In a single-institution study reported in the Journal of Clinical Oncology, Justin Jee, MD, PhD, of the Department of Medicine, Memorial Sloan Kettering Cancer Center (MSK), New York, and colleagues found that receipt of cytotoxic chemotherapy within 35 days of COVID-19 diagnosis in patients with cancer was not associated with an increased risk of severe or critical COVID-19; they also identified several factors that were associated with severe COVID-19.1
The study involved a review of clinical characteristics and outcomes among 309 patients with cancer and concurrent COVID-19 at MSK through March 31, 2020, with follow-up for clinical endpoints through April 13, 2020. The primary study endpoint consisted of a severe or critical COVID-19 event defined as one or more of the following: documented hypoxemia (oxygen saturation by pulse oximetry ≤ 93%), tachypnea (respiratory rate ≥ 30 breaths/minute), respiratory failure (arterial partial pressure of oxygen/fraction of inspired oxygen ratio < 300), admission to the intensive care unit for intubation, or all-cause death. The primary hypothesis was that cytotoxic chemotherapy administered within 35 days of COVID-19 diagnosis would be associated with an increased risk of severe or critical COVID-19. Outcomes were also assessed in a cohort of 917 patients with cancer who tested negative for SARS-CoV-2 during the study period using the same composite endpoint components.
Justin Jee, MD, PhD
Baseline laboratory values were the most recent values obtained within the 14- to 90-day period before the date of COVID-19 diagnosis. Peri–COVID-19 values were the closest values to date of the SARS-CoV-2 test within 3 days of a positive test.
Outcomes in Patients With COVID-19
Among 309 patients in the COVID-19 cohort, 147 patients (47.6%) were admitted to the hospital, 31 (10.0%) died, and 120 (38.8%) developed severe or critical COVID-19 (primary endpoint).
On univariate analysis, no increased risk of severe or critical COVID-19 was observed among the 102 patients (33.0%) who received cytotoxic chemotherapy within 35 days of COVID-19 diagnosis (hazard ratio [HR] = 1.10, 95% confidence interval [CI] = 0.73–1.60, P = .74). Patients with an active malignancy who were treated with chemotherapy within 35 days of diagnosis did not exhibit an increased risk of adverse COVID-19 outcomes (HR = 0.87, 95% CI = 0.57–1.30).
No increased risk of severe or critical COVID-19 was observed among the relatively small group of patients (n = 18) who received immunotherapy alone within 35 days of diagnosis (HR = 1.80, 95% CI = 0.89–3.50, P = .11).
In a sensitivity analysis, receipt of targeted therapy alone (n = 49) within 35 days of diagnosis was associated with a trend toward an increased risk of intensive care unit stay or death after diagnosis (HR = 2.2, 95% CI = 1.1–4, P = .02).
Diagnosis of a hematologic malignancy (n = 74) was associated with severe or critical COVID-19 (HR = 1.90, 95% CI = 1.30–2.80, P < .01). This finding was driven by the development of critical illness in seven (87.5%) of eight patients (10.8% of total group) with acute myeloid leukemia (AML).
Lung cancer (n = 29) was associated with an increased risk for severe or critical COVID-19 (HR = 2.00, 95% CI = 1.20–3.30, P = .01). No increased risk was observed among patients with lung metastases (n = 50; HR = 1.30, 95% CI = 0.81–2.10, P = .27).
Cancer remission (n = 88) was associated with a trend toward better outcomes compared with active disease (HR = 0.63, 95% CI = 0.41–0.98, P = .04).
Lymphopenia at peri–COVID-19 diagnosis, but not at baseline, was associated with a higher risk of worse outcome (HR = 2.10, 95% CI = 1.50–3.10, P < .01). Baseline neutropenia, present in four patients, was associated with a poor outcome (HR = 4.20, 95% CI =1.70–11.00, P < .01); of the four patients, three had active AML, and one had primary central nervous system lymphoma. Peri–COVID-19 neutropenia was not significantly associated with a poor outcome (HR = 1.70, 95% CI = 0.85–3.60, P = .13).
Findings from the univariate analyses remained consistent in multivariate analysis and in sensitivity analyses.
Outcomes in Patients Without COVID-19
In the cohort of 917 patients testing negative for SARS-CoV-2, 303 (33.0%) were admitted to the hospital, 57 (6.2%) died, and 154 (17%) met the composite endpoint. A total of 314 of patients (34.2%) received cytotoxic chemotherapy within 35 days of testing. Of these patients, 48 (15.3%) developed the composite endpoint, with this incidence being similar to that in the entire cohort of patients without COVID-19.
The investigators concluded: “Recent cytotoxic chemotherapy treatment was not associated with adverse COVID-19 outcomes. Patients with active hematologic or lung malignancies, peri–COVID-19 lymphopenia, or baseline neutropenia had worse COVID-19 outcomes. Interactions among antineoplastic therapy, cancer type, and COVID-19 are complex and warrant further investigation.”
DISCLOSURE: The study was supported by grants from the National Institutes Health and National Cancer Institute. Dr. Jee holds intellectual property in MDSeq Inc.
1. Jee J, Foote MB, Lumish M, et al: Chemotherapy and COVID-19 outcomes in patients with cancer. J Clin Oncol. August 14, 2020 (early release online).