COVID-19 and Cancer Patient Risk: Lessons from New York

Very few studies have been done on COVID-19 in cancer patients and with over 180,458 cases as of April 10th in New York, it's a location with more data than anywhere else in the United States. Memorial Sloan Kettering researchers amassed data from over 423 COVID-19 positive cancer patients with some interesting findings. This information is key in helping cancer patients navigate the risk and benefits of continuing cancer care "as usual" vs. the risk of contracting the virus. Prior studies from China and Italy suggested a higher COVID-19 death rate in cancer patients, but more information is always helpful. 

In the 423 patient MSKCC study: 

• 40% of patients were hospitalized
• 20% of patients developed severe respiratory illness
• 9% of patients required mechanical ventilation
• 9% of patients died
• 23% of hospitalized patients died
• 33% of ICU admitted patients died

Who Participated in the Study?

Study participants included: 

• Breast cancer (20%)
• Colon cancer (9%)
• Lung cancer (9%)
• Lymphoma (12%)
• Solid tumors (56%)

What Were Their Symptoms?

Of the presenting symptoms we examined, fever (78%) and cough (82%) were the most common, whereas shortness of breath (44%) and diarrhea (26%) were less common but not rare. Children had mild symptoms and no serious complications.

Who Was at Highest Risk?

Patients at higher risk for hospitalization and severe outcomess were over 65 receiving an immune checkpoint inhibitor (ICI) within 90 days of hospitalization. Cancer patients who received chemotherapy or surgery within 30 days were not at higher risk.

Over 55% of patients also had high risk comorbidities that included hypertension (high blood presssure), diabetes and cardiovascular disease. 

High risk individuals were over 65 years, of a non-white race, with a blood cancer (most likely lymphoma because these patients were probably using checkpoint inhibitors), patients on corticosteroids (like dexamethasone), and patients on checkpoint inhibitors (regardless of cancer type). 

Patients having hypertension and chronic kidney disease had higher hospitalization rates. 

Having metastatic disease did not show a higher hospitalization rate. 

Treatment with checkpoint inhibitors predicted hospitalization and severe disease although the authors note that more data is necessary because the study size was small. Of the 31 checkpoint inhibitor treated patients, 12 had lung cancer and the remainder were an assortment of other cancers. The researchers didn't know whether the lung condition made the situation worse if the ICI triggered T cell hyperactivation, that in turn could cause the acute respiratory distress syndrome.

The authors note that the follow-up is short and the patients received a variety of medications including hydroxychloroquine, remdesivir, corticosteroids, and IL-6 inhibitors.

In summary, the outcome of COVID-19 illness is worse among those with underlying conditions, including cancer. According to the study authors: 

Our group of 423 patients with cancer had substantially higher rates of severe outcomes with COVID-19 illness when compared to published worldwide rates of severe disease (6.1-31.4%) and death (2.3-7.2%)

It sounds as if confounding factors of high risk features (like diabetes and high blood pressure) and checkpoint inhibiitors could have increased the risk for these patients.