Do patients with cancer have a poorer prognosis of COVID-19? An experience in New York City

Abstract

The outbreak of coronavirus disease 2019 (COVID-19) emerged in late 2019 in Wuhan, China, and has been spreading rapidly. As the infection has become widespread, concern for the influence of COVID-19 on patients with cancer has grown. Zhang et al.1Zhang L. Zhu F. Xie L. et al.Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China.Ann Oncol. 2020; 31: 894-901Abstract Full Text Full Text PDF PubMed Scopus (960) Google Scholar reported a retrospective case study of 28 COVID-19-infected cancer patients with an astonishingly high mortality rate (28.6%). However, as Oh2Oh W.K. COVID-19 infection in cancer patients: early observations and unanswered questions.Ann Oncol. 2020; 31: 838-839Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar pointed out, the result cannot be applied to other countries with different cancer epidemiology and practice. We herein sought to determine whether patients with cancer in the USA have a poorer prognosis of COVID-19 by analyzing the electronic medical records of Mount Sinai Health System (MSHS) in New York City. We analyzed the electronic medical records (EMR) of MSHS from 1 March 2020 to 6 April 2020, using Epic SlicerDicer software, Verona, WI. We extracted data (sex, age, comorbidities, intubation, and mortality status as of 8 April) from patients who were positive for the COVID-19 RT-PCR test during this period. MSHS waived Institutional Review Board approval since this research used only deidentified, aggregate-level data. A total of 5688 patients had COVID-19, and there were 334 patients (6%) with cancer among them (57, 56, 23, 18, and 16 patients with breast, prostate, lung, urothelial, and colon cancer, respectively). Without adjusting for age groups, patients with cancer were intubated significantly more frequently [relative risk, RR (95% confidence interval, CI); 1.89 (1.37–2.61)], but the rate of death was not significantly different. By stratifying patients by age groups, we detected a significantly increased risk of intubation in patients with cancer aged 66–80 years [RR (95% CI); 1.76 (1.15–2.70)]. No significant difference in intubation risk was found in other age groups. Additionally, patients younger than 50 years with cancer had a significantly higher mortality rate [RR (95% CI); 5.01 (1.55–16.2)]. However, the mortality rates of COVID-19 in cancer patients were lower than those in patients without cancer in age groups older than 50 years, though they were not statistically significant (Table 1).Table 1Relative risk of intubation or death in patients with or without cancer stratified by age groupsAge (years)Intubation (event/total)Relative risk (95% CI)Death (event/total)Relative risk (95% CI)With cancerWithout cancerWith cancerWithout cancerAll37/334314/53541.89 (1.37–2.61)37/334518/53541.15 (0.84–1.57)≤502/5352/20351.48 (0.37–5.90)3/5323/20355.01 (1.55–16.2)51–658/84113/15571.31 (0.66–2.60)4/84117/15570.63 (0.24–1.68)66–8022/143104/11911.76 (1.15–2.70)15/143173/11910.72 (0.44–1.19)≥815/5445/5711.17 (0.49–2.83)15/54168/5710.94 (0.60–1.48)The numbers of italics and bold are with statistical significance (P value <0.05). Open table in a new tab The numbers of italics and bold are with statistical significance (P value <0.05). Cytokine-associated lung injury is a potential etiology in severe cases of COVID-19.3Xu Z. Shi L. Wang Y. et al.Pathological findings of COVID-19 associated with acute respiratory distress syndrome.Lancet Respir Med. 2020; 8: 420-422Abstract Full Text Full Text PDF PubMed Scopus (5408) Google Scholar Patients with cancer have impaired immune systems, which may decrease the frequency of overwhelming lung inflammation, contributing to these patients’ non-inferior mortality rates.4Xia Y. Jin R. Zhao J. Li W. Shen H. Risk of COVID-19 for patients with cancer.Lancet Oncol. 2020; 21: e180Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar,5Schreiber R.D. Old L.J. Smyth M.J. Cancer immunoediting: integrating immunity’s roles in cancer suppression and promotion.Science. 2011; 331: 1565-1570Crossref PubMed Scopus (4030) Google Scholar Nevertheless, in young populations, whose mortality rate from COVID-19 is very low in general, baseline fragility in cancer patients may lead to a relatively higher rate of deaths. The unclear causation between COVID-19 and intubation or death is a limitation in this aggregate-level data analysis. Additionally, the heterogeneity of cancer types and varying stages of the disease may obscure the rationale of our findings. However, this is the first report on the prognosis of COVID-19 patients with cancer in the USA. The relatively large number of patients in the study allowed for the adjustment of age, which is one of the strongest prognostic factors. Further study based on the individual patients’ data is warranted for a better understanding of the risk of COVID-19 in cancer patients. We wish to thank the timely help given by Satoshi Miyashita, MD at Mount Sinai Beth Israel in organizing the study group.