMS was inconsistent across the United States. In the adjusted logistic model, perceived health (worse health), cancer prevention, fatalism, and confusion, and cancer status (no cancer) were all significantly associated with CMS. There was also a significant interaction between survey year and age.

Conclusion:
Despite recent information that cancer mortality rates are decreasing, most US adults still see cancer as a death sentence and this is especially an issue in certain subgroups. These findings have ramifications for groups of people who may be at risk for developing cancer given their attitudes and beliefs that there isn’t much they can do to prevent or control it.

Annotation

The finding:
Using data from a National Cancer Institute population-based survey administered in 2008, 2013, and 2017, the authors found that almost two-thirds of Americans surveyed consider cancer to be a death sentence; while cancer deaths have decreased over the past two decades, the perception of cancer as a death sentence has not. They found that this perception is particularly pervasive among younger individuals.

Strength and weaknesses:
Using this cross-sectional methodology, the authors are unable to comment on causality. There may be confounding variables that bias the results which cannot be accounted for.

Relevance:
Despite improvements in cancer mortality, the perception of cancer as a death sentence seems to persist. Having a bleak attitude towards the inevitability of cancer mortality may translate to less adherence to public health measures aimed at reducing or preventing cancer.

Type of study (EBM guide):

Also of interest – PUBLICATION #4 — Psychooncology

Chemotherapy and COVID-19 Outcomes in Patients With Cancer.

Justin Jee, Michael B Foote, Melissa Lumish, Aaron J Stonestrom, Beatriz Wills, Varun Narendra, Viswatej Avutu, Yonina R Murciano-Goroff, Jason E Chan, Andriy Derkach, John Philip, Rimma Belenkaya, Marina Kerpelev, Molly Maloy, Adam Watson, Chris Fong, Yelena Janjigian, Luis A Diaz Jr, Kelly L Bolton, Melissa S Pessin

Abstract: J Clin Oncol. 2020 Oct 20;38(30):3538-3546. doi: 10.1200/JCO.20.01307. Epub 2020 Aug 14.

Purpose:
Coronavirus-2019 (COVID-19) mortality is higher in patients with cancer than in the general population, yet the cancer-associated risk factors for COVID-19 adverse outcomes are not fully characterized.

Patients and methods:
We reviewed clinical characteristics and outcomes from patients with cancer and concurrent COVID-19 at Memorial Sloan Kettering Cancer Center until March 31, 2020 (n = 309), and observed clinical end points until April 13, 2020. We hypothesized that cytotoxic chemotherapy administered within 35 days of a COVID-19 diagnosis is associated with an increased hazard ratio (HR) of severe or critical COVID-19. In secondary analyses, we estimated associations between specific clinical and laboratory variables and the incidence of a severe or critical COVID-19 event.

Results:
Cytotoxic chemotherapy administration was not significantly associated with a severe or critical COVID-19 event (HR, 1.10; 95% CI, 0.73 to 1.60). Hematologic malignancy was associated with increased COVID-19 severity (HR, 1.90; 95% CI, 1.30 to 2.80). Patients with lung cancer also demonstrated higher rates of severe or critical COVID-19 events (HR, 2.0; 95% CI, 1.20 to 3.30). Lymphopenia at COVID-19 diagnosis was associated with higher rates of severe or critical illness (HR, 2.10; 95% CI, 1.50 to 3.10). Patients with baseline neutropenia 14-90 days before COVID-19 diagnosis had worse outcomes (HR, 4.20; 95% CI, 1.70 to 11.00). Findings from these analyses remained consistent in a multivariable model and in multiple sensitivity analyses. The rate of adverse events was lower in a time-matched population of patients with cancer without COVID-19.

Conclusion:
Recent cytotoxic chemotherapy treatment was not associated with adverse COVID-19 outcomes. Patients with active hematologic or lung malignancies, peri-COVID-19 lymphopenia, or baseline neutropenia had worse COVID-19 outcomes. Interactions among antineoplastic therapy, cancer type, and COVID-19 are complex and warrant further investigation.

Annotation (unstructured)

Using single-site data from early in the COVID-19 pandemic, the authors tested the presumption that recent administration of chemotherapy would be associated with worse COVID outcomes. They found that counter to their beliefs, being exposed to recent chemotherapy was not associated with worse outcomes. Instead, certain variables (hematologic malignancy, lung malignancy, lymphopenia and neutropenia) were associated with worse COVID outcomes. While the interplay between COVID, antineoplastic treatment, and cancer type is complex, this study may serve to reassure some cancer patients who are anxious about their risks related to COVID.

Type of study (EBM guide):
Cohort study