Interplay of Immunosuppression and Immunotherapy Among Patients With Cancer and COVID-19

Importance

Cytokine storm due to COVID-19 can cause high morbidity and mortality and may be more common in patients with cancer treated with immunotherapy (IO) due to immune system activation.

Objective

To determine the association of baseline immunosuppression and/or IO-based therapies with COVID-19 severity and cytokine storm in patients with cancer.

Design, Setting, and Participants

This registry-based retrospective cohort study included 12 046 patients reported to the COVID-19 and Cancer Consortium (CCC19) registry from March 2020 to May 2022. The CCC19 registry is a centralized international multi-institutional registry of patients with COVID-19 with a current or past diagnosis of cancer. Records analyzed included patients with active or previous cancer who had a laboratory-confirmed infection with SARS-CoV-2 by polymerase chain reaction and/or serologic findings.

Exposures

Immunosuppression due to therapy; systemic anticancer therapy (IO or non-IO).

Main Outcomes and Measures

The primary outcome was a 5-level ordinal scale of COVID-19 severity: no complications; hospitalized without requiring oxygen; hospitalized and required oxygen; intensive care unit admission and/or mechanical ventilation; death. The secondary outcome was the occurrence of cytokine storm.

Results

The median age of the entire cohort was 65 years (interquartile range [IQR], 54-74) years and 6359 patients were female (52.8%) and 6598 (54.8%) were non-Hispanic White. A total of 599 (5.0%) patients received IO, whereas 4327 (35.9%) received non-IO systemic anticancer therapies, and 7120 (59.1%) did not receive any antineoplastic regimen within 3 months prior to COVID-19 diagnosis. Although no difference in COVID-19 severity and cytokine storm was found in the IO group compared with the untreated group in the total cohort (adjusted odds ratio [aOR], 0.80; 95% CI, 0.56-1.13, and aOR, 0.89; 95% CI, 0.41-1.93, respectively), patients with baseline immunosuppression treated with IO (vs untreated) had worse COVID-19 severity and cytokine storm (aOR, 3.33; 95% CI, 1.38-8.01, and aOR, 4.41; 95% CI, 1.71-11.38, respectively). Patients with immunosuppression receiving non-IO therapies (vs untreated) also had worse COVID-19 severity (aOR, 1.79; 95% CI, 1.36-2.35) and cytokine storm (aOR, 2.32; 95% CI, 1.42-3.79).

Conclusions and Relevance

This cohort study found that in patients with cancer and COVID-19, administration of systemic anticancer therapies, especially IO, in the context of baseline immunosuppression was associated with severe clinical outcomes and the development of cytokine storm.

Trial Registration

ClinicalTrials.gov Identifier: NCT04354701.

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

Mexiletine effects on theophylline disposition

The effect of mexiletine administration on steady-state plasma theophylline concentrations was studied in eight normal healthy men in a prospective open label nonrandomized two-way crossover trial. Repeated doses of 300 mg of sustained-release theophylline were given every 12 hours for 9 days. Mexiletine hydrochloride, 200 mg every 8 hours, was given for five consecutive doses starting on the morning of day 6. Mexiletine increased theophylline levels in all subjects. Mean predose (trough) levels rose from 8.1 +/- 0.1 microgram.ml-1 to 13.4 +/- 0.6 micrograms.ml-1 and AUC(0-12) from 96.8 +/- 9.1 to 160.2 +/- 3.7 micrograms.ml-1.hr. Plasma clearance was reduced by mexiletine from 44.7 +/- 5.1 to 25.4 +/- 1.2 ml.hr-1. Both N-demethylated metabolites of theophylline were decreased by 60% by mexiletine, whose levels remained within its therapeutic range. Theophylline levels returned to pre-mexiletine values when this drug was discontinued. Mexiletine reduces theophylline clearance and increases its plasma concentration by inhibiting N-demethylation of theophylline. Plasma theophylline levels should be monitored when mexiletine is added.

Phase I trial of dipyridamole with 5-fluorouracil and folinic acid

We have performed two Phase I trials of the combination of dipyridamole, 5-fluorouracil (5-FU), and folinic acid in patients with advanced refractory malignancy, based upon in vitro evidence that dipyridamole can modulate the cytotoxicity of 5-FU. In the first trial, patients were treated every 4 wk with dipyridamole (50 mg/m2) p.o. every 6 h on Days 0 to 6, beginning 24 h prior to the i.v. administration of folinic acid (200 mg/m2) and escalating doses of i.v. 5-FU on Days 1 to 5. The maximum tolerated daily dose of 5-FU that could be given with this combination was 375 mg/m2. Because dipyridamole is extensively bound to plasma proteins, it was hypothesized that the concentrations of free dipyridamole achieved with a dose of 50 mg/m2 were inadequate to modulate the cytotoxicity of 5-FU and folinic acid. Therefore, a second Phase I trial of escalating dose of p.o. dipyridamole was performed. Folinic acid (200 mg/m2) and 5-FU (375 mg/m2) were given i.v. on Days 1 to 5 every 4 wk, beginning 24 h after the start of therapy with dipyridamole; dipyridamole was administered p.o. on Days 0 to 6 at doses of 75, 100, 125, 150, 175, or 200 mg/m2/dose to successive cohorts of patients. Dose-limiting neutropenia, mucositis, and nausea were produced at a dose of 200 mg/m2/dose; the recommended dose of dipyridamole for use in Phase II studies is 175 mg/m2 p.o. every 6 h, or 700 mg/m2/day. At this dose, a mean peak plasma concentration of total dipyridamole of 16.32 mumol and a mean peak plasma concentration of free dipyridamole of 38.30 nmol were observed. Trough concentrations of free dipyridamole averaged 60% of the peak concentrations. Objective antitumor responses were seen in a number of tumor types; five of 13 patients with breast cancer treated with high-dose p.o. dipyridamole, 5-FU, and folinic acid responded. High-dose p.o. dipyridamole can produce plasma concentrations of free dipyridamole within the range shown to modulate the cytotoxicity of 5-FU and other agents. Phase II trials of this combination are justified.

Metabolism, covalent binding, and mutagenicity of aflatoxin B1 by liver extracts from rats of various ages

The ability of S-9 fractions isolated from the livers of 4-, 12-, and 26-month-old male inbred F344 rats to activate and metabolize the hepatocarcinogen aflatoxin B1 [(AFB1) CAS: 1162-65-8] was studied. The following observations were made: The activation of AFB1 to compounds that are mutagenic in the Ames Salmonella-microsome test and to compounds that covalently bind DNA in vitro was similar for liver S-9 from 4- and 12-month-old rats. A 30-50% decrease in the activation of AFB1 occurred in rats between 12 and 26 months of age. The in vitro metabolism of AFB1 to chloroform-soluble and water-soluble metabolites was similar for 4- and 12-month-old rats and decreased significantly in rats after 12 months of age. The proportion of most of the chloroform-soluble metabolites of AFB1 formed by liver S-9 from 4-, 12-, and 26-month-old rats was similar. However, the proportion of aflatoxicol (CAS: 29611-03-8) produced by liver S-9 increased approximately twofold in rats between 12 and 26 months of age. The cytochrome P450 content and the NADPH cytochrome c reductase activity of liver microsomes decreased 40-45% in rats between 12 and 26 months of age. However, the activities of UDPglucuronyltransferases and most forms of glutathione S-transferase did not change significantly with increasing age in liver microsomes and cytosol, respectively.

Effect of thioacetamide-induced hepatic necrosis on the regioselective metabolism of S-warfarin by rat liver mixed-function oxidase enzymes

The biotransformation of S-warfarin was examined using liver microsomes prepared from rats 6-96 hr after treatment with a necrotizing dose (5.6 mmoles/kg) of thioacetamide. Four catalytically distinct classes of enzyme activity were observed which declined in activity with different half-lives after thioacetamide intoxication. S-Warfarin 7-hydroxylase activity was destroyed with a half-life of 16.6 +/- 3.1 hr. 6-Hydroxylase activity was destroyed with a half-life of 25.3 +/- 3.0 hr. 4'-Hydroxylase activity was destroyed with a half-life of 34.6 +/- 4.8 hr, which paralleled the loss of total hepatic cytochrome P-450 with a half-life of 33.4 +/- 3.6 hr. Production of an unidentified metabolite was not affected by thioacetamide intoxication during the first 48 hr. The ratio of rates of product formation were used as an alternative method to test the homogeneity of distinct enzyme catalytic activities. The ratio of measured responses (e.g. chromatographic peak heights) was used directly to determine the product ratios, provided that the rate of formation of each product was directly proportional to the experimentally measured response for each product. The use of product response ratios to discriminate between catalytic activities was inherently more precise because calibration errors were eliminated. Differences in the rates of destruction of warfarin hydroxylases provided further evidence of the multiplicity of hepatic mixed-function oxidases and suggested topographical differences in their location within the liver lobule.

Metabolic activation of chemical carcinogens by kidney from rats and mice of various ages

1. The ability of homogenates from kidney tissue of 4- to 26-month-old male Fischer F344 rats, 6- to 30-month-old male Sprague-Dawley rats, and 5- to 30-month-old male C57 BL/6J mice to metabolically activate the chemical procarcinogens 2-aminofluorene and aflatoxin B1 to mutagens was measured using the Ames Salmonella/microsome test. 2. The conversion of 2-aminofluorene to mutagenic compounds by kidney homogenates from Fischer F344 and Sprague-Dawley rats and C57 BL/6J mice decreased 35-50% with increasing age. 3. An age-related decrease (50-65%) in the ability of kidney homogenates from Fischer F344 rats and C57 BL/6J mice to convert aflatoxin B1 to mutagenic compounds was also observed.

Metabolic activation of aflatoxin B1 by liver tissue from male fischer F344 rats of various ages

The effect of aging on the ability of the liver to activate chemical procarcinogens was studied using 12-, 18-, and 27-month-old male Fischer F344 rats. The cytochrome P-450 content of the S9 and microsomal fractions of the liver decreased approximately 30% between 12 and 18 months of age. The structural conformation of cytochrome P-450 in microsomes from 12-, 18-, and 27-month-old rats was studied using electron-spin resonance spectroscopy. An age-related decrease in the amount of cytochrome P-450 ferric iron in the liver microsomes was observed. The conversion of the chemical procarcinogen aflatoxin B1 to mutagenic compounds by the S9 and microsomal fractions of liver was measured using the Salmonella typhimurium bioassay. A 40-50% decrease in the metabolic activation of aflatoxin B1 was observed between 12 and 18 months of age. However, the activation of aflatoxin B1 did not change after 18 months of age. The age-related decrease in the activation of aflatoxin B1 by liver appears to be due to a decrease in the metabolic activity of the mixed-function oxidase system.