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. 2022 Jan 4;5(1):e2142046.
doi: 10.1001/jamanetworkopen.2021.42046.

Assessment of Regional Variability in COVID-19 Outcomes Among Patients With Cancer in the United States

Jessica E Hawley  1   2 , Tianyi Sun  3 , David D Chism  4 , Narjust Duma  5 , Julie C Fu  6 , Na Tosha N Gatson  7   8 , Sanjay Mishra  3 , Ryan H Nguyen  9 , Sonya A Reid  3 , Oscar K Serrano  10 , Sunny R K Singh  11 , Neeta K Venepalli  12 , Ziad Bakouny  13 , Babar Bashir  14 , Mehmet A Bilen  15 , Paolo F Caimi  16 , Toni K Choueiri  13 , Scott J Dawsey  17 , Leslie A Fecher  18 , Daniel B Flora  19 , Christopher R Friese  18 , Michael J Glover  20 , Cyndi J Gonzalez  18 , Sharad Goyal  21 , Thorvardur R Halfdanarson  22 , Dawn L Hershman  1 , Hina Khan  23 , Chris Labaki  13 , Mark A Lewis  24 , Rana R McKay  25 , Ian Messing  21 , Nathan A Pennell  17 , Matthew Puc  26 , Deepak Ravindranathan  15 , Terence D Rhodes  24 , Andrea V Rivera  14 , John Roller  27 , Gary K Schwartz  1 , Sumit A Shah  20 , Justin A Shaya  25 , Mitrianna Streckfuss  28 , Michael A Thompson  28 , Elizabeth M Wulff-Burchfield  27 , Zhuoer Xie  22 , Peter Paul Yu  10 , Jeremy L Warner  3 , Dimpy P Shah  29 , Benjamin French  3 , Clara Hwang  11 ; COVID-19 and Cancer Consortium (CCC19)
Collaborators, Affiliations

Assessment of Regional Variability in COVID-19 Outcomes Among Patients With Cancer in the United States

Jessica E Hawley et al. JAMA Netw Open. .

Erratum in

  • Error in Nonauthor Collaborator Name.
    [No authors listed] [No authors listed] JAMA Netw Open. 2022 May 2;5(5):e2217965. doi: 10.1001/jamanetworkopen.2022.17965. JAMA Netw Open. 2022. PMID: 35612858 Free PMC article. No abstract available.

Abstract

Importance: The COVID-19 pandemic has had a distinct spatiotemporal pattern in the United States. Patients with cancer are at higher risk of severe complications from COVID-19, but it is not well known whether COVID-19 outcomes in this patient population were associated with geography.

Objective: To quantify spatiotemporal variation in COVID-19 outcomes among patients with cancer.

Design, setting, and participants: This registry-based retrospective cohort study included patients with a historical diagnosis of invasive malignant neoplasm and laboratory-confirmed SARS-CoV-2 infection between March and November 2020. Data were collected from cancer care delivery centers in the United States.

Exposures: Patient residence was categorized into 9 US census divisions. Cancer center characteristics included academic or community classification, rural-urban continuum code (RUCC), and social vulnerability index.

Main outcomes and measures: The primary outcome was 30-day all-cause mortality. The secondary composite outcome consisted of receipt of mechanical ventilation, intensive care unit admission, and all-cause death. Multilevel mixed-effects models estimated associations of center-level and census division-level exposures with outcomes after adjustment for patient-level risk factors and quantified variation in adjusted outcomes across centers, census divisions, and calendar time.

Results: Data for 4749 patients (median [IQR] age, 66 [56-76] years; 2439 [51.4%] female individuals, 1079 [22.7%] non-Hispanic Black individuals, and 690 [14.5%] Hispanic individuals) were reported from 83 centers in the Northeast (1564 patients [32.9%]), Midwest (1638 [34.5%]), South (894 [18.8%]), and West (653 [13.8%]). After adjustment for patient characteristics, including month of COVID-19 diagnosis, estimated 30-day mortality rates ranged from 5.2% to 26.6% across centers. Patients from centers located in metropolitan areas with population less than 250 000 (RUCC 3) had lower odds of 30-day mortality compared with patients from centers in metropolitan areas with population at least 1 million (RUCC 1) (adjusted odds ratio [aOR], 0.31; 95% CI, 0.11-0.84). The type of center was not significantly associated with primary or secondary outcomes. There were no statistically significant differences in outcome rates across the 9 census divisions, but adjusted mortality rates significantly improved over time (eg, September to November vs March to May: aOR, 0.32; 95% CI, 0.17-0.58).

Conclusions and relevance: In this registry-based cohort study, significant differences in COVID-19 outcomes across US census divisions were not observed. However, substantial heterogeneity in COVID-19 outcomes across cancer care delivery centers was found. Attention to implementing standardized guidelines for the care of patients with cancer and COVID-19 could improve outcomes for these vulnerable patients.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Hawley reported receiving grants from the National Institutes of Health (NIH) and the Prostate Cancer Foundation, receiving research funding to institution from Regeneron and Dendreon, receiving research collaboration and biospecimen sharing from Dendreon, and receiving personal fees from Genzyme outside the submitted work. Dr Chism reported serving on the virtual advisory board for Aveo and Exelixis outside the submitted work. Dr Duma reported receiving consulting fees and serving on the advisory boards of Pfizer, AstraZeneca, Genentech, Clinical Care Options, Onclive, Inivata, BI Oncology, Bristol Myers Squibb, Neogenomics, Janssen Pharmaceuticals, and Merck outside the submitted work. Dr Gatson reported receiving personal fees from Novocure outside the submitted work. Dr Mishra reported receiving personal fees from National Geographic outside the submitted work. Dr Nguyen reported receiving personal fees from Promega outside the submitted work. Dr Reid reported receiving personal fees from Novartis outside the submitted work. Dr Venepalli reported serving on the advisory board of Eli Lilly and Co outside the submitted work. Dr Bakouny reported receiving genomics and clinical data from Bristol Myers Squibb in the setting of a research study, grants from Genentech/imCORE, and personal fees from UpToDate outside the submitted work. Dr Bashir reported receiving research funding to institution from Boehringer Ingelheim, Bicycle Therapeutics, Ikena Oncology, Tarveda Therapeutics, KAHR Medical, and Syros Pharmaceuticals outside the submitted work. Dr Bilen reported receiving personal fees from Exelixis, Bayer, Bristol Myers Squibb, Eisai, Pfizer, AstraZeneca, Janssen Pharmaceuticals, Calithera Biosciences, Genomic Health, Nektar, EMD Serono, SeaGen, and Sanofi and receiving grants to institution from Xencor, Bayer, Bristol Myers Squibb, Genentech/Roche, Seattle Genetics, Incyte, Nektar, AstraZeneca, Tricon Pharmaceuticals, Genome & Company, AAA, Peloton Therapeutics, and Pfizer outside the submitted work. Dr Caimi reported receiving grants and personal fees from ADC Therapeutics; personal fees from Verastem, Amgen, Kite Pharma, Celgene, TG Therapeutics, Gilead, and Novartis; and receiving grants from Genentech outside the submitted work. Dr Choueiri reported serving on the steering committees of the COVID-19 and Cancer Consortium (CCC19) and ESMO-CoCare during the conduct of the study; receiving personal fees from Alexion Pharmaceutic, Alligent, Analysis Group, ASCO, Bayer, Cerulean Pharma, Clinical Care Options, Corvus Pharmaceuticals, Eisai, Foundation Medicine, Genentech/Roche, GlaxoSmithKline, Harborside Press, Ipsen, Kidney Cancer Association, Lancet Oncology, Lpath, Michael J. Hennessy Associates, Navinata Health, National Comprehensive Cancer Network (NCCN), Peloton Therapeutics, PER, PlatformQ Health, Prometheus, Sanofi/Aventis, The New England Journal of Medicine, Pfizer, Exelixis, Bristol Myers Squibb, Merck, Novartis, Roche/Genentech, Novartis, Eli Lilly and Co, UpToDate, AstraZeneca, and Roche; receiving research funding from Agensys, AstraZeneca, Bayer, Bristol Myers Squibb, Calithera Biosciences, Celldex, Cerulean Pharma, Corvus Pharmaceuticals, Eisai, Exelixis, Foundation Medicine, GlaxoSmithKline, Ipsen, Merck, Novartis, Peloton Therapeutics, Pfizer, Prometheus, Roche, Roche/Genentech, Seattle Genetics/Astellas, Takeda, and TRACON Pharma outside the submitted work, and serving on the National Cancer Institute (NCI) steering committee for a NCCN panel. Dr Fecher reported receiving grants from Bristol Myers Squibb, Pfizer, Array, EMD Serono, Merck, Incyte, and Kartos; receiving clinical trial funding to institution from Array; serving as the cochair of the VIA Oncology Melanoma committee for Elsevier; and serving on the data safety monitoring board for the Hoosier Cancer Research Network outside the submitted work. Dr Friese reported receiving grants from Merck and NCCN/Pfizer and serving on the board of governors of the Patient-Centered Outcomes Research Institute outside the submitted work. Dr Labaki reported receiving grants from Roche/Genentech outside the submitted work. Dr Halfdanarson reported receiving personal fees paid to institution from Advanced Accelerator Applications, a Novartis Company, and Ipsen Biopharmaceuticals; receiving personal fees from Isotopen Technologien München AG, Curium, and Terumo; and receiving research support paid to institution from Ipsen, Advanced Accelerator Applications, ThermoFisher Scientific, Agios, Basilea, and Turnstone Biologics outside the submitted work. Dr McKay reported receiving research funding from Bayer, Pfizer, and Tempus; serving on the advisory boards of AstraZeneca, Bayer, Bristol Myers Squibb, Calithera, Exelixis, Janssen Pharmaceuticals, Merck, Novartis, Pfizer, Sanofi, and Tempus; consulting for Dendreon, Myovant, and Vividion; and serving on the molecular tumor board at Caris. Dr Pennell reported serving on the advisory boards of AstraZeneca, Merck, Pfizer, Eli Lilly and Co, Genentech, Bristol Myers Squibb, Amgen, Mirati, Inivata, G1 Therapeutics, Xencor, Viosera, Janssen Pharmaceuticals, and Boehringer Ingelheim outside the submitted work. Dr Schwartz reported receiving personal fees from Apexigen, Array, Epizyme, GenCirq, Daiichii Sankyo, Fortress, Iovance Biotherapeutics, Bayer Pharmaceuticals, Pfizer Oncology, Bionaut, Oncogenuity, Puretech, PTC Therapeutics, Ellipses Pharma, and Concarlo and grants from ASTEX outside the submitted work. Dr Rhodes reported receiving personal fees from Bristol Myers Squibb and AstraZeneca outside the submitted work. Dr Thompson reported serving on the advisory boards of Adaptive, Bristol Myers Squibb, Doximity, Epizyme, Janssen Pharmaceuticals, Takeda, and GRAIL/Illumina; receiving stock and personal fees from Elsevier; receiving travel support from Syapse; serving as a reviewer for and receiving royalties from UpToDate; receiving royalties for the Connect MDS/AML Registry and the Myeloma Registry; owning stick in Doximity; receiving personal fees from VIA Oncology and GlaxoSmithKline; and receiving research funding from AbbVie, Amgen, Bristol Myers Squibb, CRAB CTC, Denovo, GlaxoSmithKline, the Hoosier Research Network, Janssen Pharmaceuticals, Eli Lilly and Co, LynxBio, Strata Oncology, Takeda, and TG Therapeutics outside the submitted work. Dr Wulff-Burchfield reported serving on the advisory boards of Bristol Myers Squibb and Exelixis; consulting for Astellas; receiving grants from Pfizer; and having a family member with stock ownership in Nektar and Immunomedics outside the submitted work. Dr Warner reported receiving grants from the American Association for Cancer Research; receiving personal fees from Westat, IBM Watson Health, Roche, and Flatiron Health; and owning HemOnc.org LLC outside the submitted work. Dr D. Shah reported receiving grants from the American Cancer Society and Hope Foundation for Cancer Research and the National Cancer Institute during the conduct of the study. Dr Hwang reported receiving funding from the Henry Ford Cancer Institute during the conduct of the study; receiving research funding paid to institution from Merck, Exelixis, Bayer, AstraZeneca, Genentech, Dendreon, and Bausch; receiving personal fees from EMD Sorono, Tempus, Sanofi/Genzyme, Dendreon, Exelixis, Bristol Myers Squibb, Astellas, Medivation, Bayer, and Janssen Scientific; and having a family member who owns stock in Johnson & Johnson outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Center-Level Unadjusted and Adjusted Rates of 30-Day All-Cause Mortality and Secondary Composite Outcome (Receipt of Mechanical Ventilation, Intensive Care Unit Admission, and All-Cause Death)
Each dot represents a center, colored according to the number of patients reported to the COVID-19 and Cancer Consortium and included in this analysis. Dots are not displayed for 6 centers with fewer than 5 patients. Median and interquartile range are denoted by the center line and box, respectively. Estimated standard deviation of the center-level random intercepts: 0.555 and 0.837 (on the log-odds scale) for 30-day mortality and the composite outcome, respectively.
Figure 2.
Figure 2.. Unadjusted Rates of 30-Day All-Cause Mortality by 9 US Census Divisions, Division-Level Average Rate of SARS-CoV-2 Diagnosis, and US Census Division and Calendar Time
A, Gray color indicates that there were no residents of that state reported to the COVID-19 and Cancer Consortium. B and C, Color-coded points represent each US census division. The size of the point is proportional to the number of patients in the COVID-19 and Cancer Consortium who were diagnosed with COVID-19 in that division during each time point. Division 7 (West South Central) is excluded at the third time point because there were fewer than 5 patients. In panel B, the black line is a lowess smoother to represent the average association between the rate of SARS-CoV-2 diagnosis and 30-day mortality; in panel C, the black line represents all divisions. Division 1, New England, includes Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; division 2, Middle Atlantic, includes New Jersey, New York, and Pennsylvania; division 3, East North Central, includes Indiana, Illinois, Michigan, Ohio, and Wisconsin; division 4, West North Central, includes Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota; division 5, South Atlantic, includes Delaware, Washington, DC, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, and West Virginia; division 6, East South Central, includes Alabama, Kentucky, Mississippi, and Tennessee; division 7, West South Central, includes Arkansas, Louisiana, Oklahoma, and Texas; division 8, Mountain, includes Arizona, Colorado, Idaho, New Mexico, Montana, Utah, Nevada, and Wyoming; and division 9, Pacific, includes Alaska, California, Hawaii, Oregon, and Washington.
See this image and copyright information in PMC

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