Patients With Lung and Blood Cancers Most Vulnerable to COVID-19

M. Alexander Otto, PA, MMS

December 10, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Patients with cancer are at significantly increased risk for COVID-19 and worse outcomes, a new review confirms. It also found that patients with leukemia, non-Hodgkin lymphoma, and lung cancer are at greatest risk.

Blacks with cancer are at even higher risk, and for patients with colorectal cancer and non-Hodgkin lymphoma, the risk is higher for women than for men. (This contrasts with findings in noncancer populations, where men are more at risk from COVID and severe outcomes than women).

These findings come from a huge review of electronic health records of 73.4 million patients in the United States. They "highlight the need to protect and monitor patients with cancer as part of the strategy to control the pandemic," say the authors.

The review was published online December 10 in JAMA Oncology.

The greater risk for COVID-19 among patients with cancer is well known, but breaking the risk down by cancer type is novel, say the investigators, led by Quanqiu Wang, MS, Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University, Cleveland, Ohio.

Cancer patients are immunocompromised and have more contact with the healthcare system, which increases their risk for COVID-19. But which bodily systems are affected by cancer seems to matter. In patients with blood cancer, for example, COVID is probably more dangerous, because blood cancer weakens the immune system directly, the authors suggest.

The increased risk for infection and hospitalization with SARS-CoV-2 among Black patients with cancer might be due to biology, but it is more likely due to factors that weren't captured in the database review. Such factors include social adversity, economic status, access to healthcare, and lifestyle, the researchers comment.

For this study, the investigators analyzed electronic health records held in the in the IBM Watson Health Explorys system, which captures about 15% of new cancer diagnoses in the United States.

The analysis found that as of August 14, 2020, 16,570 patients (0.02%) had been diagnosed with COVID-19; about 1200 also had been diagnosed with cancer. Of those, 690 were diagnosed with cancer in the previous year, which counted as a recent cancer diagnosis in the analysis. The study included 13 common cancers, including endometrial, kidney, liver, lung, gastrointestinal, prostate, skin, and thyroid cancers, among others.

Patients with any cancer diagnosis (adjusted odds ratio [aOR], 1.46) as well as those with a recent cancer diagnosis (aOR, 7.14) had a significantly higher risk for COVID-19 than those without cancer, after adjusting for asthma, cardiovascular diseases, nursing home stays, and other risk factors.

The risk for COVID was highest among patients recently diagnosed with leukemia (aOR, 12.16), non-Hodgkin lymphoma (aOR, 8.54), and lung cancer (aOR 7.66). The risk for COVID was lower for patients with cancers associated with worse prognoses, including pancreatic (aOR, 6.26) and liver (aOR, 6.49) cancer. It was weakest for patients with thyroid cancer (aOR, 3.10; P for all < .001).

Hospitalization was more common in recent cancer patients with COVID than in COVID patients without cancer (47.46% vs 24.6%), as was COVID-related death (14.93% vs 5.26%). Among cancer patients who did not have COVID-19, 12.39% were hospitalized, and 4.03% died. The findings suggest a synergistic effect between the COVID-19 and cancer, the team comments.

Among patients recently diagnosed with cancer, Black patients ― 10.3% of the overall study population ― had a significantly higher risk for COVID-19 than White patients. The racial disparity was largest for patients with breast cancer (aOR, 5.44), followed by patients with prostate cancer (aOR, 5.10), colorectal cancer (aOR, 3.30), and lung cancer (aOR, 2.53; P for all < .001).

Hospitalizations were more common among Black patients with cancer and COVID than White patients. There was also a trend toward higher mortality among Black patients (18.52% vs 13.51%; P = .11)

However, these differences may not be related to race, note oncologist Aakash Desai, MBBS, of the Mayo Clinic, Rochester, Minnesota, and colleagues in an accompanying commentary. "Interestingly, a previous study of hospitalized patients with COVID-19 without cancer demonstrated that mortality rates for Black patients were comparable to those for White patients after adjustment for both comorbidities and deprivation index, suggesting that observed differences are mainly owing to societal disparities rather than biology."

The editorialists also note that the finding that Black patients with cancer are at greater risk for COVID-19 (aOR, 1.58 – 5.44, depending on cancer) echoes the findings in the general population. The Centers for Disease Control and Prevention estimates a severalfold increased risk among Black patients. These higher rates may largely be explained by social determinants, they suggest. Such factors include increased burden of comorbidities, crowded living conditions (inner cities, multigenerational homes, etc), dependence on public transportation or child care, and higher work-related exposures. "Until such societal disparities are accounted for, we cannot presume these findings are caused by any inherent differences among racial groups," the editorialists comment.

"Clearly, the haunting spotlight of COVID-19 has dramatically illuminated known US health care and societal disparities," Desai and colleagues write. "This situation should be a wake-up call that brings much-needed improvements in US equity policies, including but not limited to better health care access. Nothing appears more critical for alleviating these disparate clinical outcomes in this time of crisis and beyond," they declare.

The study was funded by the National Institutes of Health, the American Cancer Society, and other organizations. The investigators have disclosed no relevant financial relationships.

JAMA Oncol. Published online December 10, 2020. Full text, Commentary

M. Alexander Otto is a physician assistant and award-winning medical journalist who has previously worked for several major news outlets, including McClatchy and Bloomberg BNA. He is a former MIT Knight Science Journalism fellow. Email: aotto@mdedge.com.

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