Two studies published yesterday in The Lancet indicate a high rate of mortality among COVID-19 patients who also have cancer.
In one study, US researchers analyzed data on more than 900 COVID-19 and cancer patients from the United States, Canada, and Spain and found that 13% died. In the other study, an analysis of 800 UK patients with COVID-19 and cancer found that 28% died.
The studies also found that male patients with other COVID-19 mortality risk factors, such as older age and additional comorbidities, had an increased risk of death. But cancer treatments, such as chemotherapy, did not appear to have an effect on mortality in either study.
The two studies are the largest to date to examine how cancer patients, who are often older, immunocompromised, and have high levels of contact with the healthcare system, are affected by SARS-CoV-2, the virus that causes COVID-19. Initial reports have suggested cancer patients, especially those receiving treatment, are at increased risk from the disease.
Active cancer, older age linked to death
In the first study, researchers from the COVID-19 and Cancer Consortium collected and analyzed data on adults with active or previous malignancies and confirmed coronavirus infections treated from Mar 17 through Apr 16, including data on baseline clinical conditions, medications, cancer diagnosis and treatment, and COVID-19 disease course. Patients with non-invasive cancer were not included in the analysis. The primary end point was all-cause mortality within 30 days of COVID-19 diagnosis.
Of the 928 patients who met the criteria for inclusion, the median age was 66, with 279 patients (30%) age 75 or older. Half of the patients (468) were men. The most common malignancies were breast cancer (191, 21%) and prostate cancer (152, 16%); 366 patients (39%) were on active anticancer treatment, and 396 (43%) had active cancer. At analysis, which was conducted on May 7, 121 patients (13%) had died, all within 30 days of diagnosis.
Using logistic regression analysis to assess the association between the outcome and potential prognostic variables, the researchers found that increased risk of 30-day mortality, after partial adjustment, was independently associated with increased age (per 10 years, partially adjusted odds ratio [OR], 1.84; 95% confidence interval [CI], 1.53 to 2.21), male sex (partially adjusted OR, 1.63; 95% CI, 1.07 to 2.48), smoking status (former smoker vs never smoked, partially adjusted OR, 1.60; 95% CI, 1.03 to 2.47), and number of comorbidities (two vs none, partially adjusted OR, 4.50; 95% CI, 1.33 to 15.28).
Active cancer (progressing vs remission, partially adjusted OR, 5.20; 95% CI, 2.77 to 9.77) and Eastern Cooperative Oncology Group (ECOG) performance status of 2 or higher (status 2 vs zero, partially adjusted OR, 3.89; 95% CI, 2.11 to 7.18) were also associated with an increased risk of mortality. An ECOG performance status of 2 or higher indicates cancer has progressed to the point that a patient is active but unable to work.
"Although an ECOG performance status of 2 was relatively uncommon in this cohort, the presence of active (measurable) cancer was common," the authors of the study wrote. "From our analysis, active cancer might be a risk factor associated with worse COVID-19 outcomes, especially in patients who have progressive disease."
The analysis also found that patients treated with the antimalaria drug hydroxychloroquine and the antibiotic azithromycin for COVID-19 had an increased risk of death (partially adjusted OR, 2.93; 95% CI, 1.79 to 4.79) compared with treatment with neither drug. But the investigators could not rule out confounding by indication.
Race and ethnicity, obesity status, cancer type, type of anticancer treatment, and recent surgery did not increase the risk of mortality. The authors said that the lack of association between recent surgery and mortality should be taken into consideration by healthcare facilities that are delaying surgeries during the pandemic, since delays in elective cancer surgeries can lead to poor outcomes.
The authors also noted that comparing their cohort with cancer patients without COVID-19, as well as COVID-19 patients who don't have cancer, could place the data into a larger context.
No mortality effect from cancer treatment
In the UK study, researchers from the University of Birmingham and the University of Oxford observed 800 patients enrolled in the UK Coronavirus Cancer Monitoring Project, which provides real-time reports to frontline clinicians about the effects of COVID-19 on patients who have cancer.
The primary end point of the prospective study, conducted from Mar 18 to Apr 26, was all-cause mortality or discharge from the hospital. The researchers were particularly interested in how patients receiving anticancer treatment have been affected.
Of the 800 patients studied, 412 (52%) had mild COVID-19 illness, 96 (12%) did not require hospitalization, 315 (39%) required oxygen, and 53 (7%) received intensive care. A total of 226 patients (28%) died, with the vast majority (211, 93%) dying from COVID-19. Multivariable logistic regression analysis showed that risk of death was significantly associated with advancing patient age (OR, 9.42; 95% CI, 6.56 to 10.02), being male (OR, 1.67; 95% CI, 1.19 to 2.34), and the presence of other comorbidities such as hypertension (OR, 1.95; 95% CI, 1.36 to 2.80) and cardiovascular disease (OR, 2.32; 95% CI, 1.47 to 3.64).
A univariate analysis found that, compared with patients who had not received chemotherapy within 4 weeks of testing positive for COVID-19, those who had received recent chemotherapy did not have a higher death rate (29% with recent chemotherapy vs 27% without recent chemotherapy). A multivariate analysis of 281 of patients who had received recent chemotherapy, after adjusting for age, gender, and comorbidities, found that chemotherapy had no significant effect on mortality (OR, 1.18; 95% CI, 0.81 to 1.72).
Multivariate analysis also found that, compared with patients who were not on these therapies, patients on immunotherapy (OR, 0.59; 0.27 to 1.27), hormonal therapy (OR, 0.90; 95% CI, 0.49 to 1.68), radiotherapy (OR, 0.65; 95% CI, 0.36 to 1.18), or targeted therapies (OR, 0.83; 95% CI, 0.45 to 1.54) were not at any additional risk of death.
The authors of the study said their takeaway from these findings is that anticancer treatments should not necessarily be withheld in COVID-19 patients.
"In patients presenting to UK National Health Service trusts or cancer centres, our data are strongly indicative that cancer plus COVID-19 mortality is principally driven by advancing age and the presence of other non-cancer comorbidities," they wrote. "We concluded that withholding effective cancer treatments from many cancer patients during the pandemic runs the very real risk of increasing cancer morbidity and mortality, perhaps much more so than COVID-19 itself."
The authors added that analysis of more cancer patients with COVID-19 will enable them to further clarify the risks of specific anticancer treatments.