A study team composed from clinicians from three hospitals in Wuhan, China, led by Dr Min Zhou of the Department of the Respiratory and Critical Care Medicine, Tongji Hospital, performed a retrospective case study of clinical features among 28 patients with cancer and COVID-19 infection. In particular, they analyzed the risk factors associated with admission to an intensive care unit, the use of mechanical ventilation or death. Their series was associated with poor outcomes. There was increased risk of developing severe events, especially if the last antitumour treatment was within 14 days of COVID-19 diagnosis. The findings are published on 23 March 2020 in the Annals of Oncology.
Like the other coronaviruses, SARS-CoV-2 primarily causes respiratory tract infection. The study team wrote that data published in The Lancet Oncology on 18 patients with cancer diagnosis from a cohort of 2007 cases with COVID-19 disease in China represents a relatively small sample with limited clinical information and high heterogeneity of the course of the disease. Therefore, critical issues concerning treatment principles for cancer patients with COVID-19 infection are unclear.
There is an urgent need to answer whether cancer patients with COVID-19 infection will have distinct clinical course and worse outcomes, such as death from the infection or severe pneumonia, and whether cancer patients should receive antitumour treatments as usual. The study team aimed to explore these issues by conducting a rapid retrospective case study on critical COVID-19-infected cancer patients.
They analyzed cancer patients with laboratory confirmed COVID-19. The clinical data were collected from medical records from 13 January 2020 to 26 February 2020. In total, 28 cancer patients with COVID-19 infection were included. Of those, 17 patients (60.7%) were male. Median age was 65.0 years. Lung cancer was the most frequent cancer type in the cohort with 7 patients (25.0%), followed by oesophageal cancer in 4 patients (14.3%) and breast cancer in 3 patients (10.7%). Ten patients (35.7%) were diagnosed with stage IV cancer. Eight patients (28.6%) were suspected to be from hospital-associated transmission.
All the patients had a history of antitumour therapy. Within 14 days of COVID-19 diagnosis, 6 patients (21.4%) were treated by at least one kind of antitumour therapy, such as chemotherapy in 3 patients (10.7%), targeted therapy in 2 patients (7.1%), radiotherapy in 1 patient (3.6%), immunotherapy in 1 patient (3.6%); one of them received treatment combining chemotherapy and immunotherapy.
There were two main clusters of patients: 8 patients (28.6%) who developed COVID-19 undergoing antitumour therapy in hospitals and 20 patients (71.4%) in their communities. In addition to cancer, 11 patients (39.2%) had at least one or more comorbidities.
The following clinical features were present in studied cohort: fever in 23 patients (82.1%), dry cough in 22 patients (81%) and dyspnoea in 14 patients (50.0%), along with lymphopaenia in 23 patients (82.1%), high level of high-sensitivity C-reactive protein in 23 patients (82.1%), anaemia in 21 patients (75.0%) and hypoproteinaemia in 25 patients (89.3%).
The common chest CT findings were ground-glass opacity in 21 patients (75.0%) and patchy consolidation in 13 patients (46.3%).
In total, 22 patients (78.6%) received oxygen therapy, 10 patients (35.7%) were put on invasive mechanical ventilation, with 2 patients (7.1%) requiring endotracheal intubation and invasive ventilation because of progressive hypoxia. Significantly more severe cases were subjected to mechanical ventilation (non-invasive: 53.3% vs 0%, p < 0.001; invasive: 13.3% vs 0%, p < 0.001) as compared to non-severe cases. The median period of mechanical ventilation for non-invasive and invasive ventilation was 2.5 days. None of the severe patients received extracorporeal membrane oxygenation.
In the series, 20 patients (71.4%) were prescribed at least one antiviral agent, while 9 patients (32.1%) received combinations of antiviral agents. Empirical antibiotic therapy was given to 23 patients (82.1%). Systemic corticosteroids were given to 15 patients (53.6%). Administration of corticosteroids was more frequent in patients with severe events (12/15, 80%) than non-severe cases (3/13, 23.1%). Seven of 8 patients with acute respiratory distress syndrome (ARDS) received systemic corticosteroids. The dosage and period of corticosteroids in the severe cases was higher than in non-severe cases, but the difference was not significant. Moreover, intravenous immunoglobin was prescribed to 12 patients (35.7%).
As of 26 February 2020, 15 patients (53.6%) developed severe clinical events, 6 patients (21.4%) were admitted to intensive care unit, 10 patients (35.7%) had life-threatening complications and 8 patients (28.6%) died.
Of the 10 stage IV cancer patients, 7 patients (70%) had developed severe events, while 44.4% of the non-stage IV patients had such events.
Among 6 cancer patients who received antitumor treatment within 14 days of COVID-19 disease diagnosis, 5 patients (83%) developed severe events. Additionally, 11 of 13 patients (84.6%) with patchy consolidation on CT on admission had developed severe events.
The most common complication was ARDS in 8 patients (28.6%), followed by septic shock in 1 patient (3.6%), and acute myocardial infarction (AMI) in 1 patient (3.6%). Two patients (7.1%) were suspected to have pulmonary embolism.
Ten of 28 patients (35.7%) had been discharged with a median hospital stay of 13.5 days; 10 patients (35.7%) were still inpatients with a median stay of 19.0 days.
Of the 28 patients, 8 patients (28.6%) died, with a median time of 16.0 days from admission to death. The cause of death included ARDS in 5 patients (62.5%), followed by pulmonary embolism in 1 patient (12.5%), septic shock in 1 patient (12.5%) and AMI in 1 patient (12.5%).
In univariate Cox proportional hazards model, cancer patients who received antitumour treatment within 14 days of COVID-19 diagnosis had a higher risk of developing severe events. Moreover, patchy consolidation on the first CT on admission suggested an elevated risk of developing severe events than those cases without consolidation.
Similar results were observed in the multivariate-adjusted Cox proportional hazards model after being adjusted for age and gender. If the last antitumour treatment was within 14 days, it significantly increased the risk of developing severe events with a hazard ratio (HR) 4.079 (95% confidence interval [CI] 1.086-15.322, p = 0.037). Furthermore, patchy consolidation on CT on admission was associated with a higher risk for developing severe events (HR 5.438, 95% CI 1.498-19.748, p = 0.010).
Upon commenting all limitations of their study, the authors emphasised that future studies with larger sample sizes and prospective study designs are warranted to further explore the risk factors for severe events among cancer patients and COVID-19 infection.
The study was funded by the research grants from the National Natural Science Foundation of China and HUST COVID-19 Rapid Response Call.
Reference
Zhang L, Zhu F, Xie L, et al. Clinical characteristics of COVID-19-infected cancer patients: A retrospective case study in three hospitals within Wuhan, China. Annals of Oncology; Published online 23 March 2020. DOI: https://doi.org/10.1016/j.annonc.2020.03.296