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

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.

Figure 1.. Associations of Coronavirus Disease 2019 (COVID-19) With Recent and All Cancer Diagnoses

Odds of COVID-19 infection for all cancer diagnoses and recent cancer diagnoses (cancer diagnosed within the past year only) (A) and odds of COVID-19 infection for recent cancer diagnosis for each of the 13 common cancer types (B), after adjusting for age, sex, race, and risk factors for COVID-19, including asthma, cardiovascular diseases, type 2 diabetes, obesity, chronic kidney diseases, chronic obstructive pulmonary disease, cancer treatments (chemotherapy, radiotherapy, and immunotherapy), transplants (bone marrow and solid organ), and nursing home stay. aOR indicates adjusted odds ratio.

Figure 2.. Association of Coronavirus Disease 2019 (COVID-19) Infection With Recent Cancer Diagnosis

Each of the 13 common cancer types is included as an exposure. COVID-19 was included as the outcome. Odds ratios were adjusted for age, sex, and race only. aOR indicates adjusted odds ratio.

Figure 3.. Coronavirus Disease 2019 (COVID-19) Risk Disparity Among Patients With Recent Diagnoses of Cancer

Effects of demographics on odds of COVID-19 infection among patients with recent cancer (diagnosis made within the past year), after adjusting for age, sex, race, and risk factors for COVID-19, including asthma, cardiovascular diseases, type 2 diabetes, obesity, chronic kidney diseases, chronic obstructive pulmonary disease, cancer treatments (chemotherapy, radiotherapy, and immunotherapy), transplants (bone marrow and solid organ), and nursing home stay. Adult indicates patients aged 18 to 65 years; senior, patients older than 65 years.

Figure 4.. Hospitalization and Death Rates Among Adults

Patients were adults and seniors older than 18 years stratified by having both recent diagnosis of cancer and coronavirus disease 2019 (COVID-19), COVID-19 without a recent diagnosis of cancer, and a recent diagnosis of cancer but no COVID-19. The Systematized Nomenclature of Medicine–Clinical Terms concepts hospital admission (procedure) (code 32485007) was used to obtain hospitalization status from patient electronic health records. Explorys regularly imports from the Social Security Death Index for the deceased status. Outcomes for specific cancer types were not examined owing to their small sample sizes for COVID-19 cases and outcome information. ^aP < .01. ^bP < .001.