Prevalence and Outcome of COVID-19 Infection in Cancer Patients

A National Veterans Affairs Study

Nathanael R. Fillmore, PhD; Jennifer La, PhD; Raphael E. Szalat, MD; David P. Tuck, MD; Vinh Nguyen, MS; Cenk Yildirim, MS; Nhan V. Do, MD; Mary T. Brophy, MD; Nikhil C. Munshi, MD


J Natl Cancer Inst. 2021;113(6):691-698. 

In This Article

Abstract and Introduction


Background: Emerging data suggest variability in susceptibility and outcome to coronavirus disease 2019 (COVID-19) infection. Identifying risk factors associated with infection and outcomes in cancer patients is necessary to develop healthcare recommendations.

Methods: We analyzed electronic health records of the US Veterans Affairs Healthcare System and assessed the prevalence of COVID-19 infection in cancer patients. We evaluated the proportion of cancer patients tested for COVID-19 who were positive, as well as outcome attributable to COVID-19, and stratified by clinical characteristics including demographics, comorbidities, cancer treatment, and cancer type. All statistical tests are 2-sided.

Results: Of 22 914 cancer patients tested for COVID-19, 1794 (7.8%) were positive. The prevalence of COVID-19 was similar across age. Higher prevalence was observed in African American (15.0%) compared with White (5.5%; P < .001) and in patients with hematologic malignancy compared with those with solid tumors (10.9% vs 7.8%; P < .001). Conversely, prevalence was lower in current smokers and patients who recently received cancer therapy (<6 months). The COVID-19–attributable mortality was 10.9%. Higher attributable mortality rates were observed in older patients, those with higher Charlson comorbidity score, and in certain cancer types. Recent (<6 months) or past treatment did not influence attributable mortality. Importantly, African American patients had 3.5-fold higher COVID-19–attributable hospitalization; however, they had similar attributable mortality as White patients.

Conclusion: Preexistence of cancer affects both susceptibility to COVID-19 infection and eventual outcome. The overall COVID-19–attributable mortality in cancer patients is affected by age, comorbidity, and specific cancer types; however, race or recent treatment including immunotherapy do not impact outcome.


The coronavirus disease 2019 (COVID-19) infection, first reported in China in December 2019,[1] has now spread worldwide affecting all demographics and regions. The emerging data suggest variability in susceptibility to the infection and ultimately outcome. A number of patient-related factors, socioeconomic conditions, racial and ethnic differences, and several comorbidities including obesity, diabetes, and cardiovascular diseases have been associated with higher susceptibility and/or risk of mortality.[2–5] The relatively higher transmission rate and associated greater risk of adverse outcome have highlighted the need to understand the epidemiologic characteristics of COVID-19 prevalence, and the risk factors associated with poor outcome and death, to establish the best possible public health policies. Cancer patients are considered to be at higher risk of infection. This risk varies with functional status of the patient, cancer type, and/or treatment modalities used.[6,7] Thus, along with reducing exposure to the virus, other prophylactic as well as cancer-related risk factors may need to be addressed to decrease susceptibility to COVID-19 infection or to mitigate related complications in cancer patients. Small epidemiologic studies mainly from China and the United States have also reported increased rates of death in cancer patients related to COVID-19.[8,9] These observations have informed some changes and reorganization of cancer care worldwide,[10] but larger studies are needed to understand the comprehensive cancer-related issues with COVID-19 infection. Here, we investigated the prevalence and outcome of COVID-19 infection among cancer patients in a large cohort of patients from the nationwide Veterans Affairs (VA) Healthcare System.