In a retrospective cohort study reported in the Annals of Oncology, Li Zhang, MD, of the Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China, and colleagues described characteristics and outcomes of COVID-19 infection in 28 patients with cancer from three hospitals in Wuhan. The investigators found these patients to be at high risk for severe events and mortality.
Patient Characteristics
The 28 patients with cancer were among 1,276 COVID-19–infected patients admitted to the three hospitals during January and February 2020, yielding a prevalence of 2.2%. All had laboratory-confirmed infection, and eight of the patients (28.6%) acquired COVID-19 infection in the hospital.
Nearly 61% of the patients with both cancer and COVID-19 were male (n = 17), and the median age of these patients was 65 years. Lung cancer was the most common cancer among these patients (n = 7, 25%). A total of 10 patients (35.7%) had stage IV disease. Eleven patients (39.2%) had at least one coexisting chronic disease.
Clinical and laboratory characteristics included fever in 23 patients (82%), dry cough in 22 (81%), dyspnea in 14 (50%), lymphopenia in 23 (82%), high level of high-sensitivity C-reactive protein in 23 (82%), anemia in 21 (75%), and hypoproteinemia in 25 (89%). Common chest computed tomography (CT) findings were ground-glass opacity in 21 patients (75%) and patchy consolidation in 13 patients (46%). Within 14 days of COVID-19 diagnosis, six patients (21%) had received at least one type of antitumor treatment, including chemotherapy in three, targeted therapy in two, and radiotherapy in one; in addition, one of three chemotherapy patients also received immunotherapy.
A total of 22 patients (78.6%) received oxygen therapy, with 10 (35.7%) requiring mechanical ventilation and 2 requiring invasive ventilation because of progressive hypoxia. Systemic corticosteroids were given to 15 patients. At least one antiviral agent was given to 20 patients. Intravenous immunoglobulin was given to 10 patients.
The time from diagnosis to severe events was 7 days. Severe events (admission to the intensive care unit, use of mechanical ventilation, or death) occurred in 15 patients (53.6%). Anticancer treatment, including chemotherapy, immunotherapy, targeted therapy, or radiation therapy, within the prior 14 days was associated with a significantly increased risk of severe events (hazard ratio = 4.079, P = .037). Patchy consolidation on CT scan was also associated with an increased risk of severe events. Life-threatening complications occurred in 10 patients (35.7%; including acute respiratory distress syndrome [ARDS] in 8, suspected pulmonary embolism in 2, septic shock in 1, and myocardial infarction in 1).
Causes of death were ARDS in five patients and septic shock, suspected pulmonary embolism, and myocardial infarction in one patient each. The time from COVID diagnosis to death was 16 days. At the time of analysis, 10 patients remained in the hospital, and 10 had been discharged.
The Dr. Zhang and coauthors concluded: “[Patients with cancer] show deteriorating conditions and poor outcomes from the COVID-19 infection. It is recommended that patients with cancer receiving antitumor treatments should have vigorous screening for COVID-19 infection and should avoid treatments causing immunosuppression or have their dosages decreased in case of COVID-19 co-infection.”
Additional Commentary
William K. Oh, MD
In an accompanying article, William K. Oh, MD, of Icahn School of Medicine at Mount Sinai, observed that caution is necessary in interpreting such findings. He noted that the prevalence of infection in patients with cancer cited in the report is approximately 1.7 times higher than that in the Chinese population of the same age. The mortality rate in these patients is more than 10 times higher than that reported in all COVID-19–infected patients in China. Dr. Oh suggested that the high proportion of patients who acquired the infection while already hospitalized may partly account for the excess prevalence of infection in the cohort.
Dr. Oh stated: “While these sobering numbers are cause for serious concern for patients [with cancer], caution is needed in the interpretation of these findings: This series of patients is small, and the data collected retrospectively…. In addition, extrapolation to other countries may be problematic for several reasons: first, the prevalence of cancers in China differs compared with Europe or North America; 8 of 28 cases were cancers of the esophagus, liver, stomach, or nasopharynx, which are relatively rarer in other regions. In addition, no patients with hematologic malignancies are reported; such patients may have even greater immune suppression than [patients with] solid tumors.”
Dr. Oh went on to state that the high proportion of patients in the study who received standard cancer therapy in the hospital for solid tumors may not be representative of clinical practice in the United States and other regions, where most standard treatments occur in the outpatient setting. Since the hospitals included in the study were COVID-19 referral centers, they may have contained more critically ill patients than other centers. In addition, for as yet unexplained reasons, severe complications and mortality in COVID-19 infection may be higher in European countries, such as Italy and Spain, compared with China.
“Despite these limitations, this early report by Zhang [et al] represents an important preliminary contribution to our understanding of the risk and effects of COVID-19 infection in [patients with] cancer and may allow oncologists to tailor clinical management of COVID-19 to our patients,” summarized Dr. Oh. “At the very least, patients [with cancer] must practice social distancing or isolation and be candidates for early and rapid evaluation for symptoms suspicious for COVID-19, including testing for virus and chest radiography.... For now, many questions remain unanswered.”
Disclosures: For full disclosures of the authors, visit annalsofoncology.org.
