High mortality among hospital-acquired COVID-19 infection in patients with cancer: A multicentre observational cohort study

Abstract

Introduction Studies suggest that patients with cancer are more likely to experience severe outcomes from COVID-19. Therefore, cancer centers have undertaken efforts to care for patients with cancer in COVID-free units. Nevertheless, the frequency and relevance of nosocomial transmission of COVID-19 in patients with cancer remain unknown. The goal of this study was to determine the incidence and impact of hospital-acquired COVID-19 in this population and identify predictive factors for COVID-19 severity in patients with cancer. Methods Patients with cancer and a laboratory-confirmed diagnosis of COVID-19 were prospectively identified using provincial registries and hospital databases between March 3 rd and May 23 rd , 2020 in the provinces of Quebec and British Columbia in Canada. Patient’s baseline characteristics including age, sex, comorbidities, cancer type, and type of anti-cancer treatment were collected. The exposure of interest was incidence of hospital-acquired infection defined by diagnosis of SARS-CoV-2 ≥ 5 days after hospital admission for COVID-unrelated cause. Co-primary outcomes were death or composite outcomes of severe illness from COVID-19 such as hospitalization, supplemental oxygen, intensive-care unit (ICU) admission and/or mechanical ventilation. Results A total of 252 patients (N=249 adult, and N=3 pediatric) with COVID-19 and cancer were identified, and the majority were residents of Quebec (N=233). One-hundred-and-six patients (42.1%) received active anti-cancer treatment in the last 3 months prior to COVID-19 diagnosis. During a median follow-up of 25 days, 33 (13.1%) required admission to the ICU, and 71 (28.2%) died. Forty-seven (19.1%) had a diagnosis of hospital-acquired COVID-19. Median overall survival was shorter in those with hospital-acquired infection, compared to a contemporary community-acquired population (27 days vs unreached, HR 2.3, 95% CI 1.2-4.4, p=0.0006). Multivariate analysis demonstrated that hospital-acquired COVID-19, age, ECOG status, and advanced stage of cancer were independently associated with death. Interpretation Our study demonstrates a high rate of nosocomial transmission of COVID-19, associated with increased mortality in both univariate and multivariate analysis in the cancer population, reinforcing the importance of treating patients with cancer in COVID-free units. We also validated that age and advanced cancer were negative predictive factors for COVID-19 severity in patients with cancer.

Differences in mortality of cancer patients with COVID-19 in a Brazilian cancer center

“…This increase in mortality in men is related to a higher number of comorbidities, prevalence of smoking, alcohol consumption, and occupational exposures [35 , 36 , 37] . In the present study, differences in mortality due to COVID-19 between the sexes were not identified, as reported in other studies [9 , 11 , 19] . Sex hormones are believed to be important in the immune response; estrogen is known to act as an immune booster, but androgens need to be further investigated for their interaction with COVID-19 [38 , 39] .…”

“…Other studies have also demonstrated higher mortality from COVID-19 in cancer patients, with reported mortality ranging from 9% to 50% [7 , 9 , 12 , 14 , 15 , 17 , 19 , 22] . The results of the present study fall on the lower end of this spectrum, with a 12.4% mortality.…”

“…Epidemiological and clinical evidence points to a greater risk of serious outcomes of COVID-19 in elderly patients, men, smokers, and patients with comorbidities such as hypertension, diabetes, obesity, and cancer [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] [See Text Box and Table 1 ]. Cancer patients are more vulnerable to complications and death when infected with SARS-CoV-2.…”

“… Yekedüz et al [18] 16 studies included in a meta-analysis drawn from a MEDLINE database searched on September 01, 2020 with primary endpoints of severe disease and death in cancer patients treated within the last 30 d before COVID-19 diagnosis Chemotherapy within 30 d before COVID-19 diagnosis increased risk of death in cancer patients after adjusting for confounding variables (OR, 1.85; 95%CI, 1.26–2.71); but not risk of ever COVID disease Targeted therapies, immunotherapy, surgery and radiotherapy did not increase the severe disease and death risk in cancer patients with COVID-19 Chemotherapy increased risk of death from COVID-19 in cancer patients, There was no safety concern for immunotherapy, targeted therapies, surgery and radiotherapy. Elkrief et al [19] 252 patients (N = 249 adult and N = 3 pediatric) patients with cancer and diagnosis of COVID-19 prospectively identified between March 3 and May 23, 2020 in the provinces of Quebec and British Columbia in Canada. 106/252 (42.1%) received active anticancer treatment in the 3 mo before COVID-19 diagnosis During a median follow-up of 25 d, 33/252 (13.1%) required admission to the ICU, and 71/252 (28.2%) died 47/252 (19.1%) had hospital-acquired COVID-19 Median OS shorter with hospital-acquired infection than that in a contemporary community-acquired population (27 d vs unreached (HR, 2.3, 95%CI: 1.2–4.4, P = .0006.…”

Prevention of healthcare-associated respiratory-viral infections amongst oncology inpatients: Infection prevention outcomes during coronavirus disease-2019 pandemic

“…We read with interest the paper by Elkrief et al that reported high mortality amongst healthcare-associated cases of coronavirus-disease-2019 (COVID-19) infection in oncology inpatients, with almost one-fifth of cases attributed to healthcare-associated transmission. [ 1 ] Indeed, healthcare-associated transmission of SARS-CoV-2 poses a substantial problem in cancer centres; in a study describing the impact of COVID-19 on a large cancer centre during the first wave of the pandemic, the majority of patients tested COVID-19-positive after an emergent or elective hospital attendance. [ 2 ] The ongoing pandemic has provided the impetus for introduction of extensive infection-prevention measures in cancer centres, including segregated isolation wards for symptomatic patients, screening of visitors for fever and respiratory symptoms, and heightened COVID-19 surveillance for healthcare workers (HCWs).…”