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Mortality Among Adults With Cancer Undergoing Chemotherapy or Immunotherapy and Infected With COVID-19

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Is there an association between COVID-19 infection and mortality among adults with varying cancer types undergoing active treatment?

Findings  In this cohort study of 2515 adult patients with cancer and COVID-19, hematological malignant neoplasms and lung cancer were associated with increased mortality. No association was found between recent treatment with chemotherapy and overall or COVID-19–specific mortality, and treatment with immunotherapy before COVID-19 diagnosis was associated with a significant reduction in mortality.

Meaning  In this study, active systemic anticancer treatment was not associated with mortality in patients who also had COVID-19.


Importance  Large cohorts of patients with active cancers and COVID-19 infection are needed to provide evidence of the association of recent cancer treatment and cancer type with COVID-19 mortality.

Objective  To evaluate whether systemic anticancer treatments (SACTs), tumor subtypes, patient demographic characteristics (age and sex), and comorbidities are associated with COVID-19 mortality.

Design, Setting, and Participants  The UK Coronavirus Cancer Monitoring Project (UKCCMP) is a prospective cohort study conducted at 69 UK cancer hospitals among adult patients (≥18 years) with an active cancer and a clinical diagnosis of COVID-19. Patients registered from March 18 to August 1, 2020, were included in this analysis.

Exposures  SACT, tumor subtype, patient demographic characteristics (eg, age, sex, body mass index, race and ethnicity, smoking history), and comorbidities were investigated.

Main Outcomes and Measures  The primary end point was all-cause mortality within the primary hospitalization.

Results  Overall, 2515 of 2786 patients registered during the study period were included; 1464 (58%) were men; and the median (IQR) age was 72 (62-80) years. The mortality rate was 38% (966 patients). The data suggest an association between higher mortality in patients with hematological malignant neoplasms irrespective of recent SACT, particularly in those with acute leukemias or myelodysplastic syndrome (OR, 2.16; 95% CI, 1.30-3.60) and myeloma or plasmacytoma (OR, 1.53; 95% CI, 1.04-2.26). Lung cancer was also significantly associated with higher COVID-19–related mortality (OR, 1.58; 95% CI, 1.11-2.25). No association between higher mortality and receiving chemotherapy in the 4 weeks before COVID-19 diagnosis was observed after correcting for the crucial confounders of age, sex, and comorbidities. An association between lower mortality and receiving immunotherapy in the 4 weeks before COVID-19 diagnosis was observed (immunotherapy vs no cancer therapy: OR, 0.52; 95% CI, 0.31-0.86).

Conclusions and Relevance  The findings of this study of patients with active cancer suggest that recent SACT is not associated with inferior outcomes from COVID-19 infection. This has relevance for the care of patients with cancer requiring treatment, particularly in countries experiencing an increase in COVID-19 case numbers. Important differences in outcomes among patients with hematological and lung cancers were observed.

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Article Information

Accepted for Publication: December 14, 2021.

Published: February 21, 2022. doi:10.1001/jamanetworkopen.2022.0130

Correction: This article was corrected on April 8, 2022, to fix an error in Supplement 2.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Várnai C et al. JAMA Network Open.

Corresponding Author: Gary Middleton, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, United Kingdom (g.middleton@bham.ac.uk).

Author Contributions: Profs Middleton and Cazier 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. Drs Várnai, Palles, Arnold, and Curley contributed equally. Profs Middleton and Cazier contributed equally.

Concept and design: Várnai, Palles, Arnold, Purshouse, Booth, Campton, Hughes, A. Lee, Olsson-Brown, Sharma-Oates, L. Lee, Kerr, Middleton, Cazier.

Acquisition, analysis, or interpretation of data: Várnai, Palles, Arnold, Curley, Purshouse, Cheng, Booth, Campton, Collins, Hughes, Kulasekararaj, A. Lee, Olsson-Brown, Sharma-Oates, Van Hemelrijck, L. Lee, Kerr, Cazier.

Drafting of the manuscript: Várnai, Palles, Arnold, Curley, Purshouse, Cheng, Booth, Hughes, Kulasekararaj, A. Lee, Olsson-Brown, Sharma-Oates, L. Lee, Kerr, Middleton, Cazier.

Critical revision of the manuscript for important intellectual content: Várnai, Palles, Arnold, Curley, Booth, Campton, Collins, Hughes, A. Lee, Olsson-Brown, Van Hemelrijck, Kerr, Cazier.

Statistical analysis: Várnai, Palles, Curley, Sharma-Oates, Cazier.

Obtained funding: Palles, Curley, Booth, L. Lee, Cazier.

Administrative, technical, or material support: Curley, Purshouse, Cheng, Booth, Campton, A. Lee, Van Hemelrijck, L. Lee, Cazier.

Supervision: Palles, Booth, Collins, Olsson-Brown, Kerr, Middleton, Cazier.

Conflict of Interest Disclosures: Dr Palles reported receiving grants from Blood Cancer UK and Bowel Cancer UK during the conduct of the study. Dr Arnold reported receiving grants from Blood Cancer UK during the conduct of the study. Dr Curley reported receiving grants from Blood Cancer UK during the conduct of the study. Dr Purshouse reported receiving a fellowship from the Wellcome Trust during the conduct of the study. Dr Hughes reported received research funding from Nanomab Technology, personal fees from Pfizer, and speakers’ fees from Novartis outside the submitted work. Dr Olsson-Brown reported receiving grant support from Roche, Bristol Myers Squibb, Eli Lilly and Co, Novartis, and UCB Pharma and receiving personal fees from Roche, Merck Sharpe and Dohme, Eisai, and Bristol Myers Squibb outside the submitted work. Prof Middleton reported receiving personal fees from Bristol Myers Squibb, Servier, Roche, Merck Sharpe and Dohme, AstraZeneca, Pfizer, and D2G outside the submitted work. Prof Cazier reported grants from Blood Cancer UK during the conduct of the study. No other disclosures were reported.

Funding/Support: The work was supported by University of Birmingham, University of Oxford, Blood Cancer UK (grant No. 20011), Cancer Research UK (grant No. C17422/A25154), and Bowel Cancer UK (grant No. 18PG0010).

Role of the Funder/Sponsor: The funders 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.

Group Information: A complete list of the members of the UKCCMP Team appears in Supplement 2.

Additional Contributions: We thank the patients and their families affected by COVID-19, oncologists, acute physicians, and health care staff working tirelessly on the frontlines of the COVID-19 pandemic. We thank all members of the UK Coronavirus Cancer Monitoring Project reporting network and emergency response reporting individuals for their hard work in contributing data at a challenging time.

Additional Information: Full anonymized data and analytical methods from the UKCCMP will be made available with publication upon request to the UKCCMP (https://ukcoronaviruscancermonitoring.com/) and subject to approval by the UKCCMP Executive Committee with a signed data access agreement for clinical and research applications.

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