SARS-CoV-2 Viral Load Predicts Mortality in Patients with and without Cancer Who Are Hospitalized with COVID-19

Abstract

Patients with cancer may be at increased risk of severe coronavirus disease 2019 (COVID-19), but the role of viral load on this risk is unknown. We measured SARS-CoV-2 viral load using cycle threshold (C_T) values from reverse-transcription polymerase chain reaction assays applied to nasopharyngeal swab specimens in 100 patients with cancer and 2,914 without cancer who were admitted to three New York City hospitals. Overall, the in-hospital mortality rate was 38.8% among patients with a high viral load, 24.1% among patients with a medium viral load, and 15.3% among patients with a low viral load (p < 0.001). Similar findings were observed in patients with cancer (high, 45.2% mortality; medium, 28.0%; low, 12.1%; p = 0.008). Patients with hematologic malignancies had higher median viral loads (C_T = 25.0) than patients without cancer (C_T = 29.2; p = 0.0039). SARS-CoV-2 viral load results may offer vital prognostic information for patients with and without cancer who are hospitalized with COVID-19.

Keywords: cancer; coronavirus disease 2019 (COVID-19); cycle threshold (C(T)); hematologic malignancy; mortality; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); solid tumor; viral load.

Graphical abstract

Figure 1

Flow Diagram of Patients Included in the Study and Reasons for Exclusion

Figure 2

Admission SARS-CoV-2 C_T Values in Patients with Solid Tumors, with Hematologic Malignancies, and without Active Cancer (A) These C_T values are of the SARS-CoV-2-specific gene target (ORF1ab or N2) derived from nasopharyngeal swab specimens obtained upon admission to the hospital, stratified by whether the patient had no active cancer, a solid tumor, or a hematologic malignancy; (B) SARS-CoV-2-specific gene target C_T values displayed by type of cancer. The most common other solid tumors were thoracic (n = 5) and gynecologic (n = 4), and the most common other hematologic malignancies were lymphoma (n = 6) and acute leukemia (n = 4); (C) SARS-CoV-2-specific gene target C_T values among patients with solid tumors and hematologic malignancies who received chemotherapy or targeted therapies and among those who did not receive these therapies. Median values are represented by horizontal lines and boxes represent 25th–75th percentiles. The Wilcoxon rank-sum test was used for viral load comparisons with two-sided p values.

Figure 3

Probability of In-Hospital Survival Over Time Among Patients with Cancer Stratified by Admission Viral Load Viral loads are grouped into categories based on C_T values of the SARS-CoV-2-specific gene target (cobas SARS-CoV-2 assay, ORF1ab: high, C_T < 25; medium, C_T 25–30, low, C_T > 30; and Xpert Xpress SARS-CoV-2 assay, N2: high, C_T < 27; medium, C_T 27–32, low, C_T > 32). Hazard ratios (HR) were generated using a Cox proportional hazards model with two-sided p values.