People with cancer sickened by COVID-19 have a crude death rate of 13%, according to the largest series of data released thus far from a multinational perspective. The data on more than 900 patients also revealed cancer-specific factors associated with increased mortality.
The information is the first report from an ongoing international initiative by the COVID-19 and Cancer Consortium (CCC19) to track outcomes within this vulnerable population. Dana-Farber Cancer Institute is one of five founding institutions of CCC19.
“The report tracks patients from a broad geographic distribution and across practice settings,” said Dana-Farber’s Dr Toni K. Choueiri, co-lead author of the study and CCC19 steering committee member. Choueiri is the director of the Lank Centre for Genitourinary Oncology and the Jerome and Nancy Kohlberg professor of medicine at Harvard Medical School.
“We find significant associations with increased 30-day all-cause mortality in addition to previously reported factors such as age and gender,” said Choueiri. “This has implications for patients and healthcare providers that deal with cancer patients.”
The death rate for this group of patients as a whole was 13%, more than twice that reported for all patients with COVID-19 (by the Johns Hopkins Centre for Systems Science and Engineering), the study authors said. Certain subgroups, such as patients with active (measurable) cancer and those with an impaired performance status, fared “much, much worse.”
The data in this first report from CCC19 was gathered from 928 patients in Spain, Canada and the majority from the US.
The cancer-specific factors associated with increased mortality included having an ECOG performance status of two or worse. ECOG is a grading scale for measuring how cancer impacts a patient’s daily living abilities. A score of two designates a patient who is capable of self-care but unable to work and who is up and about more than 50% during waking hours.
Another factor associated with increased mortality was an active cancer status, particularly progressive cancer. The mortality risk also increased with the number of comorbidities, such as hypertension or diabetes, particularly with two or more comorbidities. As is the case with the non-cancer population, mortality increased with age. Mortality was 6% for cancer patients younger than 65, 11% for those 65-74 and 25% for those older than 75. Males also had a higher death rate than females, 17% compared to 9%.
These early data showed no statistical association between 30-day mortality and cancer treatments, suggesting that surgery, adjuvant chemotherapy and maintenance chemotherapy could continue during the pandemic with “extreme caution.” “While older patients and those with major comorbid conditions are at substantially increased risk of dying from COVID-19, our early findings are encouraging news for patients without major medical conditions who receive their cancer therapy within four weeks of their infection. However, more data are needed to reliably assess individual higher risk therapies,” the researchers said.
The study’s corresponding author is Dr Jeremy Warner, associate professor of medicine and biomedical informatics at Vanderbilt University. Other lead authors are Dr Brian Rini, Ingram professor of cancer research and chief of clinical trials at Vanderbilt-Ingram Cancer Centre; Dr Gary H Lyman, professor of medicine-oncology at the University of Washington; Dr Nicole Kuderer, with the Advanced Cancer Research Group in Seattle; Dr Dimpy Shah, assistant professor of epidemiology and biostatistics at Mays Cancer Centre, home to UT Health San Antonio MD Anderson; and Dr Yu Shyr, the Harold L Moses chair in cancer research and chair of the department of biostatistics at Vanderbilt.
Background: Data on patients with COVID-19 who have cancer are lacking. Here we characterise the outcomes of a cohort of patients with cancer and COVID-19 and identify potential prognostic factors for mortality and severe illness.
Methods: In this cohort study, we collected de-identified data on patients with active or previous malignancy, aged 18 years and older, with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection from the USA, Canada, and Spain from the COVID-19 and Cancer Consortium (CCC19) database for whom baseline data were added between March 17 and April 16, 2020. We collected data on baseline clinical conditions, medications, cancer diagnosis and treatment, and COVID-19 disease course. The primary endpoint was all-cause mortality within 30 days of diagnosis of COVID-19. We assessed the association between the outcome and potential prognostic variables using logistic regression analyses, partially adjusted for age, sex, smoking status, and obesity. This study is registered with ClinicalTrials.gov, NCT04354701, and is ongoing.
Findings: Of 1035 records entered into the CCC19 database during the study period, 928 patients met inclusion criteria for our analysis. Median age was 66 years (IQR 57–76), 279 (30%) were aged 75 years or older, and 468 (50%) patients were male. The most prevalent malignancies were breast (191 [21%]) and prostate (152 [16%]). 366 (39%) patients were on active anticancer treatment, and 396 (43%) had active (measurable) cancer. At analysis (May 7, 2020), 121 (13%) patients had died. In logistic regression analysis, independent factors associated with increased 30-day mortality, after partial adjustment, were: increased age (per 10 years; partially adjusted odds ratio 1·84, 95% CI 1·53–2·21), male sex (1·63, 1·07–2·48), smoking status (former smoker vs never smoked: 1·60, 1·03–2·47), number of comorbidities (two vs none: 4·50, 1·33–15·28), Eastern Cooperative Oncology Group performance status of 2 or higher (status of 2 vs 0 or 1: 3·89, 2·11–7·18), active cancer (progressing vs remission: 5·20, 2·77–9·77), and receipt of azithromycin plus hydroxychloroquine (vs treatment with neither: 2·93, 1·79–4·79; confounding by indication cannot be excluded). Compared with residence in the US-Northeast, residence in Canada (0·24, 0·07–0·84) or the US-Midwest (0·50, 0·28–0·90) were associated with decreased 30-day all-cause mortality. Race and ethnicity, obesity status, cancer type, type of anticancer therapy, and recent surgery were not associated with mortality.
Interpretation: Among patients with cancer and COVID-19, 30-day all-cause mortality was high and associated with general risk factors and risk factors unique to patients with cancer. Longer follow-up is needed to better understand the effect of COVID-19 on outcomes in patients with cancer, including the ability to continue specific cancer treatments.
Funding: American Cancer Society, National Institutes of Health, and Hope Foundation for Cancer Research.
Nicole M Kuderer, Toni K Choueiri, Dimpy P Shah, Yu Shyr, Samuel M Rubinstein, Donna R Rivera, Sanjay Shete, Chih-Yuan Hsu, Aakash Desai, Gilberto de Lima Lopes Jr, Petros Grivas, Corrie A Painter, Solange Peters, Michael A Thompson, Ziad Bakouny, Gerald Batist, Tanios Bekaii-Saab, Mehmet A Bilen, Nathaniel Bouganim, Mateo Bover Larroya, Daniel Castellano, Salvatore A Del Prete, Deborah B Doroshow, Pamela C Egan, Arielle Elkrief, Dimitrios Farmakiotis, Daniel Flora, Matthew D Galsky, Michael J Glover, Elizabeth A Griffiths, Anthony P Gulati, Shilpa Gupta, Navid Hafez, Thorvardur R Halfdanarson, Jessica E Hawley, Emily Hsu, Anup Kasi, Ali R Khaki, Christopher A Lemmon, Colleen Lewis, Barbara Logan, Tyler Masters, Rana R McKay, Ruben A Mesa, Alicia K Morgans, Mary F Mulcahy, Orestis A Panagiotou, Prakash Peddi, Nathan A Pennell, Kerry Reynolds, Lane R Rosen, Rachel Rosovsky, Mary Salazar, Andrew Schmidt, Sumit A Shah, Justin A Shaya, John Steinharter, Keith E Stockerl-Goldstein, Suki Subbiah, Donald C Vinh, Firas H Wehbe, Lisa B Weissmann, Julie Tsu-Yu Wu, Elizabeth Wulff-Burchfield, Zhuoer Xie, Albert Yeh, Peter P Yu, Alice Y Zhou, Leyre Zubiri, Sanjay Mishra, Gary H Lyman, Brian I Rini, Jeremy L Warner
The Lancet abstract