Clinical Characteristics and Outcomes of COVID-19–Infected Cancer Patients

A Systematic Review and Meta-Analysis

Hua Zhang, MD, PhD; Han Han, MD; Tianhui He, BS; Kristen E. Labbe, MPH; Adrian V. Hernandez, MD, PhD; Haiquan Chen, MD, PhD; Vamsidhar Velcheti, MD; Justin Stebbing, MD, PhD; Kwok-Kin Wong, MD, PhD


J Natl Cancer Inst. 2021;113(4):371-380. 

In This Article

Abstract and Introduction


Background: Previous studies have indicated coronavirus disease 2019 (COVID-19) patients with cancer have a high fatality rate.

Methods: We conducted a systematic review of studies that reported fatalities in COVID-19 patients with cancer. A comprehensive meta-analysis that assessed the overall case fatality rate and associated risk factors was performed. Using individual patient data, univariate and multivariable logistic regression analyses were used to estimate odds ratios (OR) for each variable with outcomes.

Results: We included 15 studies with 3019 patients, of which 1628 were men; 41.0% were from the United Kingdom and Europe, followed by the United States and Canada (35.7%), and Asia (China, 23.3%). The overall case fatality rate of COVID-19 patients with cancer measured 22.4% (95% confidence interval [CI] = 17.3% to 28.0%). Univariate analysis revealed age (OR = 3.57, 95% CI = 1.80 to 7.06), male sex (OR = 2.10, 95% CI = 1.07 to 4.13), and comorbidity (OR = 2.00, 95% CI = 1.04 to 3.85) were associated with increased risk of severe events (defined as the individuals being admitted to the intensive care unit, or requiring invasive ventilation, or death). In multivariable analysis, only age greater than 65 years (OR = 3.16, 95% CI = 1.45 to 6.88) and being male (OR = 2.29, 95% CI = 1.07 to 4.87) were associated with increased risk of severe events.

Conclusions: Our analysis demonstrated that COVID-19 patients with cancer have a higher fatality rate compared with that of COVID-19 patients without cancer. Age and sex appear to be risk factors associated with a poorer prognosis.


Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread rapidly around the world since it emerged in late 2019 in China.[1–3] In early March 2020, the World Health Organization declared the COVID-19 outbreak a global pandemic and as of July 15, this virus has infected nearly 14 million individuals with 580 000 deaths.[4] As the number of new cases continues to rise, challenges to the global healthcare system remain.

Cancer is one of the leading causes of death, with an estimated 9.6 million deaths worldwide in 2018.[5] Compared with the general population, cancer patients are more vulnerable to infection.[6,7] In addition to being in immunosuppressive states directly caused by cancer itself as well as cytotoxic treatments, this population presents an overall poorer health status, tends to be older, and has coexisting medical conditions. These are all risk factors that could contribute to severe COVID-19 infection[3,8–10] and lead to a potentially poorer prognosis and an increased risk of death.

The challenges facing the healthcare and research community have been unprecedented in response to the COVID-19 pandemic, prompting several national and international collective efforts dedicated to understanding the impact of COVID-19 on cancer patients.[11–13] For instance, the COVID-19 and Cancer Consortium (CCC19) is a multicenter registry that includes more than 90 institutions from the United States, Canada, and Spain.[12] It aims to collect and analyze observational data from cancer patients with COVD-19 to inform clinical practice in real time. In addition, clinicians and scientists from over 28 countries initiated another global consortium, The Thoracic Cancers International COVID-19 Collaboration (TERAVOLT) registry, dedicated to studying the effects of COVID-19 on patients with thoracic malignancies.[11]

The effects of the COVID-19 pandemic on patients with cancer have been detrimental and profound.[12] Current evidence based on individual reports from China suggests that cancer patients infected with COVID-19 may be at an increased risk of severe events, including hospitalization, admission to the intensive care unit, requiring invasive ventilation, or death.[6,14,15] Preliminary analysis of data from the CCC19 and TERAVOLT cohorts also suggest a higher risk of fatality in cancer patients.[10,16]

Although these individual reports provide valuable data on the clinical outcome of cancer patients with COVID-19, the majority of the studies analyzed have a small sample size or are limited by geographical regions (eg, either China, Europe, or the United States) or 1 cancer type (thoracic malignancies in the TERAVOLT). It is crucial to assess the data collected from these individual studies and evaluate them in a systematic manner.

Using data from 15 cohort studies involving 3019 patients, this meta-analysis aims to comprehensively characterize the clinical features, outcome of cancer patients with COVID-19, and potential risk factors contributing to higher fatality. Findings from this analysis will improve our understanding of the impact of the COVID-19 pandemic on cancer patients and highlight the urgent need to provide optimal clinical management to this vulnerable patient population.