Chemotherapy and COVID-19 Outcomes in Patients With Cancer

Abstract

Purpose: Coronavirus-2019 (COVID-19) mortality is higher in patients with cancer than in the general population, yet the cancer-associated risk factors for COVID-19 adverse outcomes are not fully characterized.

Patients and methods: We reviewed clinical characteristics and outcomes from patients with cancer and concurrent COVID-19 at Memorial Sloan Kettering Cancer Center until March 31, 2020 (n = 309), and observed clinical end points until April 13, 2020. We hypothesized that cytotoxic chemotherapy administered within 35 days of a COVID-19 diagnosis is associated with an increased hazard ratio (HR) of severe or critical COVID-19. In secondary analyses, we estimated associations between specific clinical and laboratory variables and the incidence of a severe or critical COVID-19 event.

Results: Cytotoxic chemotherapy administration was not significantly associated with a severe or critical COVID-19 event (HR, 1.10; 95% CI, 0.73 to 1.60). Hematologic malignancy was associated with increased COVID-19 severity (HR, 1.90; 95% CI, 1.30 to 2.80). Patients with lung cancer also demonstrated higher rates of severe or critical COVID-19 events (HR, 2.0; 95% CI, 1.20 to 3.30). Lymphopenia at COVID-19 diagnosis was associated with higher rates of severe or critical illness (HR, 2.10; 95% CI, 1.50 to 3.10). Patients with baseline neutropenia 14-90 days before COVID-19 diagnosis had worse outcomes (HR, 4.20; 95% CI, 1.70 to 11.00). Findings from these analyses remained consistent in a multivariable model and in multiple sensitivity analyses. The rate of adverse events was lower in a time-matched population of patients with cancer without COVID-19.

Conclusion: Recent cytotoxic chemotherapy treatment was not associated with adverse COVID-19 outcomes. Patients with active hematologic or lung malignancies, peri-COVID-19 lymphopenia, or baseline neutropenia had worse COVID-19 outcomes. Interactions among antineoplastic therapy, cancer type, and COVID-19 are complex and warrant further investigation.

FIG 1.

Risk factors for severe COVID-19 in patients with cancer. Hazard ratios (HRs) and 95% CIs for risk factors for severe COVID-19 infection using a time-to-event analysis. Red bars indicate that criteria were met for statistical significance with a Benjamini-Hochberg–adjusted false discovery rate P < .10 (BH-P). BMI, body mass index; ECOG PS, Eastern Cooperative Oncology Group performance status.

FIG 2.

Multivariable Cox regression analysis of significant covariates from univariable analyses. Multivariable analysis with suspected COVID-19–related comorbidities and significant variables from the univariable primary and secondary analyses in Figure 1. Bars represent hazard ratio (HRs) with 95% CIs. BH-P, Benjamini-Hochberg–adjusted P value; BMI, body mass index; ECOG PS, Eastern Cooperative Oncology Group performance status.

FIG 3.

Laboratory abnormalities in patients with COVID-19. Boxplots (indicating quartiles and 10th-90th percentiles) are shown for the respective laboratory values obtained. (A) Samples from peri–COVID-19 laboratory values stratified by severity of COVID-19 infection (mild v severe or critical). Statistical significance assessed using Mann-Whitney U test. (B) Samples stratified by time point. Baseline includes the most recent laboratory values obtained within a 14- to 90-day period before the date of COVID-19 diagnosis. COVID-19 includes peri–COVID-19 values. Statistical significance was assessed using the Wilcoxon signed rank test. Note that patients with chronic lymphocytic leukemia were excluded from this analysis. *P < .05, **P < .01, ***P < .001, ****P < .0001. ALC, absolute lymphocyte count; ANC, absolute neutrophil count; CPK, creatine phosphokinase; CRP, C-reactive protein; IL-6, interleukin-6; LDH, lactate dehydrogenase.