Inside Excess Deaths From Cancer and COVID Early in the Pandemic

Tara Haelle

October 10, 2022

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

In the first 10 months of the pandemic before vaccines were available, 16,561 US deaths occurred among people with both cancer and COVID-19, according to a research letter published in JAMA Oncology.

The deadliest cancer types to pair with COVID-19 were blood cancers and prostate cancer; in addition, researchers found these patients were more likely to die in a hospital or long-term care facility if they had COVID-19 and cancer than if they only had cancer.

Having a more granular understanding of the deaths associated with COVID-19 and cancer can help oncologists identify patients most at risk for poor outcomes and a host of other factors.

For instance, lead author Xuesong Han, PhD, noted that "the place of death not only affects patients' end-of-life quality and family and caregivers' grief during bereavement…but additionally, more inpatient deaths can affect end-of-life medical expenditures by the family and the healthcare system."

Although previous research has demonstrated the effect the pandemic has had on cancer care and outcomes, limited evidence exists on excess deaths associated with COVID-19 and cancer during the first year of the pandemic, prior to vaccine availability.

The researchers used the CDC WONDER database to examine causes of death based on US residents' death certificates from March 1 through December 31, 2020, and identified four groups:

  • Those who died from cancer as an underlying cause and COVID-19 as a contributing cause.

  • Those who died from COVID-19 as an underlying cause and cancer as a contributing cause.

  • Those who died from cancer without COVID-19 as a contributing cause.

  • Those who died from COVID-19 without cancer as a contributing cause.

Among the 16,561 people who died with COVID-19 and cancer, 3142 were cancer deaths with COVID-19 as a contributing factor, and 13,419 were COVID-19 deaths among people whose cancer contributed to death. Nearly half a million people (497,965) died of cancer without having COVID-19, and 337,393 people died of COVID-19 without cancer.

A quarter of cancer-related COVID deaths (25.5%) and 13.7% of COVID-related cancer deaths involved hematologic cancers, compared with just 9.5% of cancer deaths that didn't involve COVID-19. As for solid tumors, prostate cancer was more prevalent among deaths from cancer and COVID-19 than in non–COVID-related cancer deaths, whereas gastrointestinal cancer and female genital cancers weren't as prevalent among cancer-COVID-19 deaths.

"Patients with blood cancers are immunocompromised, and patients with prostate cancer tend to be older, both of which can increase the risks of COVID-19 complications and death," said Han, scientific director of Health Services Research at the American Cancer Society.

Deaths involving both cancer and COVID-19 were more likely to occur in larger metropolitan areas as well as in inpatient care facilities, nursing homes, or long-term care homes. In addition, deaths involving cancer and COVID-19 were more common among people at least 85 years old and among members of American Indian, or Alaska Native, Black, or Hispanic racial and ethnic groups.

In addition, the leading cause of cancer deaths independent of COVID-19 was lung cancer, responsible for 22.5% of non–COVID-related cancer deaths.

The researchers noted that a limitation to the analysis was a lack of information on cancer stage and treatment details among those who died. For instance, among non–COVID-related cancer deaths noted in the study, it's unclear how delays in care may have contributed to patients' outcome.

Jim Boonyaratanakornkit, MD, PhD, of Fred Hutchinson Cancer Center in Seattle, Washington, highlighted a few potential limitations of relying on ICD codes to determine cause of death.

"Estimates based on ICD codes can be biased by changes in coding practices over time," said Boonyaratanakornkit, who wasn't associated with the current research. And "importantly, a cause of death in cancer patients can sometimes be challenging to pinpoint to a single cause."

The percentage of total deaths involving COVID-19 and cancer was low compared with deaths attributed to either COVID-19 or cancer, but COVID-cancer-related deaths were "likely an underestimate given the differences in testing practices and availability in the early part of the pandemic," he said.

Although Boonyaratanakornkit did not see anything surprising in the study findings, he did note its significance.

"Although difficult to do with just ICD codes, I think understanding the primary cause of death is important, because knowing the true burden and mortality rates attributed to COVID-19 can help with public health decision-making to target efforts and strategies to protect cancer patients from COVID-19," he said.

No external funding for the study was noted. Han and co-author Jingxuan Zhao, MPH, have received research funding from AstraZeneca. Boonyaratanakornkit has received research funding from GSK .

JAMA Oncol. Published online September 29, 2022. Research Letter

Tara Haelle is a health/science journalist based in Dallas. Follow her at @tarahaelle.

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