The new coronavirus can be dangerous for cancer patients. People with cancer who develop Covid-19 are much more likely to die from the disease within a month than those coronavirus patients without cancer, according to new studies. Analysis shows that 28% of cancer patients with Covid-19 died in one study, and 13% died in the other. Current estimates (till May 29) suggest that close to 6% of Americans confirmed to have Covid-19 have died. As of May 29, 1,721,926 Covid-19 cases have been reported from across the US, and more than 101,617 have died in the coronavirus pandemic. Globally, 360,776 or 6% have died out of 5,829,474 reported coronavirus cases.
 
According to experts, the findings emphasize the need to prevent cancer patients from contracting Covid-19, and if they do, to identify and closely monitor these individuals for dangerous symptoms. The findings also have implications for patients and healthcare providers who will be confronted with difficult decisions during the coronavirus pandemic, such as whether to withhold or continue anticancer treatments, and whether to accelerate end-of-life planning under some circumstances, say researchers.

According to the US National Cancer Institute, roughly 1.8 million people will be diagnosed with cancer in the US in 2020. An estimated 276,480 women and 2,620 men will be diagnosed with breast cancer, which makes it the most common cancer diagnosis. Lung and bronchus cancer is the second most common cancer diagnosis with an estimated 228,820 new cases. Further, estimates suggest that in 2020, about 606,520 people will die of cancer in the US. Lung and bronchus cancer is responsible for the most deaths with 135,720 people expected to die from this disease. That is nearly three times the 53,200 deaths due to colorectal cancer, which is the second most common cause of cancer death.

The studies

In one study, researchers found that overall, 13% of cancer patients died within a month of catching the novel coronavirus. This is the first report from an ongoing international initiative by the Covid-19 and Cancer Consortium (CCC19) to track outcomes within this vulnerable population. The CCC19 registry was built and is maintained as an electronic REDCap database housed at Vanderbilt University Medical Center. The data in this first report from CCC19 was gathered from 928 patients in US, Canada, and Spain. Among patients with cancer and Covid-19, 30-day all-cause mortality was high and associated with general risk factors and risk factors unique to patients with cancer. “The most prevalent malignancies were breast (191 or 21%) and prostate (152 or 16%). 366 (39%) patients were on active anticancer treatment, and 396 (43%) had active (measurable) cancer. At analysis (May 7, 2020), 121 (13%) patients had died, all within 30 days of Covid-19 diagnosis,” says the study published in The Lancet. 

Dr Jeremy Warner, associate professor of medicine and biomedical informatics at Vanderbilt University, writes in the analysis that people with cancer face a great deal of uncertainty in the era of Covid-19, including whether the “balance of risks and benefits in the treatment of cancer has shifted in some fundamental way.” “The death rate for this group of patients as a whole was 13%, more than twice that reported for all patients with Covid-19 (by the Johns Hopkins Center for Systems Science and Engineering). Certain subgroups, such as patients with active (measurable) cancer and those with impaired performance status, fared much, much worse,” says Warner. The cancer-specific factors associated with increased mortality included having an “ECOG performance status of two or worse.” ECOG is a grading scale for measuring how cancer impacts a patient's daily living abilities. A score of two designates a patient who is capable of self-care but unable to work and who is up and about more than 50% during waking hours. Another factor associated with increased mortality was an active cancer status, particularly progressive cancer.

The mortality risk also increased with the number of comorbidities, such as hypertension or diabetes, particularly with two or more comorbidities. As is the case with the non-cancer population, mortality increased with age: it was 6% for cancer patients younger than 65, 11% for those 65-74, and 25% for those older than 75. Males also had a higher death rate than females, 17% compared to 9%. In this study, the risk of death was also higher for patients taking the drug hydroxychloroquine plus the antibiotic azithromycin versus treatment with neither. These early data showed no statistical association between 30-day mortality and cancer treatments, suggesting that surgery, adjuvant chemotherapy, and maintenance chemotherapy could continue during the pandemic with “extreme caution.” The research team has recommended a longer follow-up to better understand the effect of Covid-19 on outcomes in patients with cancer, including the ability to continue specific cancer treatments. “Several important hypotheses have emerged from this initial analysis. Patients with cancer appear to be at increased risk of mortality and severe illness due to SARS-CoV-2 infection, regardless of whether they have active cancer, are on anticancer treatment, or both. Most members of our cohort had symptoms compatible with Covid-19, and the overall rate of complications was high,” says the team.

In the second study, experts analyzed 800 patients with a diagnosis of cancer and symptomatic Covid-19 from March 18, to April 26, 2020. Underlying health conditions were common, including hypertension, diabetes, cardiovascular disease, and chronic obstructive pulmonary disease. The study says that 169 (21%) patients were listed as having no comorbidities apart from their cancer diagnosis. Among the patients, 172 (22%) had their anticancer treatments interrupted because of the Covid-19 pandemic, but the exact nature of this interruption was not captured in this study. The analysis shows that 28% or 226 patients died, says the research team from the University of Birmingham, and the University of Oxford, UK. According to the researchers, the risk of death was significantly associated with advancing patient age, being male, and the presence of other underlying health conditions such as hypertension, and cardiovascular disease. 

Compared with patients who had not received chemotherapy within 4 weeks of testing positive for Covid-19, those who had received recent chemotherapy did not suffer increased deaths: 27% death rate with chemotherapy versus 29% death rate without recent chemotherapy. “Our data are strongly indicative that Covid-19 mortality in patients with cancer is principally driven by advancing age and the presence of other non-cancer comorbidities. At a population level, our data do not suggest that chemotherapy or anticancer treatments will necessarily increase the risk of mortality from Covid-19, and gives confidence to oncologists and other clinicians that delivery of effective anticancer regimens should continue during this difficult time,” recommend the researchers in their findings published in The Lancet. 

The third study involved 218 cancer patients who tested positive for Covid-19 from March 18 to April 8 at Montefiore Medical Center in the Bronx, New York City, one of the regions in the US hit hardest by the pandemic. A total of 61 cancer patients died from Covid-19, a dramatically high case-fatality rate of 28%, says the study published in Cancer Discovery. As a group, Covid-19 patients with hematologic (blood) cancers, such as leukemia and lymphoma, had the highest mortality rate: 37% (20 of 54 patients), says the research team from Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York City. For patients with solid malignancies, the mortality rate was 25% (41 of 164). Striking differences were observed among specific solid cancers: the death rate for patients with lung cancer was 55% and colorectal cancer was 38%, compared with mortality rates of 14% for breast cancer and 20% for prostate cancer.

Certain underlying conditions -- older age, hypertension, heart disease, and chronic lung disease -- were significantly associated with increased mortality among cancer patients with coronavirus. A detailed analysis of patients with cancer who died from Covid-19 shows that more than half of these individuals -- 37 of 61 -- had been in places with a higher risk of exposure to Covid-19, such as nursing homes, hospitals or emergency departments within the 30 days before being diagnosed with the new coronavirus. This was before widespread social distancing had been implemented. This research team also made similar conclusions as the previous studies. They say a key element is that mortality appears to be more closely related to frailty, age, and underlying medical conditions than to active therapy for cancer. According to the authors, the findings suggest that lifesaving cancer therapies should not be stopped. Instead, strategies must be developed to minimize potential Covid-19 exposures and re-evaluate therapies for the most vulnerable cancer populations, recommends the team.