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Analyses of Risk, Racial Disparity, and Outcomes Among US Patients With Cancer and COVID-19 Infection

Educational Objective
To learn the association of cancer diagnosis with the risk of coronavirus disease 2019 (COVID-19) infection and to identify factors that modify risk.
1 Credit CME
Key Points

Question  Are patients with cancer at increased risk for coronavirus disease 2019 (COVID-19) infection and its adverse outcomes?

Findings  In this case-control analysis of electronic medical records from 73.4 million unique patients, patients with a recent diagnosis of cancer were at significantly increased risk for COVID-19 infection and its adverse outcomes, especially in African Americans.

Meaning  Based on these findings, it is important to closely monitor patients with cancer and protect them from exposure to severe acute respiratory syndrome coronavirus 2 and the severe outcomes of COVID-19.

Abstract

Importance  Patients with specific cancers may be at higher risk than those without cancer for coronavirus disease 2019 (COVID-19) and its severe outcomes. At present, limited data are available on the risk, racial disparity, and outcomes for COVID-19 illness in patients with cancer.

Objectives  To investigate how patients with specific types of cancer are at risk for COVID-19 infection and its adverse outcomes and whether there are cancer-specific race disparities for COVID-19 infection.

Design, Setting, and Participants  This retrospective case-control analysis of patient electronic health records included 73.4 million patients from 360 hospitals and 317 000 clinicians across 50 US states to August 14, 2020. The odds of COVID-19 infections for 13 common cancer types and adverse outcomes were assessed.

Exposures  The exposure groups were patients diagnosed with a specific cancer, whereas the unexposed groups were patients without the specific cancer.

Main Outcomes and Measures  The adjusted odds ratio (aOR) and 95% CI were estimated using the Cochran-Mantel-Haenszel test for the risk of COVID-19 infection.

Results  Among the 73.4 million patients included in the analysis (53.6% female), 2 523 920 had at least 1 of the 13 common cancers diagnosed (all cancer diagnosed within or before the last year), and 273 140 had recent cancer (cancer diagnosed within the last year). Among 16 570 patients diagnosed with COVID-19, 1200 had a cancer diagnosis and 690 had a recent cancer diagnosis of at least 1 of the 13 common cancers. Those with recent cancer diagnosis were at significantly increased risk for COVID-19 infection (aOR, 7.14 [95% CI, 6.91-7.39]; P < .001), with the strongest association for recently diagnosed leukemia (aOR, 12.16 [95% CI, 11.03-13.40]; P < .001), non–Hodgkin lymphoma (aOR, 8.54 [95% CI, 7.80-9.36]; P < .001), and lung cancer (aOR, 7.66 [95% CI, 7.07-8.29]; P < .001) and weakest for thyroid cancer (aOR, 3.10 [95% CI, 2.47-3.87]; P < .001). Among patients with recent cancer diagnosis, African Americans had a significantly higher risk for COVID-19 infection than White patients; this racial disparity was largest for breast cancer (aOR, 5.44 [95% CI, 4.69-6.31]; P < .001), followed by prostate cancer (aOR, 5.10 [95% CI, 4.34-5.98]; P < .001), colorectal cancer (aOR, 3.30 [95% CI, 2.55-4.26]; P < .001), and lung cancer (aOR, 2.53 [95% CI, 2.10-3.06]; P < .001). Patients with cancer and COVID-19 had significantly worse outcomes (hospitalization, 47.46%; death, 14.93%) than patients with COVID-19 without cancer (hospitalization, 24.26%; death, 5.26%) (P < .001) and patients with cancer without COVID-19 (hospitalization, 12.39%; death, 4.03%) (P < .001).

Conclusions and Relevance  In this case-control study, patients with cancer were at significantly increased risk for COVID-19 infection and worse outcomes, which was further exacerbated among African Americans. These findings highlight the need to protect and monitor patients with cancer as part of the strategy to control the pandemic.

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Article Information

Accepted for Publication: August 21, 2020.

Published Online: December 10, 2020. doi:10.1001/jamaoncol.2020.6178

Corresponding Authors: Nathan A. Berger, MD, Center for Science, Health, and Society, School of Medicine, Case Western Reserve University, 2103 Cornell Rd, Cleveland, OH 44106 (nab@case.edu); Rong Xu, PhD, Center for Artificial Intelligence in Drug Discovery, School of Medicine, Case Western Reserve University, 2103 Cornell Rd, Cleveland, OH 44106 (rxx@case.edu).

Author Contributions: Mr Wang and Dr Xu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Berger, Xu.

Acquisition, analysis, or interpretation of data: Wang, Xu.

Drafting of the manuscript: Berger, Xu.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Wang, Xu.

Administrative, technical, or material support: Wang, Xu.

Supervision: Berger, Xu.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by New Innovator Award DP2HD084068 from the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (NIH); grants R01 AG057557, R01 AG061388, and R56 AG062272 from the NIH National Institute of Aging; Research Scholar Grant RSG-16-049-01–MPC from the American Cancer Society; grant 1UL1TR002548-01 from the Clinical and Translational Science Collaborative of Cleveland; grant P30 CA043703 from the Case Comprehensive Cancer Center; and Cancer Health Disparities SPORE Planning Grant P20 CA2332216 from the Case Comprehensive Cancer Center.

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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