As reported in The Lancet by Kuderer et al, a cohort study using the COVID-19 and Cancer Consortium (CCC19) database has shown that increased risk of severe COVID-19 in patients with cancer is associated with such factors as age, comorbidities, performance status, hematologic malignancy, and progressing cancer, but not with recent cancer treatments.

The primary analysis from the CCC19 cohort showed that increased risk of 30-day all-cause mortality was associated with such factors as increased age, male sex, and number of comorbidities, as well as active cancer, but not with such factors as cancer type, recent anticancer therapy, or recent surgery.

Study Details

The CCC19 was formed on March 15, 2020, to study the characteristics and course of illness among patients with COVID-19 and a current or past diagnosis of cancer. Accrual to the registry began on March 17, 2020. The registry is an electronic REDCap database maintained at Vanderbilt University Medical Center. Participating institutions have been restricted to the United States and Canada. Participation of anonymous individual health-care practitioners in Argentina, Canada, the European Union, the United Kingdom, and the United States is permitted.

The current cohort study used deidentified data on 928 patients with active or previous malignancy aged ≥ 18 years with laboratory-confirmed COVID-19 infection from the United States, Canada, and Spain. Information was entered into the database between March 17 and April 16, 2020, and follow-up data through May 7, 2020.

A key secondary outcome measure was a composite outcome of severe illness defined as death, severe illness requiring admission to hospital, admission to the intensive care unit (ICU), use of mechanical ventilation, or a combination of these. 

Cohort Characteristics

Among the 928 patients, median age was 66 years, with 30% aged ≥ 75 years or older; 468 (50%) were male. A total of 811 patients (87%) were from the United States (Northeast = 40%, Midwest = 22%, South = 13%, and West = 13%); 49 (5%) were from Canada; and 68 (7%) were from Spain. Race/ethnicity was non-Hispanic white for 50%, black for 28%, Hispanic for 21%, and other/unknown for 29%.

A total of 22% of patients were known to have hematologic malignancies and 82%, solid tumors, with the most common malignancies being breast (21%) and prostate (16%) cancers. Cancer status was in remission/no evidence of disease in 45%, stable/responding to treatment in 32%, progressing in 11%, and unknown in 6%.

Overall, 39% of patients were on active cancer treatment and 43% had active (measurable) cancer. A total of 60% of patients had received no anticancer treatment within 4 weeks prior to COVID-19 diagnosis, 22% had received noncytotoxic therapy (including targeted therapy in 8%, endocrine therapy in 9%, immunotherapy in 4%, radiotherapy in 1%, and cancer-related surgery in < 1%) and 17% had received cytotoxic systemic therapy; 3% had received any surgery within 4 weeks of diagnosis.

Risk of Severe Illness Composite Endpoint

In total, 242 patients (26%) met the composite severe illness endpoint. Among these patients, 132 (14% of cohort) were admitted to the ICU, 116 (12% of cohort) required mechanical ventilation, and 121 died (13% of cohort; 50% of those meeting composite endpoint). Of the 132 patients admitted to the ICU, 52 (39%) had 30-day follow-up; of these, 16 (31%) died, 13 (25%) were still in the ICU, and 19 (37%) had recovered. Of the 121 patients who died, 71 (59%) were never admitted to ICU. Among other secondary outcome measures examined, 466 patients in the cohort (50%) were admitted to hospital and 405 (44%) required supplemental oxygen.

On post hoc multivariate analysis, factors significantly associated with increased risk of meeting the composite endpoint were:

• Increasing age (odds ratio [OR] = 1.99, 95% confidence interval [CI] = 1.48–2.68)
• Other or unknown race/ethnicity vs non-Hispanic white (OR = 1.78, 95% CI = 1.10–3.15)
• Two (OR = 2.95, 95% CI = 1.39­­–6.23) and four or more (OR = 2.49, 95% CI = 1.14–5.48) vs no comorbidities
• Hematologic malignancy vs solid tumor (OR = 2.02, 95% CI = 1.27–3.21)
• Progressive cancer (OR = 2.41, 95% CI = 1.32–2.48) and unknown status (OR = 2.97, 95% CI = 1.48–5.97) vs remission/no evidence of disease
• Eastern Cooperative Oncology Group performance status of 2 (OR = 1.94, 95% CI = 1.07–3.51) and 3/4 (OR = 2.48, 95% CI = 1.21–5.09) vs 0/1.

Treatment with azithromycin alone (10% of cohort; OR = 2.08, 95% CI = 1.16–3.75), hydroxychloroquine alone (10% of cohort; OR = 2.06, 95% CI = 1.18–3.6), and both (20% of cohort (OR = 6.06, 95% CI = 3.78–9.71) were also associated with increased risk of the composite outcome; however, as noted by the authors, these findings may be biased by use of these agents primarily in patients with severe illness.

No significant increase in risk for the composite endpoint was observed for use of noncytotoxic therapy, cytotoxic chemotherapy, or any surgery within 4 weeks prior to COVID-19 diagnosis vs no treatments within 4 weeks of diagnosis.

With regard to the CCC19 initiative as a whole, the authors stated, “This study of patients with cancer and COVID-19 reinforces several important considerations for clinical care, and emphasizes the urgent need for more data. Longer-term follow-up and larger sample sizes are needed to more completely understand the effect of SARS-CoV-2 on outcomes in patients with cancer.”

Jeremy L. Warner, MD, of Vanderbilt-Ingram Cancer Center at Vanderbilt University Medical Center, is the corresponding author for The Lancet article. 

Disclosure: The study was funded by the American Cancer Society, National Institutes of Health, and Hope Foundation for Cancer Research. For full disclosures of the study authors, visit thelancet.com.