COVID-19 in patients with thoracic malignancies (TERAVOLT): first results of an international, registry-based, cohort study

Our plain-English summary of COVID-19 in patients with thoracic malignancies (TERAVOLT): first results of an international, registry-based, cohort study, by M.C. Garassino, J.G. Whisenant, L.C. Huang, et al (The Lancet. Oncology, 2020).

The study

• Authors: M.C. Garassino, J.G. Whisenant, L.C. Huang, A. Trama, V. Torri, F. Agustoni, J. Baena, G. Banna, R. Berardi, A.C. Bettini, E. Bria, M. Brighenti, J. Cadranel, A. De Toma, C. Chini, A. Cortellini, E. Felip, G. Finocchiaro, P. Garrido, C. Genova, R. Giusti, V. Gregorc, F. Grossi, F. Grosso, S. Intagliata, N. La Verde, S.V. Liu, J. Mazieres, E. Mercadante, O. Michielin, G. Minuti, D. Moro-Sibilot, G. Pasello, A. Passaro, V. Scotti, P. Solli, E. Stroppa, M. Tiseo, G. Viscardi, L. Voltolini, Y.L. Wu, S. Zai, V. Pancaldi, A.M. Dingemans, J. Van Meerbeeck, F. Barlesi, H. Wakelee, S. Peters, L. Horn, TERAVOLT investigators
• Journal: The Lancet. Oncology
• Published: 2020;21(7):914-922
• Cited by: 491 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Early reports on patients with cancer and COVID-19 have suggested a high mortality rate compared with the general population. Patients with thoracic malignancies are thought to be particularly susceptible to COVID-19 given their older age, smoking habits, and pre-existing cardiopulmonary comorbidities, in addition to cancer treatments. We aimed to study the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on patients with thoracic malignancies.

Methods: The Thoracic Cancers International COVID-19 Collaboration (TERAVOLT) registry is a multicentre observational study composed of a cross-sectional component and a longitudinal cohort component. Eligibility criteria were the presence of any thoracic cancer (non-small-cell lung cancer [NSCLC], small-cell lung cancer, mesothelioma, thymic epithelial tumours, and other pulmonary neuroendocrine neoplasms) and a COVID-19 diagnosis, either laboratory confirmed with RT-PCR, suspected with symptoms and contacts, or radiologically suspected cases with lung imaging features consistent with COVID-19 pneumonia and symptoms. Patients of any age, sex, histology, or stage were considered eligible, including those in active treatment and clinical follow-up. Clinical data were extracted from medical records of consecutive patients from Jan 1, 2020, and will be collected until the end of pandemic declared by WHO. Data on demographics, oncological history and comorbidities, COVID-19 diagnosis, and course of illness and clinical outcomes were collected. Associations between demographic or clinical characteristics and outcomes were measured with odds ratios (ORs) with 95% CIs using univariable and multivariable logistic regression, with sex, age, smoking status, hypertension, and chronic obstructive pulmonary disease included in multivariable analysis. This is a preliminary analysis of the first 200 patients. The registry continues to accept new sites and patient data.

Findings: Between March 26 and April 12, 2020, 200 patients with COVID-19 and thoracic cancers from eight countries were identified and included in the TERAVOLT registry; median age was 68·0 years (61·8-75·0) and the majority had an Eastern Cooperative Oncology Group performance status of 0-1 (142 [72%] of 196 patients), were current or former smokers (159 [81%] of 196), had non-small-cell lung cancer (151 [76%] of 200), and were on therapy at the time of COVID-19 diagnosis (147 [74%] of 199), with 112 (57%) of 197 on first-line treatment. 152 (76%) patients were hospitalised and 66 (33%) died. 13 (10%) of 134 patients who met criteria for ICU admission were admitted to ICU; the remaining 121 were hospitalised, but were not admitted to ICU. Univariable analyses revealed that being older than 65 years (OR 1·88, 95% 1·00-3·62), being a current or former smoker (4·24, 1·70-12·95), receiving treatment with chemotherapy alone (2·54, 1·09-6·11), and the presence of any comorbidities (2·65, 1·09-7·46) were associated with increased risk of death. However, in multivariable analysis, only smoking history (OR 3·18, 95% CI 1·11-9·06) was associated with increased risk of death.

Interpretation: With an ongoing global pandemic of COVID-19, our data suggest high mortality and low admission to intensive care in patients with thoracic cancer. Whether mortality could be reduced with treatment in intensive care remains to be determined. With improved cancer therapeutic options, access to intensive care should be discussed in a multidisciplinary setting based on cancer specific mortality and patients' preference.

Funding: None.

Copyright © 2020 Elsevier Ltd. All rights reserved.

In plain English

This was an international registry study (TERAVOLT) of people with chest cancers who developed COVID-19. It did not study asbestos exposure. It covered the first 200 patients entered March 26 to April 12, 2020, from 42 institutions in eight countries, mostly European. Most had non-small-cell lung cancer (151 of 200). All eight patients with malignant pleural mesothelioma were hospitalised; their deaths were not reported separately. Of the 200 patients, 152 (76%) were hospitalised and 66 (33%) died. For 52 of the 66 deaths, the cause was listed as complications from COVID-19 only. Of 134 hospitalised patients who met criteria for intensive care, 13 were admitted. Taken one at a time, age over 65, current or former smoking, chemotherapy alone, and having any other illness were each associated with higher odds of death. When sex, age, smoking, high blood pressure and chronic obstructive pulmonary disease were considered together, only smoking history remained associated with death (odds ratio 3.18, 95% CI 1.11 to 9.06). The authors concluded their data suggest high mortality and low intensive-care admission, calling the data preliminary.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Multicentre observational registry study with a cross-sectional component and a longitudinal cohort component; this paper is a preliminary analysis of the first 200 patients
• Who was studied: 200 patients with thoracic cancers and COVID-19, entered March 26 to April 12, 2020, from 42 institutions in Italy, Spain, France, Switzerland, Netherlands, USA, UK and China. 151 had non-small-cell lung cancer, 29 small-cell lung cancer, 8 thymoma or thymic carcinoma, 4 carcinoid or neuroendocrine tumours, and 8 malignant pleural mesothelioma (all 8 hospitalised).
• Exposure: COVID-19 (SARS-CoV-2 infection) in patients with thoracic cancer, confirmed by RT-PCR or suspected on symptoms or lung imaging. Asbestos exposure was not studied or discussed.
• Main results:
  • 152 (76%) of the 200 patients were hospitalised and 66 (33%) died. For 52 (79%) of the 66 deaths, the cause was listed as complications from COVID-19 only. The outcome was unknown for nine patients.
  • All 8 patients with malignant pleural mesothelioma were in the hospitalised group, and none were in the not-hospitalised group. The article gives no separate mortality, ICU or risk figures for them.
  • Of the 152 hospitalised patients, 134 (88%) met criteria for intensive care unit admission, but only 13 (10%) of these were admitted to the ICU.
  • In univariable analyses (one factor at a time), each of the following was associated with increased risk of death: age over 65 years (OR 1.88, 95% CI 1.00 to 3.62), current or former smoking (OR 4.24, 1.70 to 12.95), chemotherapy alone (OR 2.54, 1.09 to 6.11), and any comorbidity (OR 2.65, 1.09 to 7.46).
  • In the multivariable analysis (sex, age, smoking, hypertension and COPD considered together), only smoking history was associated with increased risk of death (OR 3.18, 95% CI 1.11 to 9.06).
  • Patients treated with tyrosine kinase inhibitors alone (n=28) were less likely to be hospitalised than patients not on therapy (OR 0.24, 0.08 to 0.71).
• The authors' conclusion: The authors concluded that their data suggest high mortality and low admission to intensive care among patients with thoracic cancer who had COVID-19.
• Limitations the authors state:
  • The data are preliminary, and more events are needed to observe and confirm effects.
  • The report lacks the statistical power to give final answers for subgroup analyses.
  • The cohort may be a selected population: it captured few patients after surgery or radiotherapy, and only a small fraction managed at home.
  • The study could not properly capture the patient, cultural and institutional reasons behind the low ICU admission rate.

Topics

Medical terms in this study, explained in our Lexicon: Cohort Study, Habit, Lung Cancer, Mesothelioma, Neoplasm, Histology, Odds Ratio, Performance Status.

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