Updated COVID-19 clearance time among patients with cancer in the Delta and Omicron waves

BACKGROUND

COVID-19 infection delays therapy and in-person evaluation for oncology patients, but clinic clearance criteria are not clearly defined.

METHODS

We conducted a retrospective review of oncology patients with COVID-19 at a tertiary care center during the Delta and Omicron waves and compared clearance strategies.

RESULTS

Median clearance by two consecutive negative tests was 32.0 days (Interquartile Range [IQR] 22.0-42.5, n = 153) and was prolonged in hematologic malignancy versus solid tumors (35.0 days for hematologic malignancy, 27.5 days for solid tumors, p = 0.01) and in patients receiving B-cell depletion versus other therapies. Median clearance by single negative test was reduced to 23.0 days (IQR 16.0-33.0), with recurrent positive rate 25.4% in hematologic malignancy versus 10.6% in solid tumors (p = 0.02). Clearance by a predefined waiting period required 41 days until an 80% negative rate.

CONCLUSIONS

COVID-19 clearance remains prolonged in oncology patients. Single-negative test clearance can balance delays in care with risk of infection in patients with solid tumors.

Immunotherapy for the treatment of multiple myeloma

Despite advances in treatment for multiple myeloma, the majority of patients ultimately develop relapsed disease marked by immune evasion and resistance to standard therapy. Immunotherapy has emerged as a powerful tool for tumor-directed cytotoxicity with the unique potential to induce immune memory to reduce the risk of relapse. Understanding the specific mechanisms of immune dysregulation and dysfunction in advanced myeloma is critical to the development of further therapies that produce a durable response. Adoptive cellular therapy, most strikingly CAR T cell therapy, has demonstrated dramatic responses in the setting of refractory disease. Understanding the factors that contribute to immune evasion and the mechanisms of response and resistance to therapy will be critical to developing the next generation of adoptive cellular therapies, informing novel combination therapy, and determining the optimal time to incorporate immune therapy in the treatment of myeloma.

COVID-19 clearance among patients with cancer during the Delta and Omicron waves

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Background: COVID-19 presents a particular challenge in oncology, as in-person visits and treatments can be delayed during infection and patients are at risk for prolonged viral shedding. Our center uses two consecutive negative PCR tests for patients to return to clinic. As vaccination rates increase, we questioned the need for this strategy vs a time-based clearance approach. Methods: We identified cancer patients who tested positive for COVID-19 from 10/1/2021 to 3/31/2022 at a single tertiary care center and performed chart review under an IRB-approved protocol. Subgroups were compared using the Welch’s t-test and Welch’s ANOVA for 2 or > 2 groups, respectively. Results: 169 patients were identified. 153 had documented clearance defined as two consecutive negative PCR tests. The mean clearance time was 35.7 days (95% CI 32.3-39.0). There was a trend toward longer clearance time in patients with hematologic vs solid tumors (39.6 vs 33.2, p =.06) and a significant increase in patients treated with B cell depletion (58.0) vs chemo/targeted therapy (35.7, p =.01) or immunotherapy (29.0, p =.004). No significant difference was found by vaccination status or between the Delta and Omicron waves. If defined as one negative test, mean clearance time was 25.9 days (95% CI 23.6-28.1), and there was a significant difference in patients with hematologic vs solid tumors and in those treated with B cell depletion vs other therapies. However, 16.0% (27/169) of patients had a subsequent positive test after a first negative result, with increased incidence in patients with hematologic malignancy (26.2%, 16/61) and stem cell/adoptive cell transplant (46.2%, 6/13). Conclusions: COVID-19 is a significant barrier to oncologic care, and clearance times remain longer than reported for the general population. In this single center study, clearance time was > 1 month and further increased in patients with hematologic malignancy or on B cell depleting therapy. While adjusting clearance criteria to a single negative test or specific timeframe may be an attractive option to reduce delays, a large proportion of patients may have further positive PCR testing.[Table: see text]

Smoking cessation counseling in patients with active malignancy

e18655

Background: Tobacco smoking increases risk of multiple malignancies, most notably lung cancer, and is a leading cause of premature morbidity and mortality. Tobacco cessation counseling is effective in assisting patients to quit smoking and improving health outcomes, but over one third of smokers report receiving no counseling by healthcare providers. In this study, we investigated rates of tobacco cessation education at ambulatory visits among patients with active malignancy. Methods: We identified ambulatory visits among current smokers with a diagnosis of malignancy using the National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of ambulatory visits in the US, from 2008 to 2018. We first determined weighted rates of documented smoking cessation counseling. We next evaluated sociodemographic characteristics, provider and visit type, and chronic conditions as determinants of counseling in this population using logistic regression. Results: We identified 2,437 total visits during the study period, representing an estimated 48.9 million such visits in the US. In this cohort, smoking cessation counseling was provided at 14.2% (95% confidence interval [CI] 12.1-16.7%) of visits. Patients were significantly less likely to receive counseling with older age (adjusted OR 0.97 per year of age; 95% CI 0.96-0.98) and less likely in surgical (OR 0.49; 95% CI 0.32-0.75) or medical subspecialties (OR 0.60; 95% CI 0.36-0.99) compared to primary care visits. Sex, race, year of visit, insurance type, and previous visit to the same provider were not significantly related to receipt of counseling. Patients with concomitant COPD were substantially more likely to receive counseling (OR 3.50; 95% CI 2.21-5.53), with 28.4% (95% CI 21.5-36.4%) of such visits including tobacco cessation education. Conclusions: Tobacco smoking is a modifiable risk factor associated with multiple malignancies and substantial non-neoplastic morbidity and mortality. Nonetheless, smokers with current malignancy receive smoking cessation counseling at only about one in seven outpatient visits, with lower frequency with advanced age and at subspecialty visits. As more effective treatments improve survival for cancer patients, further work is needed to improve tobacco cessation efforts that could improve survival and quality of life.[Table: see text]

Clinical and microbiological characteristics of patients with bacteremia and normal procalcitonin

Procalcitonin is a biomarker of bacterial infection used to guide antimicrobial therapy. However, emerging studies have highlighted bacteremic patients with low procalcitonin, potentially limiting its clinical utility. Here, we conducted an observational, retrospective study analyzing clinical and microbiological parameters of adult patients with bacteremia and procalcitonin <2 ng/mL. High proportions of patients required intensive care (31.2%) with vasopressor (14.9%) or ventilatory (17.7%) support, developed renal injury (30.7%), or had in-hospital mortality (14.4%). When divided into subgroups by procalcitonin level, patients with procalcitonin 0.5 to 2.0 ng/mL had significantly higher rates of in-hospital mortality, vasopressor requirement, and renal injury than those with procalcitonin <0.5 ng/mL. Altogether, bacteremic patients had significant morbidity and mortality despite low procalcitonin. While subgroup analysis suggested that higher procalcitonin may correlate with illness severity, a more sensitive procalcitonin cutoff did not eliminate patients with significant disease. Procalcitonin-based algorithms may not be clinically appropriate for management of bacteremia.