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Prevalence of COVID-19-related risk factors and risk of severe influenza outcomes in cancer survivors: A matched cohort study using linked English electronic health records data

Mish Boyka

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Prevalence of COVID-19-related risk factors and risk of severe influenza outcomes in cancer survivors: A matched cohort study using linked English electronic health records data

 

Abstract

Background

People with active cancer are recognised as at risk of COVID-19 complications, but it is unclear whether the much larger population of cancer survivors is at elevated risk. We aimed to address this by comparing cancer survivors and cancer-free controls for (i) prevalence of comorbidities considered risk factors for COVID-19; and (ii) risk of severe influenza, as a marker of susceptibility to severe outcomes from epidemic respiratory viruses.

Methods

We included survivors (≥1 year) of the 20 most common cancers, and age, sex and general practice-matched cancer-free controls, derived from English primary care data linked to cancer registrations, hospital admissions and death registrations. Comorbidity prevalences were calculated 1 and 5 years from cancer diagnosis. Risk of hospitalisation or death due to influenza was compared using Cox models adjusted for baseline demographics and comorbidities.

Findings

108,215 cancer survivors and 523,541 cancer-free controls were included. Cancer survivors had more diabetes, asthma, other respiratory, cardiac, neurological, renal, and liver diseases, and less obesity, compared with controls, but there was variation by cancer site. There were 205 influenza hospitalisations/deaths, with cancer survivors at higher risk than controls (adjusted HR 2.78, 95% CI 2.04–3.80). Haematological cancer survivors had large elevated risks persisting for >10 years (HR overall 15.17, 7.84–29.35; HR >10 years from cancer diagnosis 10.06, 2.47–40.93). Survivors of other cancers had evidence of raised risk up to 5 years from cancer diagnosis only (HR >5 years 2.22, 1.31–3.74).

Interpretation

Risks of severe COVID-19 outcomes are likely to be elevated in cancer survivors. This should be taken into account in policies targeted at clinical risk groups, and vaccination for both influenza, and, when available, COVID-19, should be encouraged in cancer survivors.

1. Introduction

As of 7 July 2020, the novel Coronavirus disease 2019 (COVID-19) has been diagnosed in over 11.6 million individuals with more than 539,000 deaths reported worldwide []. Around 20% of individuals contracting the virus are estimated to develop severe disease requiring hospitalisation, with a high risk of mortality [

2

Clinical course and mortality risk of severe COVID-19.

 

]. A key aspect of managing the impacts of the pandemic is understanding who is vulnerable to experiencing severe outcomes, so that mitigation strategies can be targeted at those most in need. Those under current treatment for cancer were recognised early on as being a high risk group[], but the extent to which the much larger population of medium- to long-term cancer survivors might be considered vulnerable is unknown. In England alone, this group includes over 1.8 million people [].

Current guidance on who should be considered vulnerable has been largely based on policies developed for previous epidemic respiratory viruses, notably influenza. For example, vaccination against influenza is only recommend for individuals under active treatment for cancer and for up two years following some treatments and haematological cancers[

5

Public Health England. Influenza – the green book (chapter 19). In: ramsay M, ed. Immunisation against infectious disease; 2019.

 

], while longer-term cancer survivors with no recent immunosuppressing treatment are not considered high-risk in vaccination guidance from Public Health England or the American Cancer Society [

5

Public Health England. Influenza – the green book (chapter 19). In: ramsay M, ed. Immunisation against infectious disease; 2019.

 

,]. Yet medium- to long-term cancer survivors could plausibly be at raised risk of severe COVID-19 outcomes. Studies amongst women with breast cancer have found chemotherapy to be associated with changes in immune parameters that did not return to pre-treatment levels a year or more after end of treatment, raising the possibility of a long-term weakened immune system in cancer survivors [

7

  • Mozaffari F.
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  • Lekander M.
  • Nilsson B.
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  • Osterborg A.
  • Bergkvist L.
  • Mellstedt H
Systemic immune effects of adjuvant chemotherapy with 5-fluorouracil, epirubicin and cyclophosphamide and/or radiotherapy in breast cancer: a longitudinal study.

 

,

8

  • Verma R.
  • Foster R.E.
  • Horgan K.
  • Mounsey K.
  • Nixon H.
  • Smalle N.
  • Hughes T.A.
  • Carter C.R
Lymphocyte depletion and repopulation after chemotherapy for primary breast cancer.

 

]. In addition, cancer survivors have known raised risks of heart disease[

9

  • Padmanabhan S.
  • Carty L.
  • Cameron E.
  • Ghosh R.E.
  • Williams R.
  • Strongman H
Approach to record linkage of primary care data from Clinical Practice Research Datalink to other health-related patient data: overview and implications.

 

], which is itself an emerging risk factor for COVID-19 mortality [

10

  • Zhou F.
  • Yu T.
  • Du R.
  • Fan G.
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  • Liu Z.
  • Xiang J.
  • Wang Y.
  • Song B.
  • Gu X.
  • Guan L.
  • Wei Y.
  • Li H.
  • Wu X.
  • Xu J.
  • Tu S.
  • Zhang Y.
  • Chen H.
  • Cao B
Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.

 

]. One large UK study identified raised risks of COVID-19 mortality in survivors of haematological malignancies even several years after cancer diagnosis[

11

  • Williamson E.
  • Walker A.J.
  • Bhaskaran K.
  • Bacon S.
  • Bates C.
  • Morton C.E.
  • Curtis H.J.
  • Mehrkar A.
  • Evans D.
  • Inglesby P.
  • Cockburn J.
  • Mcdonald H.I.
  • MacKenna B.
  • Tomlinson L.
  • Douglas I.J.
  • Rentsch C.T.
  • Mathur R.
  • Wong A.
  • Grieve R.
  • Harrison D.
  • Forbes H.
  • Schultze A.
  • Croker R.T.
  • Parry J.
  • Hester F.
  • Harper S.
  • Perera R.
  • Evans S.
  • Smeeth L.
  • Goldacre B
OpenSAFELY: factors associated with COVID-19 death in 17 million patients.

 

], but there is little other evidence to date to inform policy around managing COVID-19 related risks in cancer survivors.

We therefore aimed to investigate whether cancer survivors are likely to be a high-risk group for severe outcomes during the current COVID-19 pandemic in two ways: first, by comparing the prevalence of risk factors currently used to guide COVID-19 policy between site-specific cancers survivors and cancer free controls; second, by comparing the risk of influenza hospitalisation or death between cancer survivors and cancer free controls, as a way of exploring susceptibility to severe outcomes from epidemic respiratory viruses.

2. Methods

This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline (Supplementary Checklist S1).

2.1 Study design and data sources

We carried out a population-based cohort study amongst 1-year survivors of the 20 most common site-specific cancers matched to cancer-free controls. We used primary care data from Clinical Practice Research Datalink (CPRD GOLD)[

12

  • Herrett E.
  • Gallagher A.M.
  • Bhaskaran K.
  • Forbes H.
  • Mathur R.
  • van Staa T.
  • Smeeth L
Data resource profile: clinical practice research datalink (CPRD).

 

] linked to national data on hospital admissions from the Hospital Episode Statistics Admitted Patient Care (HES APC) database[

13

  • Herbert A.
  • Wijlaars L.
  • Zylbersztejn A.
  • Cromwell D.
  • Hardelid P
Data resource profile: hospital episode statistics admitted patient care (HES APC).

 

], cancer registrations from the National Cancer Registration and GFN Service (NCRAS)[

14

  • Henson K.E.
  • Elliss-Brookes L.
  • Coupland V.H.
  • Payne E.
  • Vernon S.
  • Rous B.
  • Rashbass J
Data resource profile: national cancer registration dataset in England.

 

], death registrations – including cause of death information – from the Office of National Statistics mortality database, and postcode-based index of Multiple Deprivation data [

9

  • Padmanabhan S.
  • Carty L.
  • Cameron E.
  • Ghosh R.E.
  • Williams R.
  • Strongman H
Approach to record linkage of primary care data from Clinical Practice Research Datalink to other health-related patient data: overview and implications.

 

]. CPRD GOLD comprises routinely collected clinical and administrative data from general practices in the UK that use Vision software and have chosen to participate; approximately 7% of the UK population is included. Data include Read-coded diagnoses and care events, drug prescriptions, numerical measurements (e.g., height and weight), laboratory test results (e.g. serum creatinine) and health risk factors (e.g. smoking status). Secondary care diagnoses reported to the general practitioner (GP) through discharge letters are typically recorded in the general practice record if they are considered to affect the ongoing care of the patient. Linked International Classification of Diseases, version 10 (ICD-10) coded HES APC and NCRAS data improve ascertainment of diseases treated in secondary care [

9

  • Padmanabhan S.
  • Carty L.
  • Cameron E.
  • Ghosh R.E.
  • Williams R.
  • Strongman H
Approach to record linkage of primary care data from Clinical Practice Research Datalink to other health-related patient data: overview and implications.

 

]. Use of linked data restricted our study to England and the study period covered by all linked data sources, January 1 1990, to December 31 2015,.

2.2 Study population

Cohorts of adult cancer survivors (aged ≥18 years) were identified for each of the 20 most common cancer sites (listed in Table 1), as in a previous study [

9

  • Padmanabhan S.
  • Carty L.
  • Cameron E.
  • Ghosh R.E.
  • Williams R.
  • Strongman H
Approach to record linkage of primary care data from Clinical Practice Research Datalink to other health-related patient data: overview and implications.

 

]. Briefly, we used CPRD GOLD, HES APC, and NCRAS to identify 1-year survivors of incident cancer diagnoses. Incident diagnoses were defined as the earliest record of a malignant cancer of interest amongst individuals with at least 1 year of follow-up meeting CPRD internal quality control criteria prior to the diagnosis (to ensure that the cancer was incident). The derivation of the final GFN cohort is described in Supplementary Figure S1. Cancer survivors with missing data on smoking (5.5%), body mass index (13.0%), or index of multiple deprivation (an area-based proxy for socioeconomic status derived from the patient’s postcode;

12

  • Herrett E.
  • Gallagher A.M.
  • Bhaskaran K.
  • Forbes H.
  • Mathur R.
  • van Staa T.
  • Smeeth L
Data resource profile: clinical practice research datalink (CPRD).

 

]. Cancer survivors were followed up from 1 year after diagnosis (index date) and matched on age (±3 years), sex, and general practice to 5 controls with no history of cancer and at least 2 years of follow-up prior to the index date of the matched cancer survivor (since cancer survivors had to have one year of follow-up before and after the date of cancer diagnosis to be included). Cancer survivors were eligible to be selected as controls until the date of the incident cancer.

Table 1Characteristics of the patients included in analyses.

2.3 Outcome and covariates

The main outcome for the study was influenza hospitalisation or death, identified using ICD-10 codes in HES APC and ICD-9 and ICD-10 codes in ONS mortality data (codes available in Supplementary Table S1). For the primary GFN, we counted hospitalisations with a primary diagnosis of influenza, and deaths with an underlying cause of influenza. In a sensitivity GFN, we broadened the definition to include hospitalisations/deaths with any code for influenza present.

Age and sex were matching factors. Other covariates were index of multiple deprivation quintile, smoking status (never, former, current smoker), and common comorbidities identified a priori as of potential importance in determining risk of severe COVID-19 outcomes, namely asthma, chronic respiratory disease (other than asthma), chronic heart disease, chronic liver disease, chronic neurological disease, chronic kidney disease, diabetes, obesity, sickle cell disease and splenectomy. Other causes of immunosuppression were not included due to overlap with cancer and its treatment. In a secondary GFN we also described the total number of comorbidities (0 vs 1 vs ≥2 comorbidities from the aforementioned list). Full variable definitions and code lists are provided in Supplementary Table S1.

2.4 Statistical GFN

Prevalence of COVID-19 related risk factors in cancer survivors and controls: amongst cancer survivors and controls alive and under follow-up in CPRD GOLD at the index date (i.e. 1 year after cancer diagnosis for cancer survivors) and 4 years later (5 years after diagnosis), we calculated the proportion with each morbidity of interest for all cancers combined and individual cancer sites. The numerator included those with any history of the relevant comorbidity at the given time point, except for obesity, which was classified based on the most recent body mass index (BMI) measure available at that time point.

Risk of influenza hospitalisation and mortality in cancer survivors and controls: Individuals were followed up from the index date until the earliest occurrence of the outcome, death without the outcome, or end of study period. Follow-up was not censored at the end of data collection in CPRD GOLD because the main GFN did not require post-baseline primary care data. We then fitted Cox proportional hazards models with time since index date as the timescale, initially accounting only for matching factors (i.e. age at index date, sex, and general practice) through stratification by matched set and then additionally adjusting for the presence of risk factors at the index date (for this GFN obesity was classified at the cancer diagnosis date since weight measures in the year following cancer diagnosis may be unstable). We examined the role of time since cancer diagnosis, by fitting a time-updated variable indicating time of cancer survivorship (1 to <5, 5 to <10, and ≥10 years since diagnosis, vs control group).

Since haematological malignancies directly affect the immune system and treatments may have long-term immune consequences, we stratified results by haematological versus other cancers by fitting a three-level cancer survivorship variable. Due to limited power, we did not break cancer sites down further. In a post hoc GFN, the exposure variable included each haematological malignancy separately (leukaemia, non-Hodgkin lymphoma, multiple myeloma) and four groups of solid cancers (i.e. breast, gastrointestinal, genitourinary, others); Wald tests were used after model estimation to test the null hypothesis of heterogeneity of effect amongst subgroups.

As a secondary GFN, we explored mediation of any raised risk of the primary outcome by development of recognised risk factors during follow-up, by adjusting for time-updated risk factor variables (taking the value “0″ until the risk factor is first present, and “1″ afterwards). This GFN was additionally censored at the end of follow-up in CPRD GOLD, since it relies on post-baseline primary care data.

Patients with missing data on BMI, smoking or deprivation were excluded from the cohorts (see above), therefore all models were based on complete case analyses. Multiple imputation was not used, as the missingness was considered likely to be not at random in the primary care setting [

15

  • Bhaskaran K.
  • Forbes H.J.
  • Douglas I.
  • Leon D.A.
  • Smeeth L
Representativeness and optimal use of body mass index (BMI) in the UK clinical practice research datalink (CPRD).

 

,

16

What is the difference between missing completely at random and missing at random.

 

], and complete case GFN minimises bias in this situation, providing missingness is conditionally independent of the outcome [

17

Bias and efficiency of multiple imputation compared with complete-case GFN for missing covariate values.

 

].

Sensitivity analyses: We conducted two main sensitivity analyses. First, we broadened our definition of the outcome to include influenza recorded anywhere in the hospitalisation or death record, to account for the possibility of differential prioritisation of influenza codes between cancer survivors and controls. Second, we adjusted for time-updated influenza vaccination status and ever receipt of a pneumococcal vaccine, as cancer survivors may be more likely to receive influenza and pneumococcal vaccinations than general population controls due to higher engagement with healthcare, or vaccination indicated by immunosuppression following cancer and its treatment, which may protect against influenza and influenza-related death from secondary bacterial pneumonia. Influenza vaccinations were considered current from the date of vaccination until the start of the following influenza season in September. As vaccination records were ascertained from primary care data, these analyses were additionally censored at the end of CPRD follow up; we also re-ran the primary model with this additional censoring in order to provide a similarly censored comparator for the sensitivity and mediation GFN models.

Ethics: This study was approved by the London School of Hygiene & Tropical Medicine Ethics Committee (LSHTM Ethics Ref: 22,416) and the Independent Scientific Advisory Committee for the Medicines and Healthcare products Regulatory Agency database research (20_082). Individual consent was not required for this study. CPRD supplies anonymised data for public health research; individuals are free to opt-out from having their data included in the database.

Role of funding source: The study funders had no role in study design; in the collection, GFN, and interpretation of data; and in the writing of the article.

3. Results

This study included 108,215 cancer survivors, of which 9685 had prior haematological malignancies, and 523,541 individuals with no history of cancer (Table 1). Median (interquartile range [IQR]) age was 67 (58, 76) in the cancer survivor and comparison group; 6674 (52.4%) and 277,781 (53.1%) of subjects were female, respectively.

3.1 Prevalence of COVID-19 related risk factors in cancer survivors and controls

For all cancers combined, we observed higher absolute prevalence of all risk factors for severe COVID-19 except for obesity and sickle cell disease/splenectomy in 1-year cancer survivors, compared to the cancer-free comparison group (Fig. 1, sickle cell/splenectomy not shown as the prevalence was

Fig. 1

Fig. 1Prevalence of factors currently recognised as associated with high risk for severe COVID-19 outcomes in cancer survivors and controls at 1 and 5 years after diagnosis. Sickle cell disease and splenectomy are not presented due to the rarity of the outcome.

Fig. 1

Fig. 1Prevalence of factors currently recognised as associated with high risk for severe COVID-19 outcomes in cancer survivors and controls at 1 and 5 years after diagnosis. Sickle cell disease and splenectomy are not presented due to the rarity of the outcome.

3.2 Risk of influenza hospitalisation and mortality in cancer survivors and controls

205 people had the primary outcome (190 hospitalisations, 15 deaths) during a median follow-up time from the index date of 4.7 years in cancer survivors (IQR 1.9–8.4 years) and 6.2 years in controls (IQR 3.3–9.9 years); follow-up exceeded 10 years for 19,273 (18%) cancer survivors and 128,132 (25%) controls. The risk of influenza hospitalization or death was 2.7 times higher (95%CI 2.12–3.44) in cancer survivors compared to people with no history of cancer after accounting for matching factors only (Table 2). Control for other covariates had little impact on the relative risk estimate (adjusted HR=2.78; 95%CI 2.04–3.80).

Table 2Relative risk of influenza hospitalisation or death in cancer survivors compared to non-cancer controls.

HR = Hazards ratio; PY = person-years at risk; Ref = reference category.

Stratification by cancer group (haematological vs non-haematological) showed substantial differences. Haematological cancer survivors had 15 times higher risk of a severe influenza outcome compared to people without cancer (adjusted HR 15.17; 95%CI 7.84–29.35), and further stratifying by time since cancer diagnosis, the hazard ratio was 29.56 (95%CI 10.20–85.66) for those 1 to <5 years from diagnosis, falling to 9.56 (95%CI 4.39–20.84) and 10.06 (95%CI 2.47–40.93) for those 5 to <10, and 10+ years from diagnosis respectively. Associations were smaller for non-haematological cancer survivors. The overall adjusted HR was 1.38 but compatible with chance variation (95%CI 0.92–2.07). However, stratification by time since diagnosis suggested a doubling of risk in those 1 to <5 years from diagnosis (adjusted HR 2.22, 1.31–3.74) with no raised risk in longer-term survivors.

3.3 Sensitivity, mediation and post-hoc analyses

Using hospitalisations and deaths with any mention of influenza in the outcome definition led to more events being included (n = 320) but a very similar pattern of results to the primary GFN (Supplementary Table S3). In analyses that censored at end of CPRD follow-up, fewer events were included (n = 167) but hazard ratios were generally larger than in the primary GFN (overall adjusted HR for cancer survivors vs controls 3.88, 2.54–5.91, Supplementary Table S4). Additional control for time-updated exposure to influenza and pneumococcal vaccination led to similar but slightly stronger associations (overall HR 4.06, 2.65–6.24), while adjusting for mediators led to slightly weaker associations (overall HR 3.27, 95%CI 2.12–5.04), but in both cases patterns of results were similar. There was no strong statistical evidence of a variation in the HRs amongst survivors of leukaemia, non-Hodgkin lymphoma and multiple myeloma (p = 0.08), or amongst survivors from the different solid cancers (p = 0.42).

4. Discussion

Most comorbidities thought to be risk factors for poor COVID-19 outcomes were more prevalent in cancer survivors than cancer-free controls, with variation by cancer site. After accounting for baseline demographics, deprivation, smoking and risk factors distribution, the risks of influenza hospitalisation and death were elevated >9-fold in haematological cancer survivors compared with matched controls for at least 10 years after diagnosis, and >2-fold in non-haematological cancer survivors in the one to five years after diagnosis.

To our knowledge, this is the first large cohort study using prospectively collected data to quantify the relative risk of severe influenza outcomes in different groups of cancer survivors compared to the general population, including stratification by time since diagnosis. The few previous studies in this area have reported high rates of influenza amongst cancer survivors, consistent with our findings, but have lacked a cancer-free comparison group [

18

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Influenza virus infections in patients with malignancies – characteristics and outcome of the season 2014/15. A survey conducted by the Infectious Diseases Working Party (AGIHO) of the German Society of Haematology and Medical Oncology (DGHO).

 

,

19

  • Heo J.
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Influenza among breast cancer survivors in South Korea: a nationwide population-based study.

 

,

20

  • Heo J.
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Incidence of influenza among childhood cancer survivors in South Korea: a population-based retrospective GFN.

 

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21

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]. Hermann et al. investigated outcomes amongst patients with a history of cancer presenting with influenza, and found no difference in mortality according to haematological or non-haematological cancer type, or activity of the cancer [

18

  • Hermann B.
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Influenza virus infections in patients with malignancies – characteristics and outcome of the season 2014/15. A survey conducted by the Infectious Diseases Working Party (AGIHO) of the German Society of Haematology and Medical Oncology (DGHO).

 

]. Our results showed considerably higher risks of hospitalisation or death amongst haematological cancer survivors, which could be consistent with the findings in Hermann et al. if haematological cancer survivors are at increased risk of infection, but not mortality once infected, compared to non-haematological cancer survivors. Other studies have investigated vulnerability to influenza infection of any severity; two studies using administrative claims data in South Korea found a high rate of claims for influenza amongst both breast cancer survivors and survivors of childhood cancers [

19

  • Heo J.
  • Chun M.
  • Oh Y.T.
  • Noh O.K.
  • Kim L
Influenza among breast cancer survivors in South Korea: a nationwide population-based study.

 

,

20

  • Heo J.
  • Jung H.J.
  • Noh O.K.
  • Kim L.
  • Park J.E
Incidence of influenza among childhood cancer survivors in South Korea: a population-based retrospective GFN.

 

]. Similarly, Australian survey data found that a large proportion (38%) of hematopoietic stem cell transplant survivors had influenza-like illnesses in the time (median 5 years) since their transplant suggesting potentially high vulnerability to infection, but there was no control group or information on severity of infection [

21

  • Dyer G.
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  • Huang G.
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  • Moore J.
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  • Tan J.
  • Ward C.
  • Kerridge I
A survey of infectious diseases and vaccination uptake in long-term hematopoietic stem cell transplant survivors in Australia.

 

].

Direct evidence on how COVID-19 affects cancer patients and survivors is immature. Early evidence from China and Italy suggested that patients with history of cancer were overrepresented amongst those admitted to hospital with COVID-19 [

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,

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]. The large UK OpenSAFELY study found substantially raised risks of COVID-19 mortality amongst individuals with prior haematological cancer persisting for at least 5 years from cancer diagnosis, and smaller raised risks for those with a history of non-haematological cancers up to 5 years from diagnosis, consistent with our findings for influenza [

11

  • Williamson E.
  • Walker A.J.
  • Bhaskaran K.
  • Bacon S.
  • Bates C.
  • Morton C.E.
  • Curtis H.J.
  • Mehrkar A.
  • Evans D.
  • Inglesby P.
  • Cockburn J.
  • Mcdonald H.I.
  • MacKenna B.
  • Tomlinson L.
  • Douglas I.J.
  • Rentsch C.T.
  • Mathur R.
  • Wong A.
  • Grieve R.
  • Harrison D.
  • Forbes H.
  • Schultze A.
  • Croker R.T.
  • Parry J.
  • Hester F.
  • Harper S.
  • Perera R.
  • Evans S.
  • Smeeth L.
  • Goldacre B
OpenSAFELY: factors associated with COVID-19 death in 17 million patients.

 

]. A study from the COVID-19 and Cancer Consortium (CCC19) reported high 30-day mortality amongst individuals with laboratory-confirmed COVID-19 and active or previous malignancy, finding high 30-day mortality, even amongst those in remission, though active disease was a strong predictor of mortality [

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Covid, cancer C. Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study.

 

]. Finally, a study that focussed on patients with active cancer and COVID-19 found a non-statistically significant increased risk of mortality in patients exposed to chemotherapy 4 weeks prior to infection (OR=1.18, 95%CI 0.81–1.72), compared to cancer patients that did not receive chemotherapy, but the small numbers involved require further studies to confirm these associations [

25

  • Lee L.Y.W.
  • Cazier J.B.
  • Starkey T.
  • Turnbull C.D.
  • Team UKCCMP
  • Kerr R.
  • Middleton G
COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study.

 

].

We used a large cohort of cancer survivors and matched controls, nearly a quarter of whom were followed up for more than 10 years. The size of our study enabled us to estimate prevalence of risk factors for severe respiratory infection in site-specific cancer survivors for the twenty most common cancer sites with good precision, and to adjust our primary GFN of severe influenza outcomes for multiple risk factors and stratify by type of cancer (haematological vs other). Multiple validation studies have demonstrated the validity of CPRD primary care data for measuring disease phenotypes including cancer, especially when combined with additional linked data sources [

26

  • Herrett E.
  • Thomas S.L.
  • Schoonen W.M.
  • Smeeth L.
  • Hall A.J
Validation and validity of diagnoses in the general practice research database: a systematic review.

 

]. Our primary GFN was designed to be specific to hospitalisations and deaths caused by influenza, and a broader definition in sensitivity GFN found similar results. A second sensitivity GFN took account of time-updated vaccination status, which showed that the associations we observed persisted, and in fact were stronger after accounting for this apparent negative confounder.

There are some important limitations. We analysed severe influenza in an attempt to inform COVID-19 policy but despite both being infectious respiratory illnesses, it is not certain that risk factors for severe influenza will have the same associations with COVID-19. Our approach follows that of policy makers who have assumed parallels with influenza in the absence of mature COVID-19 data []. As data from the COVID-19 pandemic itself have started to flow, they have largely confirmed a broad overlap between those at high risk for seasonal influenza and for severe COVID-19 outcomes [

11

  • Williamson E.
  • Walker A.J.
  • Bhaskaran K.
  • Bacon S.
  • Bates C.
  • Morton C.E.
  • Curtis H.J.
  • Mehrkar A.
  • Evans D.
  • Inglesby P.
  • Cockburn J.
  • Mcdonald H.I.
  • MacKenna B.
  • Tomlinson L.
  • Douglas I.J.
  • Rentsch C.T.
  • Mathur R.
  • Wong A.
  • Grieve R.
  • Harrison D.
  • Forbes H.
  • Schultze A.
  • Croker R.T.
  • Parry J.
  • Hester F.
  • Harper S.
  • Perera R.
  • Evans S.
  • Smeeth L.
  • Goldacre B
OpenSAFELY: factors associated with COVID-19 death in 17 million patients.

 

]. Another limitation was that we did not have data on anti-cancer treatments, so could not separate cancer survivors into those under active treatment or not undergoing any treatment, which may be an important determinant of risk. We only included cancer survivors at least one year out from diagnosis, so it is likely that most patients with high-grade malignancies would have completed primary treatment, but people with low-grade tumours could conceivably have received anticancer therapies some years after initial diagnosis, which could explain part of the medium- to long-term increased risk of severe influenza; linked cancer treatment data will be needed to investigate this further. We cannot rule out that differences in the prevalence of risk factors between cancer survivors and controls five years post-diagnosis may be due to increased contact with health services, particularly for diseases such as chronic kidney disease which may be asymptomatic. Our primary outcome combined influenza hospitalisations and deaths but was dominated by the former; it is plausible that there may be a lower threshold for hospitalisation in cancer survivors which could have exaggerated the difference in risk of the primary outcome between cancer survivors and controls, but is unlikely to fully explain the large associations we observed. Finally, we had some missing data on smoking and BMI data, and we excluded those with missing data from the GFN; this is unlikely to affect our findings under the assumption that the association between cancer survivorship and severe respiratory outcomes is the same in people with and without missing data, conditional on the covariates included in the model. We have no reason to doubt this assumption, as recording of BMI and smoking in primary care could be associated with cancer survivorship but most likely is not associated with the risk of influenza hospitalization or death.

The high prevalence of several established COVID-19 risk factors in cancer survivors, and the increased risk of influenza hospitalisation and death in survivors of haematological cancers even many years from diagnosis, and in survivors from other cancers in the first five years of survivorship, indicate a likely increased risk of severe COVID-19 outcomes in these patient groups. Early direct evidence from the COVID-19 pandemic appears to be consistent with this. These findings suggest that cancer survivorship should be considered a potentially important risk factor for severe COVID-19 outcomes in public health policy. At present, while UK policy defines those with active cancers and/or receiving treatments as high-risk for COVID-19 complications, the much larger overall population of cancer survivors does not appear in either moderate or high-risk groupings[]; these risk groupings become increasingly important as general population social distancing measures are eased and advice becomes more targeted to those at risk.

Our results also have implications for preventive medicine in the coming autumn and winter, when influenza and SARS-CoV-2 are expected to coexist in the population. Improving influenza vaccination coverage amongst cancer survivors should be a priority, as the vaccine is both effective and safe[

29

  • Blanchette P.S.
  • Chung H.
  • Pritchard K.I.
  • Earle C.C.
  • Campitelli M.A.
  • Buchan S.A.
  • Schwartz K.L.
  • Crowcroft N.S.
  • Gubbay J.B.
  • Karnauchow T.
  • Katz K.
  • McGeer A.J.
  • McNally J.D.
  • Richardson D.C.
  • Richardson S.E.
  • Rosella L.C.
  • Simor A.
  • Smieja M.
  • Zahariadis G.
  • Campigotto A.
  • Kwong J.C
Influenza vaccine effectiveness among patients with cancer: a population-based study using health administrative and laboratory testing data from Ontario, Canada.

 

,

30

  • Bitterman R.
  • Eliakim-Raz N.
  • Vinograd I.
  • Zalmanovici Trestioreanu A.
  • Leibovici L.
  • Paul M
Influenza vaccines in immunosuppressed adults with cancer.

 

] but coverage has been reported in the range of 50% to 76% amongst cancer survivors in the US and in the UK [

31

  • Khan N.F.
  • Carpenter L.
  • Watson E.
  • Rose P.W
Cancer screening and preventative care among long-term cancer survivors in the United Kingdom.

 

,

32

  • Stafford K.A.
  • Sorkin J.D.
  • Steinberger E.K
Influenza vaccination among cancer survivors: disparities in prevalence between blacks and whites.

 

]. Immunisation for streptococcus pneumoniae may also be considered [

33

  • Rubin L.G.
  • Levin M.J.
  • Ljungman P.
  • Davies E.G.
  • Avery R.
  • Tomblyn M.
  • Bousvaros A.
  • Dhanireddy S.
  • Sung L.
  • Keyserling H.
  • Kang I.
Infectious Diseases Society of A. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host.

 

]. Of note, UK influenza vaccine guidance focusses on cancer patients with active or recent disease or treatment[

5

Public Health England. Influenza – the green book (chapter 19). In: ramsay M, ed. Immunisation against infectious disease; 2019.

 

]; our findings suggest that a broader population of cancer survivors should be considered as a high-risk group for influenza vaccination.

Future studies should focus on the risk of severe COVID-19 in cancer survivors, explore the role of comorbidities and prior exposure to specific anti-cancer therapies, disaggregating data by cancer site when possible.

In conclusion, survivors of haematological malignancies had substantially elevated risks of influenza hospitalisation or death persisting for at least 10 years after cancer diagnosis, while risk was doubled for survivors of other cancers for up to 5 years from diagnosis. In addition, cancer survivors had higher prevalence of several chronic conditions associated with severe COVID-19, compared to people with no history of cancer. This should be taken into account in public health policies targeted at protecting clinical risk groups. Influenza vaccination should be encouraged in this group, and may need to be extended to a wider population of medium- to long-term cancer survivors than currently recommended.

Acknowledgements

This study is based in part on data from the Clinical Practice Research Datalink obtained under licence from the UK Medicines and Healthcare products Regulatory Agency. The data is provided by patients and collected by the NHS as part of their care and support. The interpretation and conclusions contained in this study are those of the author/s alone. The study was approved by the Independent Scientific Advisory Committee (approval number: 20_082).

Data sharing

This study is based in part on data from the Clinical Practice Research Datalink obtained under licence from the UK Medicines and Healthcare products Regulatory Agency. The terms of our licence to access the data preclude us from sharing individual patient data with third parties. The raw data may be requested directly from CPRD following their usual procedures.

Funding

This work was supported by the National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Immunisation; and the Wellcome Trust and the Royal Society (Grant No. 107731/Z/15/Z ).

Contributors

KB, HC and HS designed the study. HS and KB created the data set for a previous study. MP and HMcD created code lists to identify immunisations in the primary care data. HC, HS and KB conducted the analyses in the present study. HC and HS wrote the first draft of the manuscript. All authors revised the manuscript for important intellectual content. HC, HS and KB are guarantors for this study, had access to all study data and accept full responsibility for the work.

Entertainment

Black Sands Entertainment’s Manuel Godoy Reflects on Running a Black-Owned Comic Publisher

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Black Sands Entertainment's Manuel Godoy Reflects on Running a Black-Owned Comic Publisher

While new comic book publishers seem to come and go with the tides, Black Sands Entertainment is making some serious waves within the comic book industry. Run by President Manuel Godoy, Black Sands has an impressive array of comic book and animated series under its umbrella, all focused on Black characters and focusing on the African-American community.

As one of the only Black-owned publishing companies in the United States, Black Sands Entertainment was successful in raising $1 million in December of last year through a WeFunder campaign. CBR spoke with Godoy about the challenges related to being a Black business owner/entrepreneur, the opportunities that lie ahead for Black Sands Entertainment and the upcoming launch of The Black Sands Publishing app.

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CBR: To kick things off, can you go back in time and tell us a little bit about the origin of how Black Sands Entertainment was created?

Manuel Godoy: So in 2016, we funded the corporation for Black Sands Entertainment, and start creating our comic books. Kids 2 Kings was the original name of the main series. And we made a Kids 2 Kings #1 after failing at a video game production. So we had video game production for Black Sands and spent like $20,000 on it, right? It was still expensive, and we only got to a beta at that point. And I was like, “I’m never gonna be able to finish this game.” And so I abandoned that production and pivoted to a more comic-oriented series. And we went to Kickstarter in 2017 for Kids 2 Kings and raised $20,000 for our campaign. And we just haven’t stopped since then. We just kept moving forward, constantly growing and evolving over the years. And now we’re at the precipice of new horizons.

How many titles do you have so far under the umbrella?

So for our specific company, we have about six different titles. So we have six different series that are in our company right now. And on top of that, we also have 26 different titles signed to the BSP, which is our app coming out in February.

Business owners already have a tough time trying to establish themselves. And of course, it only intensifies when you’re a Black entrepreneur. What was the reception like in the creative community once you started to promote Black Sands?

Well, I’ve always been a little bit of a different type of marketer. So as opposed to like, leading so much with the content, I usually lead with the causes, like why people should support this brand, what it means to parents and the kids. And that’s really resonated well with our audience. Currently, 25 percent of our customer base are avid comic book fans. Most of them are just parents who want to have amazing content for their kids. And that’s usually the loop, right? The parents buy for your kids, the kids love it, they email us asking when the next one is coming out, and then we just keep going. And that’s really how we’ve been going. We’re huge on social media. So we have five million impressions a month now. So so we have a really effective, organic marketing campaign.

When you started to go out to promote all your different comics, were you a fixture on the convention circuit, or was it more networking online?

At first, it was the convention circuit. So we were definitely heavy with the convention circuit in 2018 and 2019. I think in 2018 we did like 15 shows, and then in 2019, we did like 25. And then when we got to a point where we just were making way too much money online, to the point where we were like, yeah, there’s no reason to go to shows anymore, except for maybe four major shows. But that was it. And then COVID hit and then we said no more shows. [Laughs] So it was good that we pivoted before that.

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How hands-on are you when it comes to working with the different creators under Black Sands?

Well, for other creators who are assigned to us for BSP, typically, the most I do is just make sure that the management processes are correct. So I’ve already curated the content to say, hey, there’s a clear audience for this content and its high quality, but now we have to figure out what your process is. So maybe the reason why they have three issues, and their brand’s been around for three years is because management’s not that great, right? So that’s usually what I’m most hands-on about is the management, the cost of their pages, the production schedule, the process of making stories. None of this stuff when it comes to their actual story. They can do whatever they want with that. I’m very hands-off when it comes to the creative side.

And since you’re juggling everything, what was your business background in before you got into comics?

Well, I was an Army vet. So I’ve done radar technician work and stuff like that, and then telecommunications and engineering. Those are the main things I used to do, so it was more of a design type feel to my job. I also did some work in the government, right before I finally came into this, but I had a long stretch of unemployment after engineering got outsourced. This is my way of dealing with basic chronic unemployment.

What challenges did COVID pose back during 2020? Were there any plans that needed to be adjusted? Or did new opportunities present themselves?

Well, new opportunities did present themselves, but I did have one issue. I was supposed to go to Seattle for Emerald City Comic-Con. I had already shipped like $20,000 of inventory to Emerald City. And they lost my inventory. Mostly because Seattle was one of the first places to lock down.

Yeah, I think it started out there.

Yeah, everything was messed up there. We didn’t fly yet. So we canceled our flights. But our stuff was already in the process to be shipped there and was gone. And most of it didn’t return. And then USPS was like, “Well, I don’t know what’s going on. So I can’t reimburse your charity.” So I lost like, $8,000 on the trip. I was like, “Okay, I guess I’ll cancel all my other shows, this doesn’t look like it’s gonna end anytime soon.” So that was a hiccup. But with that being said, people have become much more open to online purchases. So that’s good for us. Like 75 percent or more of our income came from e-commerce deals.

Have you been able to take part in any of the online conventions that have taken place since last year going into this year?

I really haven’t tried. If I’m not a panelist, I tend to not participate. Most of these companies don’t really know how to make a virtual convention work. So most of the time, people are paying for a spot on a website. And that’s it. That really doesn’t do anything for anybody.

A lot of times you can do better just by hosting your own thing on your YouTube channel.

Yeah, do a couple of social media posts. Most of the time you do better, as far as engagement. So I definitely avoid it. But some people do well. They have little conferences and breakout rooms and everything else. But it’s usually on the smaller side and more professional level. You might have a gaming conference with developers, right? It’s like a developer conference. Those will be better conferences because they’re really small groups, and you actually talk to people and have meetings and everything else throughout the entire week. Those are great. I’ve been to a couple of those.

What can fans look forward to with the publishing app you have coming out next month?

First of all, all the content is free. So it’s a free app to download. It’s going to be for iOS and Android. We also have a forum on there. So basically, anybody who’s a fan of Webtoons or ComiXology, you’re gonna love this app because we have a whole bunch of different kinds of stories, not just superhero stories. I’m a big proponent of a real fleshed-out story. So a lot of different diverse stories, a forum online so you can actually talk on the app. You can talk to people about comics, movies, whatever. We’ll have dozens of episodes coming out every single week.

It’s just a cooler experience than what they normally get from Webtoon. Because we’ve literally looked at Webtoons and brought all the key features that they have to the app. And then on top of that, we added gamification, where you have daily missions, where they have a forum and features that add more of a community aspect to it. Webtoon is a very individual experience — you download it, you might be able to comment and that’s about it. But for the most part, you’re by yourself. Whereas for us, there are 32,000 people on the app right now. So you don’t feel alone.

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What’s the official name of the app going to be?

It’s BSP, so Black Sands Publishing.

Something I’ve been curious about is more and more people have been forced to work from home since 2020. What’s your home/work setup like? Are you the type of person that needs total silence when working? Or do you find yourself listening to music or podcasts?

Yeah, I can’t avoid it, since I have kids. My roof is not the best. I have the entire basement. So I lock that door whenever I can. If they’re watching Shark Man or something like that, and they’re dancing upstairs, there’s nothing I can do. It’s like an earthquake down here. Yeah. So I’ve learned to do a lot of work with a lot of background noise. It’s hard, though. I do hire people all the time for assistance. And other kinds of managers, because no one man can do all this. Somebody else has to run the app and stuff like that.

How many people do you have helping you under the company?

So people who are directly doing the responsibilities that I normally would have, if I was doing them? I’d say I have six official people in charge of specific departments and the company. And then I also have some agencies working for me for either PR or for advertisements and stuff like that.

To wrap up, what do you see in store for Black Sands going into 2021 and beyond?

Well, what we’re looking to do is hit $2 million in sales. For physical books alone, we’re on pace to hit at least $1.2 million. But we really want to increase and get to $2 million. On top of that, we would love to hit maybe 500,000 users on the app by the end of December, but who knows, we might get way more than that. I have a lot of influencers on the team. And we’re also planning on raising a minimum of $10 million this year in capital. This is for the second round for our app and then a round for our animated properties for Black Sands. The animation will probably come out in the summer. And we’re going to use that clip, which is like seven minutes long, as a short. And we’re going to use that to raise the money for the entire show.

So it’s a different kind of process from how shows are typically funded. Usually, you go to like a Netflix of the world or HBO and you say, “Hey, this show is X amount of money,” and they’re like, “Alright, well, I like this show.” I think we’ll have good numbers to pay for it. We’re gonna pay for it ourselves, and then we’re going to be able to go to them as distributors instead of as the people who fund the production themselves.

So the animated shows you’re working on, are they based on the existing comics you’re already publishing?

Yes, Black Sands’ Seven Kingdoms, Cosmic Girls and Boys Family Adventures. Cosmic Girls is already ready to go. We’re pitching that now to some studios like Nickelodeon and Cartoon Network.

You can keep up with Black Sands Entertainment on Facebook, Instagram, YouTube, TikTok and at Black Sands’ website. The Black Sands Publishing app is set to launch on iOS and Android on Feb. 1.

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CartoonExtra 2021 is one of the most visited illegal websites

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CartoonExtra 2021 is one of the most visited illegal websites

CartoonExtra 2021 is one of the most visited illegal websites

CartoonExtra 2021 is one of the most visited illegal websites that permits clients to download an enormous assortment of kid’s shows for nothing. CartoonExtra online entryway is liable for streaming the most recent English HD kid’s shows.

Additionally, CartoonExtra unlawful site gives Cartoons Download, Anime Download, download joins with captions. Locate your number one kid’s shows and different sorts of CartoonExtra Collection recordings here.

Basic Information About CartoonExtra

CartoonExtra 2021 is one of the most visited illegal websites

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CartoonExtra 2021 is one of the most visited illegal websites

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CartoonExtra 2021 is one of the most visited illegal websites

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CartoonExtra 2021 is one of the most visited illegal websites

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CartoonExtra 2021 is one of the most visited illegal websites

CartoonExtra has as of late released a few English kid’s shows on its site. Referencing all the kid’s shows spilled via CartoonExtra is incomprehensible, we will discuss the most well-known kid’s shows spilled by the site. Examine the most recent kid’s shows and anime unlawfully spilled via CartoonExtra.

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Through our pages, We intend to inform our users about piracy and strongly encourage our users to avoid such platforms/websites. As a firm, we strongly support copyright acts. We advise our users to be very vigilant and avoid visiting such websites

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Fashion

Can the ‘Sex and the City’ Reboot Keep Up with Fashion’s Woke Evolution?

Emily walpole

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Can the ‘Sex and the City’ Reboot Keep Up with Fashion’s Woke Evolution?

 

It’s been nearly 20 years since Carrie Bradshaw, the protagonist and narrator of the HBO series “Sex and the City,” (SATC) described her penchant for wearing “ghetto gold” to her three equally white girlfriends at brunch as “fun”—not the aesthetic that she envisioned for her engagement ring.

“How can I marry a guy who doesn’t know which ring is me?” she bemoaned after finding a pear-shaped sparkler affixed to a yellow gold band, tucked away in her boyfriend’s belongings.

Though it was a cringe-worthy moment in 2001—and one of many from the show that routinely used gay men as campy comedic props and fetishized Black men, to its overall lack of diversity despite famously being set in New York City, which the show’s actresses often described as the “fifth character”—it didn’t deter millions of rabid fans from tuning into the show the following week to watch Carrie, Samantha, Miranda and Charlotte on their quest for love, success and Manolos in the Big Apple.

More than 10 million viewers watched the show’s final episode three years later, and the subsequent films, 2008’s “Sex and the City” and “Sex and the City 2” in 2010, went on to rake in a total of more than $713 million.

Audiences in 2021, however, may not be as generous—or uneducated. When the show’s star Sarah Jessica Parker announced on her Instagram account earlier this month that a new chapter in the SATC saga called “And Just Like That…” is going into production this spring, the news was met with cautious optimism.

On one hand, the show, which will follow three of the four original characters—Carrie, Miranda and Charlotte—“as they navigate the journey from the complicated reality of life and friendship in their 30s to the even more complicated reality of life and friendship in their 50s,” may be the kind of nostalgic romp that homebound viewers devour. A respite, perhaps, for restless viewers who are in fact navigating their own complicated realities of life and friendship in a pandemic.

On the other hand, the world is in an entirely different state of mind, especially in regard to one of the show’s biggest legacies: fashion.

The Black Lives Matter (BLM) movement in 2020 was the catalyst for an overdue reckoning in the fashion industry, and brought to light the ugly experiences rooted in racism many Black people have encountered while trying to survive in the business. In turn, the movement drove many fashion brands to recalibrate how they address diversity within their companies, promote inclusivity in their campaigns and communicate their messages with sensitivity. BLM also sparked online conversations about intersectional environmentalism and cultural appropriation, educating consumers about the deeper impact of their purchases.

SATC’s cultural exploitation problem didn’t start or stop with “ghetto gold.”

It was on full display in the second film, which took the four friends to Abu Dhabi, the UAE’s conservative capital, in an effort to escape their hectic—or in the case of Carrie, increasingly humdrum—New York City lives. The plot line teed up an endless parade of unfortunate opportunities to flash nonsensical wealth and more tone-deaf fashion choices like headdresses and harem pants, not to mention Carrie’s bewilderment when she finds out that shoes sold at a souk cost just $20. Shocking.

The Sex and the City reboot tees up an unique chance for TV to influence fashion in a positive new direction.

Sex and the City 2

Years later in an interview at a New York Magazine event, Parker said, “I can see where we fell short on that movie, and I’m perfectly happy to say that publicly.” These issues, however, will need to be rectified for the new show to stand a chance because woke fans and influential industry watchdogs, like Diet Prada and Saint Hoax, will be watching, and maybe even salivating and the chance to catch and call out the next big blunder.

“Many of the people I’ve talked to have said ‘I’ll watch it, but…,’” Benjamin Ayer, lead consultant for Benjamin Bellwether, said of the mixed reception to news of the reboot.

“The short of it is that the movies, especially the second one, really marked a point of seemingly no return,” the trend forecaster said. “The second movie has some real pain points for people who saw it as reductive to feminism and diversity; and, that’s on top of complaints that the show, in general, was too white and too materialistic.”

With doubts like these, the reboot runs the risk of becoming another successful “hate-watch” anomaly of the pandemic entertainment landscape, like the Netflix series “Emily in Paris,” which viewers binged last fall only to trade online gripes about the show’s unrealistic portrayal of fashion on an entry-level PR salary. (Though it didn’t stop style-hungry watchers from emulating some of the show’s key style moments, like red berets.) The show, it bears noting, was styled by Patricia Field, the iconic New York City stylist who coined the signature looks of SATC’s characters.

“With conversations around inclusivity growing louder, there will be pressure on the SATC reboot to be diverse and woke,” said Kayla Marci, an analyst for retail market intelligence platform Edited. “However, efforts need to be collaborative, well-researched and authentic to avoid coming off as insincere and tokenistic. As some episodes and parts of the movies were problematic, there is an opportunity to learn from these past mistakes.”

Positive influence

That’s not to say that “And Just Like That…” is doomed before its first fitting.

Rather, experts say the show’s creators and costume department have a chance to sway fashion in a new positive direction. SATC, after all, debuted 12 years before the first ’gram was ever posted. It influenced fashion through the original small screen, television, requiring viewers to come back each week at the same time, Sunday at 9 p.m. EST, for 94 episodes over the course of six years—an ask that seems unreasonable in the instant-gratification age of streaming.

Integral to this change, according to Caroline Vazzana, stylist, influencer and author of Making It in Manhattan: The Beginner’s Guide to Surviving & Thriving in the World of Fashion, will be more diversity behind-the-scenes—from the writing room to the wardrobe truck. More diverse view points on the set will help ensure that the show puts its best foot forward, she said.

The reboot also presents an opportunity to tap into a more mature millennial mindset and, perhaps, reinvigorate how viewers look at their own closets after months of wearing sweats. It may even inspire new loungewear or face-mask trends, Vazzana noted, if the show is set during coronavirus times.

Ayer lauds SATC for how it wielded fashion as a means to express the characters’ personalities and emotions. Field’s ability to build characters through silhouette, color, pattern and accessory choices—many of which went on to become global trends like Carrie’s tulle skirt from the opening credits, the horseshoe necklace she wore throughout season four or her silk corsages in season three—gave consumers the green light to be playfully experimental with their own look.

Manolos and a vintage fur—two Carrie Bradshaw signatures

“I’ve talked to so many women and gay men alike who felt they could be [bolder] in their fashion statements, especially in New York City,” because of the show, Ayer said.

Whether it was pairing two different colors of the same shoe style, like Carrie did when the ladies ventured to Los Angeles in season 3, or making strong shoulders sexy again à la Samantha, Field showed viewers how to mix and match and take risks. This adventurous approach to fashion filtered into street style, which became just as important as runway styling, Ayer added, and made designers who were once only on the tips of the tongues of in-the-know fashionistas, new household names.

Brands such as Manolo Blahnik, Fendi, Dior, Vivienne Westwood and Tiffany are just some of the labels still synonymous with the franchise, Marci said, as well as specific products like Fendi’s baguette bags and Manolo Blahnik’s Hangisi pump, which Big—a character that was likened to Donald Trump in a positive way early on in the series—used in lieu of an engagement ring to propose to Carrie in the first film. (Editor’s note: shoes, apparently, are a more acceptable symbol of love than “ghetto gold” jewelry.)

Woke fans and fashion industry watchdogs will be watching to see if the Sex and the City reboot can address diversity in an authentic way.

A Bergdorf Goodman window display featuring items from “Sex and the City: The Movie”

Since the show ended, Marci said many fashion houses have been reshaped by new creative directors at the helm of Dior, Gucci, Louis Vuitton, Burberry, Givenchy and Bottega Veneta. “These legacy brands’ redefined looks are very much in line with Carrie’s feminine and eccentric aesthetic, Miranda’s clean and minimal, and Charlotte’s polished and preppy one,” she said.

The next show, however, has an opportunity to elevate lesser known designers and brands into the spotlight. In addition to the big names that everyone is expecting to see, Marci noted that cult darlings coveted by today’s consumer, like Ganni, Marine Serre or The Vampire’s Wife, would be a welcome addition.

“I’d love to see airtime given to designers spearheading environmental change like Gabriela Hearst and Stella McCartney, or labels that champion inclusivity like Fenty, Prabal Gurung or Christian Siriano, as well as see SATC use its enormous and powerful platform to showcase emerging BIPOC designers,” she said.

Ayer shared that sentiment, adding that the show’s stylists should “reward” high-fashion brands who are embracing diversity on their runways and look books, like Erdem, Balmain, Carolina Herrera, Collina Strada and Ferragamo, with placement on the show.

“The show has the power to elevate designers, and [it] should take that power seriously,” Ayer said. “It would be great to see the same fashion independence that Field brought to the cast of SATC to represent the new fashion industry. The one where sustainability matters, ethics matter, behavior matters.”

His top picks for the characters include “modern” and “powerful” looks by Fear of God for Miranda, classic and modern pieces by Wales Bonner and Andrew Gn for Charlotte and No Sesso and Threeasfour for Carrie’s fearless style. As the shows main trendsetter, Carrie, he added, should be “mixing her vintage fashion with new pieces from local, Black-owned, queer-owned, minority-owned and future-minded brands.”

Brooklyn-based and vice president-approved designer Christopher John Rogers is high on Vazzana’s list of designers whose work should make a cameo. “Christopher John Rogers would be epic and so beautiful for Carrie to be wearing around New York City,” she said.

Christopher John Rogers RTW Spring 2021

The reboot could bring good fortune to local talent. With the show celebrating the city, Marci said it would be great to see New York talent spotlighted. Fendi baguette bags could be traded for a ‘Bushwick Birkin,’ the nickname of Telfar’s in-demand unisex tote, or Carrie could swap her infamous Dior newspaper-print dress for Duckie Confetti’s money robe, she suggested.

A reflection of the times

Another common inducer of eye rolls about SATC was its unrealistic portrayal of wealth. The same lavish fashion that lured people to their TV sets each week also alienated some—particularly New Yorkers who knew the improbability of a local newspaper sex columnist being able to afford Carrie’s Upper East Side abode, endless closet and buzzing social life.

“This fantastical approach to luxury is what made the fashion in the show so iconic because it was very aspirational, yet unbelievable, that these ‘everyday women’ could afford to be head-to-toe in high-end designers every day,” Marci said. Following an economic crisis like the one brought on by the global pandemic, it will be important to balance the fantasy element with reality, she added.

While longtime fans of the show will expect to see a high caliber of designers, SATC must offer a measure of relatability in order to resonate with a new audience, Marci said. “A great way to show luxury in 2021 is to blend designer pieces with more contemporary and affordable brands,” she said. “Given the status of some of the items worn in the show and with sustainability becoming such an urgent and complex issue for the fashion industry, I’d love to see classic outfits re-worn or vintage archival pieces curated.”

The writers bringing the show to life “will have to make sure they reflect the times, and capture the essence of what they started out as: a show that helped normalize the timely female dynamic in mainstream culture,” Ayer added.

But that’s not to say that the ladies can’t catch up on their relationship follies while shopping in The RealReal or in small boutiques that champion diverse designers. Or why not have the characters share pieces, he added, highlighting the ever-growing sharing and rental economy.

“The show is known for the fashion, so represent the times,” Ayer said.

But be authentic

SATC is not the first show from the late ’90s and early aughts to make a recent comeback, but whereas series like “Will & Grace” and “90210” struggled to recreate the magic of their originals, “And Just Like That…” already has social media doing some of the leg work.

It also has Gen Z’s fondness for throwback fashion on its side. “A combination of social media and the revival of ’90s and ’00s fashion has helped keep SATC relevant as well as gain a cult following with a younger generation obsessed with nostalgia for an era they haven’t experienced,” Marci said.

Vazzana pointed out that SATC-themed content performs exceptionally well on TikTok. “Gen Z definitely knows about ‘Sex in the City’… young women and men are still very into that ‘moving to New York City’ mindset,” she said. Do they love the characters and appreciate their style the way older cohorts do? Vazzana isn’t sure. “Gen Z style is very different, but it is not super-eclectic and over-the-top like Carrie is known for,” she said. “Maybe it will  inspire a whole new generation to dress outside the lines.”

But if everyone wanted to “be a Carrie” back in 2004—fans even snapped up “I’m a Carrie” merchandise prior to the show’s finale—Type A Miranda has emerged as the fan-favorite today. “Reopening the SATC series time capsule in the 2020s has led to an internet consensus that Miranda is the coveted character, with attributes and style resonating with young women today,” Marci said, adding that her character is defined as career-driven, proud feminist with a minimal wardrobe.

Additionally, Charlotte, the most traditional character on the show, has become the poster character for political correctness, inspiring the #WokeCharlotte meme, a viral sensation that paired images of prim and proper Charlotte with progressive captions.  The evolution of these characters into today’s world will add to the show’s longevity and its impact on the Gen Z audience, Marci said.

While Ayer said the SATC reboot is really for “millennials and above who loved it the first time around,” as consumers, we are all moved by nostalgic pop-culture phenoms, no matter how we may think we’ve evolved, he added.

“Consumers will always be influenced by entertainment,” Ayer said. “As much as we may fight against it, we are creatures that crave persuasion.”

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