In a large study of 5,671 older adults with COVID-19 and cancer, performed by the COVID-19 and Cancer Consortium (CCC19), the CCC19 geriatric risk index was associated with poorer outcomes, including clinical complications, hospitalization, and mortality. A higher CCC19 geriatric risk index was significantly associated with higher COVID-19 severity and 30-day all-cause mortality after adjustment of major prognostic confounding factors and explained the greatest amount of variation in these outcomes compared with all other risk factors. The results suggest that the CCC19 geriatric risk index, using a combination of previously studied poor prognostic factors for COVID-19 mortality, may effectively risk stratify this vulnerable patient population. The findings were published by Elkrief et al in The Lancet Healthy Longevity.
The investigators explained that older age is associated with poorer COVID-19 outcomes, although the heterogeneity of aging results in some older adults being at greater risk than others. Despite heightened risk of mortality, there is insufficient understanding of which subpopulations are at high risk for adverse outcomes of COVID-19.
Studies in the general geriatric population have shown that the presence of comorbidities and frailty increases the risk of death and other complications of COVID-19, as do the presence of comorbidities and poor performance status in those with cancer.
The Cancer and Aging Research Group and the International Society of Geriatric Oncology released statements on older people with cancer but noted that these statements were based on clinical consensus, not robust evidence. As a result, there is an urgent need to determine the effect of COVID-19 in older adults with cancer and identify those most vulnerable for adverse outcomes.
Study Details
The primary objective of this CCC19 analysis was to determine whether a measure of geriatric risk that combined age, comorbidities, and performance status could capture risk of severe clinical outcomes among older patients with cancer and COVID-19. The study team also sought to describe the presentation, complications, and effect of COVID-19 on subsequent cancer care among older adults with cancer.
The CCC19 cohort study enrolled patients aged 60 years and older with a current or previous cancer diagnosis and a current or previous laboratory-confirmed COVID-19 diagnosis who reported to the CCC19 multinational, multicenter registry between March 17, 2020, and June 6, 2021. The exposure of interest was the CCC19 geriatric risk index. The primary outcome was COVID-19 severity, and the secondary outcome was 30-day all-cause mortality; both were assessed in the full data set. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated from ordinal and binary logistic regression models.
In total, 5,671 patients were included in the analysis. Median follow-up was 56 days, and median age was 72 years (interquartile range [IQR] = 66–79 years). The CCC19 geriatric risk index identified 2,365 patients (41.7%) as at standard risk, 2,217 patients (39.1%) as at intermediate risk, and 1,089 patients (19.2%) as at high risk. In addition, 36 patients (0.6%) were excluded due to noncalculable geriatric risk index.
Compared with standard-risk patients, high-risk patients had significantly higher COVID-19 severity (adjusted OR = 7.24; 95% CI = 6.20–8.45). A total 920 of 5,671 patients (16.2%) died within 30 days of a COVID-19 diagnosis, including 161 of 2,365 standard-risk patients (6.8%), 409 of 2,217 intermediate-risk patients (18.5%), and 350 of 1,089 high-risk patients (32.1%). High-risk patients had higher adjusted odds of 30-day mortality (adjusted OR = 10.7; 95% CI = 8.54–13.5) than standard-risk patients.
The authors concluded that CCC19 geriatric risk index was strongly associated with COVID-19 severity and 30-day mortality. The CCC19 geriatric risk index, based on readily available clinical factors, might provide clinicians with an easy-to-use risk stratification method to identify older adults with cancer most at risk for severe COVID-19, as well as mortality.
Study Limitations and Next Steps
The authors commented that despite being a large multicenter study examining a comprehensive cohort of older adults with cancer and COVID-19, this study has several limitations that are inherent to its retrospective registry nature.
Future research questions include the extent to which vaccines will reduce the incidence and severity of COVID-19 in this vulnerable population who might not mount as robust an immune response to vaccination. These studies are ongoing, with encouraging initial results with regard to older adults with cancer. Older adults with cancer should be prioritized for vaccination rollout, they noted.
It is unknown how modifications of anticancer therapy may affect cancer control and whether functional decline due to COVID-19 may affect the subsequent ability to tolerate cancer therapy in a group that might already have been at high risk for toxicity of therapy.
Arielle Elkrief, MD, of McGill University Health Centre, Montreal, is the corresponding author of the Lancet Healthy Longevity article.
Disclosure: The study was funded by the U.S. National Institutes of Health National Cancer Institute Cancer Center. For full disclosures of the study authors, visit www.thelancet.com.
