Among patients with cancer, different tumor types and patient demographics are associated with varying COVID-19 risk and mortality, with patients with hematologic malignancies experiencing the highest susceptibility and poorest outcomes, according to a study recently published in The Lancet Oncology.
Patients with cancer have been identified as a subgroup with increased susceptibility to SARS-CoV-2, the virus that causes COVID-19. "However, cancer encompasses many different diseases, with a diverse array of primary tumor subtypes and stages affecting a heterogenous group of patients of all ages, with very different prognoses and outcomes," note the investigators, led by first author Lennard Y.W. Lee, DPhil, an Honorary Research Fellow at the University of Birmingham's Institute of Cancer and Genomic Sciences. "Therefore, labelling all patients with cancer as susceptible to COVID-19 is probably neither reasonable nor informative."
In their study, Dr. Lee and colleagues investigated susceptibility to and mortality from COVID-19 among patients with cancer based on differing tumor types and patient demographics. The study included 1,044 patients with cancer and COVID-19 enrolled in the UK Coronavirus Cancer Monitoring Project (UKCCMP) between March 18 and May 8, 2020, compared with 282,878 patients with cancer only in the Office of National Statistics dataset. Eligible patients in the UKCCMP cohort were at least 18 years old, had received a positive COVID-19 test, and had active cancer, defined as having metastatic disease, currently undergoing anticancer treatment in any setting, or having received systemic anticancer therapy, surgery, or radiotherapy within the past 12 months.
Compared with cancer patients who did not contract COVID-19, cancer patients who contracted COVID-19 were more likely to be male (56.9% vs 51.3%); the age distribution was similar between the two groups. Tumor types in the study included breast, colorectal, prostate, lung, digestive organ, genitourinary, head and neck, central nervous system, mesothelial and soft tissue, respiratory and intrathoracic organs, bone/articular cartilage, male genital organs, endocrine glands, and hematological cancers. The primary end point was the association of tumor type and patient age and sex with the risk of SARS-CoV-2 infection and all-cause inpatient case fatality rate during COVID-19–associated hospital stay. Follow-up was performed at either hospital discharge or death, with a median follow-up of six days.
The UKCCMP cohort saw a mortality rate of 30.6%, with 92.5% of deaths attributed to COVID-19. Patients with hematologic malignancies experienced the highest risk of contracting COVID-19 compared with the control group, with an odds ratio of 2.82 for leukemia, 2.03 for myeloma, and 1.63 for lymphoma. Multivariable-adjusted all-cause case fatality, which corrected for the clinically relevant confounders of age and sex, was also highest in patients with hematologic malignancies, including leukemia (odds ratio 2.25), lymphoma (1.72), and myeloma (1.65). All-cause mortality risk in the other tumor types included central nervous system (1.87), mesothelial and soft tissue (1.52), lung (1.41), prostate (1.09), breast (0.97), respiratory and intrathoracic organ (0.96), urinary tract (0.87), colorectal (0.85), female genital (0.79), and lip, oral cavity, and pharynx (0.77). All-cause case fatality was significantly higher in male patients with COVID-19 and cancer compared with females (35.6% vs 23.6%, odds ratio 1.92) and in older patients, with those aged 80 and older experiencing the poorest outcomes.
Compared with other patients with cancer and COVID-19, patients with hematologic malignancies had a significantly higher likelihood of being admitted to the intensive care unit for ventilation (odds ratio 2.73), receiving non-invasive ventilation (2.10), receiving high-flow oxygen (1.82), and experiencing a severe or critical COVID-19 disease course (1.57). After adjustment for age and sex, patients with hematologic malignancies who had received chemotherapy within four weeks of being diagnosed with COVID-19 had an increased mortality risk during COVID-19–related hospital admission (odds ratio 2.09).
"Our results show that patients with cancer with different tumor types have differing susceptibility to SARS-CoV-2 and differing COVID-19 disease phenotypes, with notable increased SARS-CoV-2 hospital presentations in patients with hematological cancers," conclude Dr. Lee and colleagues. "Our study is unique in comparing a large COVID-19 population with cancer to an accurate and geographically appropriate cancer population control dataset. Morbidity and case-fatality rates from COVID-19 in UK patients with cancer who attend the hospital are relatively high, particularly in older patients and those with hematological malignancies, but not all cancer patients are affected equally. This important finding could allow clinicians some ability to risk stratify their patients and make informed decisions on appropriate levels of social isolation and shielding."
For More Information
Lee LYW, Cazier JB, Starkey T, et al (2020). COVID-19 prevalence and mortality in patients with cancer and the effect of primary tumour subtype and patient demographics: a prospective cohort study. Lancet Oncol. [Epub ahead of print] DOI:10.1016/S1470-2045(20)30442-3
Image credit: National Institute of Allergy and Infectious Diseases—Rocky Mountain Laboratories