COVID-19 outcomes by cancer status, type, treatment, and vaccination

  1. Maxwell Salvatore
  2. Miriam M. Hu
  3. Lauren J. Beesley
  4. Alison M. Mondul
  5. Celeste Leigh Pearce
  6. Christopher R. Friese
  7. Lars G Fritsche
  8. Bhramar Mukherjee

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Abstract

Background

Observational studies have identified patients with cancer as a potential subgroup of individuals at elevated risk of severe SARS-CoV-2 (COVID-19) disease and mortality. Early studies showed an increased risk of COVID-19 mortality for cancer patients, but it is not well understood how this association varies by cancer site, cancer treatment, and vaccination status.

Methods

Using electronic health record data from an academic medical center, we identified 259,893 individuals who were tested for or diagnosed with COVID-19 from March 10, 2020, to February 2, 2022. Of these, 41,218 tested positive for COVID-19 of whom 10,266 had a past or current cancer diagnosis. We conducted Firth-corrected, covariate-adjusted logistic regression to assess the association of cancer status, cancer type, and cancer treatment with four COVID-19 outcomes: hospitalization, intensive care unit (ICU) admission, mortality, and a composite “severe COVID-19” outcome which is the union of the first three outcomes. We examine the effect of the timing of cancer diagnosis and treatment relative to COVID diagnosis, and the effect of vaccination.

Results

Cancer status was associated with higher rates of severe COVID-19 infection [OR (95% CI): 1.18 (1.08, 1.29)], hospitalization [OR (95% CI): 1.18 (1.06, 1.28)], and mortality [OR (95% CI): 1.22 (1.00, 1.48)]. These associations were driven by patients whose most recent initial cancer diagnosis was within the past three years. Chemotherapy receipt was positively associated with all four COVID-19 outcomes (e.g., severe COVID [OR (95% CI): 1.96 (1.73, 2.22)], while receipt of either radiation or surgery alone were not associated with worse COVID-19 outcomes. Among cancer types, hematologic malignancies [OR (95% CI): 1.62 (1.39, 1.88)] and lung cancer [OR (95% CI): 1.81 (1.34, 2.43)] were significantly associated with higher odds of hospitalization. Hematologic malignancies were associated with ICU admission [OR (95% CI): 1.49 (1.11, 1.97)] and mortality [OR (95% CI): 1.57 (1.15, 2.11)], while melanoma and breast cancer were not associated with worse COVID-19 outcomes. Vaccinations were found to reduce the frequency of occurrence for the four COVID-19 outcomes across cancer status but those with cancer continued to have elevated risk of severe COVID [cancer OR (95% CI) among those fully vaccinated: 1.69 (1.10, 2.62)] relative to those without cancer even among vaccinated.

Conclusion

Our study provides insight to the relationship between cancer diagnosis, treatment, cancer type, vaccination, and COVID-19 outcomes. Our results indicate that it is plausible that specific diagnoses (e.g., hematologic malignancies, lung cancer) and treatments (e.g., chemotherapy) are associated with worse COVID-19 outcomes. Vaccines significantly reduce the risk of severe COVID-19 outcomes in individuals with cancer and those without, but cancer patients are still at higher risk of breakthrough infections and more severe COVID outcomes even after vaccination. These findings provide actionable insights for risk identification and targeted treatment and prevention strategies.

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  1. Version published to 10.1101/2022.04.19.22274047v2 on medRxiv
  2. ScreenIT

    SciScore for 10.1101/2022.04.19.22274047: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: Thank you for sharing your code.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has important limitations. First, as it is reliant on Michigan Medicine EHR data, the quality of the data depends on patient utilization of Michigan Medicine services. We estimate that only 48.9% of all COVID-19 positive patients received primary care services at Michigan Medicine. As such, many patients may have been hospitalized elsewhere and not had their downstream COVID-19 test results or outcomes captured outside of the Michigan Medicine EHR. Second, COVID-19 testing is not a simple random process. Though it has since expanded from targeted protocols at the start of the pandemic, factors like health insurance and access to and utilization of care present challenges to obtaining a representative testing cohort. Third, we define individuals with cancer as the presence of a cancer related phecode at any point in their Michigan Medicine EHR. As a result, there are concerns about survival bias – that cancer patients represent individuals who are cancer survivors, and these individuals are likely to differ systematically from current cancer patients. However, of the 10,266 COVID-19 positive individuals with a cancer diagnosis, 47% (n = 4,846) had an initial cancer diagnosis in the three years prior to testing positive. We also conducted additional analyses by timing of most recent cancer diagnosis (within 3 years, 3-10 years, 10 or more years). Fourth, the data comes from a single site - specifically a large, academic healthcare system in Michigan – and may not be r...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

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  3. Version published to 10.1101/2022.04.19.22274047v1 on medRxiv