Higher viral loads may be associated with a greater risk of death among patients with cancer—and individuals without cancer—hospitalized with COVID-19, according to a report by Westblade et al in Cancer Cell. Among hospitalized patients infected with COVID-19, those with hematologic malignancies who had recently been treated for cancer had the highest levels of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

“As a community, we've only begun to understand the relationship between SARS-CoV-2 viral load and outcomes,” said senior study author Michael Satlin, MD, Assistant Professor of Medicine in the Division of Infectious Diseases at Weill Cornell Medicine and an assistant attending physician at NewYork-Presbyterian/Weill Cornell Medical Center. “Currently, this quantitative information is not given to patient care teams, and providers only know if a patient's test is positive or negative. Giving this information to providers of patients with cancer who have COVID-19 could help them decide on which patients should receive more intensive monitoring when they are in the hospital, and which should receive new antiviral medicines if these treatments are in short supply.”

Study Background, Methods

At the time of publication, COVID-19 has affected more than 27 million people and has resulted in approximately 900,000 deaths worldwide. Initial reports have suggested that patients with cancer may be more likely to develop severe COVID-19 than patients without cancer. Dr. Satlin and his collaborators previously found that high SARS-CoV-2 viral load upon presentation to the emergency department is associated with in-hospital mortality among the general inpatient population. Until now, it was not clear how admission viral load may affect the clinical outcomes of hospitalized patients who have both cancer and COVID-19.

In the new study, Dr. Satlin and his team used two standard diagnostic tests to measure the amount of SARS-CoV-2 in nasopharyngeal swab specimens obtained upon admission to three New York City hospitals between March 15 and May 14, 2020. One hundred patients had active cancer, and 2,914 patients did not. Patients with solid tumors and hematologic malignancies were both included in the analysis.

Results

Half of patients with hematologic malignancies had high viral loads compared to approximately 30% of patients without cancer. Among patients with hematologic malignancies, only those who had received chemotherapy or targeted therapy during the previous 6 months had significantly higher viral loads than the general inpatient population with COVID-19.

“We suspect that this finding may be from the underlying immunodeficiencies conferred by either the hematologic malignancies or the administered therapies, which may decrease the ability to inhibit proliferation of SARS-CoV-2,” said co-first author Lars Westblade, PhD, Associate Professor of Pathology and Laboratory Medicine at Weill Cornell Medicine and a clinical microbiologist at NewYork-Presbyterian/Weill Cornell Medical Center. “Additional studies with a larger sample size of patients with hematologic malignancies are needed to more definitely assess whether these patients have increased mortality when hospitalized with COVID-19.”

Overall, the in-hospital mortality rate was 38.8% among patients with a high viral load, 24.1% among patients with a medium viral load, and 15.3% among patients with a low viral load. Patients with cancer showed a similar pattern, with mortality rates of 45.2%, 28.0%, and 12.1%, respectively. High viral loads in patients with cancer were associated with increased in-hospital mortality vs low viral loads. This finding remained statistically significant, even after adjusting for factors such as age and need for supplemental oxygen within 3 hours of presentation to the emergency department.

One important caveat is that it is not clear whether viral load predicts mortality rate in nonhospitalized individuals with COVID-19. “We encourage subsequent studies to assess the potential role of using SARS-CoV-2 viral load to guide care for outpatients with and without cancer,” said co-first author Gagandeep Brar, MD, Assistant Professor of Medicine in the Division of Hematology and Medical Oncology at Weill Cornell Medicine and an assistant attending physician at NewYork-Presbyterian/Weill Cornell Medical Center.

The researchers plan to conduct larger studies to confirm their findings and investigate whether specific types of cancer and cancer treatments lead to higher viral loads and worse outcomes. They would also like to assess whether measuring viral loads over time in a given patient could be used to personalize the type and duration of therapy.

Disclosure: This work was partially supported by the National Center for Advancing Translational Science at the National Institutes of Health. For full disclosures of the study authors, visit cell.com.