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i repeat a question

Posted By
tkoss
9/11/2020 4:06pm
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Replies: 7

ed, bubbles, others with tremendous knowledge and experience, i ask this question again. the last time i asked the responses were meager.

what is the issue of Immo and covid?
my docs can't or won't give me an answer. the web says little.

does taking Nivo make me more likely to die from Covid whilst doing infusions? After my last infusion, how long is my immune system supercharged so that i remain at high risk of death from Covid.

Bubbles - (9/11/2020 - 4:35pm)

The bottom line, Tkoss is - we don't know. Here are two differing opinions - Here is the link to one:

https://www.oncnursingnews.com/web-exclusives/immunotherapy-does-not-inc....

This link states:
Immunotherapy Does Not Increase Death Risk in Patients With COVID-19 RACHEL NAROZNIAK, MA Wednesday, July 22, 2020

Treatment with immune checkpoint inhibitors (ICIs) did not increase the risk of mortality in patients with COVID-19 and cancer, according to findings from a multicenter, retrospective analysis presented during the 2020 AACR Virtual Meeting: COVID-19 and Cancer.

Data showed that the mortality rate of patients with COVID-19 and cancer who received immuno-oncology agents was 8%. “This rate is similar to the mortality rate in the general cancer population, which is reported to be in the range of 7.6% to 12%,” lead study author, Aljosja Rogiers, said during the medical meeting.

Nine of the 113 patients included in the study population died, however, none of these deaths were attributed to treatment with checkpoint inhibitors. All patients who died on study had advanced cancer; 7 died due to COVID-19.

The analysis by Rogiers et al analysis included data from 113 patients with laboratory-confirmed COVID-19 from 19 centers across North America, Europe, and Australia who received immunotherapy within 12 months of testing positive for COVID-19. Most patients (82%) received 1 anti–PD-1 or PD-L1 agent; 13%, an anti–PD-1 agent in combination with an anti–CTLA-4 drug; and 5%, another immunologic therapy. None of the patients were treated with chemotherapy. Data points included symptoms, comorbidities, and medications, in addition to investigations and treatments implemented for COVID-19. Investigators assessed the following outcomes: hospital and intensive care unit (ICU) admission and mortality.

The evaluation was conducted to shed light on the clinical implications of immune checkpoint blockade. “To what extent immune checkpoint inhibition [affects] COVID-19 infection in patients with cancer is unclear. Theoretically, inhibition could either mitigate or exacerbate COVID-19 infection. This study was designed to help us answer this question,” said Rogiers, a fellow at the Melanoma Institute Australia, in Sydney.

Patient Characteristics

At the data cutoff of May 15, 2020, the median age was 63 years (range, 27-86) and the majority of patients (65%) were male. Few patients had an ECOG performance status of 2 or greater compared with 0 to 1 (10% vs 90%). Regarding the geographic regions to which patients belonged, most of the patients included in the analysis were from Europe (64%). North America and Australia accounted for 33% and 3% of the patient population, respectively.

Sixty percent of the 113 patients were symptomatic for COVID-19. Having contact with someone who was COVID-19–positive provided the rationale for testing the asymptomatic individuals included in this study, Rogiers said. Among the symptomatic patients, fever (68%) and cough (59%) were the symptoms of COVID-19 witnessed, followed by dyspnea (34%) and myalgia (15%). Beyond diabetes, which affected 15% of patients, the comorbidities that investigators observed were of a cardiovascular (27%), pulmonary (12%), and renal (5%) nature. When investigators examined the use of immunosuppressive agents used in this population, they noted the use of 10 mg or more of prednisone per day in 13% of patients, and use of another immunosuppressive agent in 3%.

Fifty-seven percent of patients had melanoma; 17%, melanoma; 9%, renal cell carcinoma (RCC); and 17%, another type of cancer. Most cases were treated in the advanced/metastatic setting (74%); 26% were addressed with a neoadjuvant treatment intervention. Reponses to therapy were as follows: partial response, complete response, or no evidence of disease, 30%; stable disease, 18%; progressive disease, 15%; not available, 37%.
Hospital, ICU Admissions and Mortality Outcomes

Twenty-nine percent of patients were admitted to the hospital, where antibiotics, oxygen therapy, glucocorticoids, antivirals, intravenous immunoglobulins, and anti–interleukin-6 agents were administered to 25%, 20%, 10%, 6%, 2%, and 2% of patients, respectively. Five percent of patients were admitted to the ICU, where were put on mechanical ventilation and vasopressin (3%; 2%). One percent underwent renal replacement therapy.

Results from the outcome concerning hospital and ICU admission showed that 61% of patients were discharged, 12% remained in the hospital, and 27% of those admitted (9 patients) had died by the data cutoff. Data from the mortality outcome assessment demonstrated that 92% of the 113 patients were alive and 8% (9 patients) died.

“Median age of the patients who died was slightly higher [than in the general population,” Rogiers said, citing the median as 72 years (range, 49-81). Among the patients who died, 2 had melanoma; 2, NSCLC; 2, RCC; and 3, another type of cancer. “Although the numbers are small, they may indicate that COVID-19 has a slightly higher mortality rate in patients with non–small cell lung cancer than melanoma, given that 57% of patients had melanoma and 17% of patients had non–small cell lung cancer,” he added.

Seven of the patients who died were treated with an anti–PD-1 agent. The other 2 patients received a combination anti–PD-1 and anti–CTLA-4 regimen.

Reference
1. Rogiers A, Tondini C, Grimes JM, et al. Clinical characteristics and outcomes of coronavirus 2019 disease (COVID-19) in cancer patients treated with immune checkpoint inhibitors (ICI). Presented at: 2020 AACR Virtual Meeting: COVID-19 and Cancer; July 20-23; Virtual.

This article was originally published on OncLive as, "Immunotherapy Use Does Not Correlate With Increased Mortality in Patients with COVID-19, Cancer."

Bubbles - (9/11/2020 - 4:42pm)

The second link: https://www.medpagetoday.com/infectiousdisease/covid19/87263

It states:
Cancer Immunotherapy Tied to Severe COVID-19 Outcomes — Nearly threefold increased risk of hospitalization, severe respiratory illness
by Ian Ingram, Deputy Managing Editor, MedPage Today June 25, 2020

Cancer patients receiving immunotherapy were at increased risk for severe outcomes from COVID-19, according to retrospective findings from Memorial Sloan Kettering Cancer Center in New York City.

Among over 400 cancer patients with symptomatic COVID-19, those treated with immune checkpoint inhibitors saw a nearly threefold risk of hospitalization (HR 2.84, 95% CI 1.24-6.72, P=0.013) and severe respiratory illness (HR 2.74, 95 CI 1.37-5.46, P=0.004) in a multivariate analysis, Mini Kamboj, MD, and colleagues from Sloan Kettering reported.

In the 35 patients with lung cancer, higher rates of hospital admission and severe respiratory illness were seen for those on immunotherapy (83% and 58%, respectively) compared to those not treated with these agents (52% and 35%). To a lesser degree, this pattern was seen among patients with other solid cancers receiving immune checkpoint inhibitors as well.

Writing in Nature Medicine, however, they cautioned that treatment decisions regarding these anticancer agents in patients with symptomatic COVID-19 should not be altered without further evidence, and recommended increased testing to ward of potential infections in this vulnerable population.

In contrast with earlier reports, there was no increased risk of worse outcomes among patients undergoing chemotherapy within 30 days of their COVID-19 diagnosis, and major surgery and metastatic disease did not predict worse outcomes.

"If you're an oncologist and you're trying to figure out whether to give patients chemotherapy, or if you're a patient who needs treatment, these findings should be very reassuring," co-author Ying Taur, MD, PhD, said in a press release.

On multivariate analysis, patients with hematologic malignancies had an increased risk of hospitalization (HR 2.49, 95% CI 1.35-4.67) and potentially severe respiratory illness as well (HR 1.79, 95% CI 0.97-3.32), in line with a previous report showing higher mortality in this group.

Non-white race (HR 1.62, 95% CI 1.05-2.51) and chronic lymphopenia or corticosteroid use (HR 1.85, 95% CI 1.06-3.24) were also significantly associated with an increased risk of hospitalization.

"The course and clinical spectrum of this disease is still not fully understood and this is just one of many studies that will need to be done on the connections between cancer and COVID-19," Kamboj said in the statement. "But the big message now is clear: People shouldn't stop or postpone cancer treatment."

For their study, Kamboj, Taur, and colleagues examined 423 cancer patients diagnosed with COVID-19 at Memorial Sloan Kettering from March 10 to April 7. A majority of patients were 60 and older (56%), and older age was tied to worse outcomes. Overall, a fifth of patients developed severe respiratory illness, 9% required mechanical ventilation, and 12% died.

Hospitalization was required in 40% of patients, and 20% were admitted to the ICU. Among these hospitalized and ICU patients, respectively, 24% and 35% died.

About three-fourths of patients in the cohort had solid tumors, and breast cancer was the most common tumor type (20%), followed by lymphoma in 11%, colorectal cancer in 9%, lung cancer and leukemia in 8% each, prostate cancer in 6%, and myeloma in 5%.

Limitations noted by the authors included the single-center design, that COVID-19-directed therapies (of which patients received a number of investigational agents) were not evaluated for this analysis, and the fact that testing at the center was only directed toward symptomatic patients.

Here is a link to the actual data upon which this report is based: https://www.nature.com/articles/s41591-020-0979-0

Bubbles - (9/11/2020 - 4:49pm)

So - there you go! Sometimes whether we are the patient or the doc - we have to do the best you can. I don't think anyone can say definitely one way or the other for several reasons. Are you a melanoma/immunotherapy patient in good health apart from taking a treatment with a risk of significant side effects and having been diagnosed with a deadly disease? Or, did you come to melanoma in a high risk group (older, over weight, smoker, etc) for COVID-19? Are you suffering from wheezing and cough due to pneumonitis caused by immunotherapy? Or are you going through immunotherapy with little difficulty? So there are those things - and then - with COVID, it is still a crap shoot. Partly because it is a disease we are very much in process of learning about. Partly because it seems to act in ways that we cannot fully anticipate, no matter the presence of risk factors or not. Perfectly healthy children and young people have died of COVID-19 while older folks with pre-existing conditions have pulled through.

Not sure if that helps but that is as complete an answer as I can give. celeste

Bubbles - (9/11/2020 - 5:11pm)

And finally, since this is your thread, I will give you a response to a personal comment you made on a prior post. It may not be wise to call a person a bully one minute and ask for their help the next. Most folks who have been treated that way would give you a "big leaving alone" - as my elders called it when I was growing up. Ed has been an integral part of this board for years and I for one, am eternally grateful for his presence. He will scour the world for information for those in need and comes through when the rest of us have no answers. Real data and accurate information matters. I could give you a ton of bull shit data right now regarding your question about immunotherapy and COVID risk. What would you think of me if I did that? More importantly - what would I think of me? I would think that I did not only you - but anyone else who reads the post I put up a disservice. The reason Ed, very politely and kindly took umbrage with the prior post - as did I - is that the headline - and unfortunately what you took away from it - was misleading. The study was based on looking at 20 patients at one point in their care, via a scan, and an opinion was drawn that their immunotherapy treatment MAY have had an effect on their arthrosclerosis. There was no follow-up. There was no conclusion. There was no recommendation for treatment of arthrosclerosis for those immunotherapy patients. That is a far cry from saying - IMMUNOTHERAPY CAUSES CARDIOVASCULAR PROBLEMS - isn't it? I think it is. We can only protect ourselves if we are armed with accurate and full disclosure of the facts. A big headline, that doesn't tell you what was really found, does none of us any good. Ed is very good at cutting to the chase in situations like that. And we are all better for it.

Everyone on this board has the freedom to post whatever they like. Though it is actually against the rules to call out individuals and certainly against to the rules to resort to rude accusations and petty name calling. But, most of us are adults and it ain't no thang! And just like everyone having the right to post what they like. Everyone has the right to question it or post a rebuttal. That is not being a bully. That is having an adult discussion of some very critical important information.

I hope you and everyone else here will post things they think are important. I also hope that when others question, doubt, agree, support, disagree, etc - ANYTHING I or ANYBODY else posts, they will state their position and back it up either with data or an experience they or someone they know has dealt with. Otherwise, what is the point?

Yours, BOG!

tkoss - (9/11/2020 - 6:59pm)

I appreciate the response. My onc doc and PA have had about 2 sentences of commentary on subject.

if you will note i did not call you a bully, just Ed.

Months back you questioned some stats on SR i offered up. Admittedly they were rounded off or commentary from my docs so not exactly the latest in empirical science. I explained this in a response to you and to which you didn't reply.

In blogging its easy to misunderstand and get hurt feelings. By the same token your experience and knowledge gets peoples attention and you have great credibility, , so if you want to criticize me , try to be less academic and definitive in tone. and if you have a strong critique email privately. I cannot edit what has been posted buy i can correct it.

you will note i went on to praise you in my next post after our little dust up over SR's.

i heartily lobby for an edit button if you talk to the blogsite managers.

Bubbles - (9/11/2020 - 7:56pm)

I'm good, TKOSS. Melanoma and advocacy has given me a very thick skin. I don't really recall any "dust up". I am aware of who you called what. I am sorry if my academic definitive tone is not your preference. We all speak differently. We all come from different backgrounds. We all have something to offer. We all need to be tolerant of others. I feel very strongly about accuracy. Melanoma is deadly. So we desperately need facts when we can find them. Further, lots of our posts are read by folks who never ever comment. Therefore, the accuracy of what we share matters to far more people than just the writer and responder. I feel that I am in a privileged position when it comes to melanoma. I happen to have survived it for 17 years. I have seen the change in treatment options firsthand. I am medically trained. I have access to papers and literature that many do not. And hopefully, due to my training, I have the ability to explain the information I have access to in a way that makes it comprehensible to others without minimizing the data. Perhaps I am mistaken in that, but I do my best. I long to retire from this "job" and have considered doing so many times in recent years. It takes a lot of time and work to stay abreast of the data and share it here and on my blog. It is the worst paying gig, with the most criticism I have ever participated in! That's saying something as I worked an entire summer in South Alabama cleaning bricks retrieved from a demolished building at a penny per brick. Still, I do it because I feel that I do help many people and actual real live bullies - NOT ED!!!! - have run off other dedicated intelligent responders leaving a big whole in the information provided on this forum, and whom I miss dreadfully. Thant's all I got. I wish you my best. c

ed williams - (9/11/2020 - 7:38pm)

Hi tKoss, old geezer with links for you. First one features Dr. Long from Australia, second link is written by some of the top names in the melanoma business on the topic you are interested in and last link is to new published ranking of melanoma experts based on publishing history which is kind of different and new. https://www.youtube.com/watch?v=U4w__yYA_wk&feature=youtu.be https://clincancerres.aacrjournals.org/content/26/16/4201 https://expertscape.com/ex/melanoma