SARS-CoV-2 Clinical Outcomes in Patients with Cancer in a Large Integrated Health Care System in Northern California.

The SARS-CoV-2 (COVID-19) pandemic continues to affect many lives globally. Patients with cancer undergoing potentially immunosuppressive therapies appear to be at particular risk for the disease and its complications. Here, we describe the experience of patients with cancer within Kaiser Permanente, a large, integrated health system in Northern California. Between February 25, 2020, and June 8, 2020, 4,627 patients were diagnosed with COVID-19, of whom 33 had active cancer treatment within 180 days and 214 had a history of cancer. Patients with active cancer treatment had a statistically higher risk of requiring noninvasive ventilation (odds ratio [OR], 2.57; confidence interval [CI], 1.10-6.01), and there was a nonsignificant trend toward higher risk of death (OR, 2.78; CI, 0.92-8.43). Those with a history of cancer had comparable outcomes to those without cancer. These data demonstrate an increased risk of complications from COVID-19 for patients with active cancer treatment.

Introduction

The SARS‐CoV‐2 (COVID‐19) pandemic has affected more than 10 million people as of July 2020, with the U.S. reporting the highest number of cases and deaths [1]. Patients with cancer appear to be at particular risk for COVID‐19 and its complications. Oncologic societies and health care systems have been modifying guidelines for the care of patients with cancer with emerging data. Based on the experience in China and Italy thus far, the overall trend is toward worse COVID‐19 outcomes for those with a diagnosis of cancer, especially those with thoracic malignancies [2, 3, 4].

Northern California was one of the first areas to have documented community transmission within the U.S. Myers et al. reported hospitalization and intensive care unit (ICU) admissions from Kaiser Permanente Northern California (KPNC), a regional integrated health care system serving 4.4 million members, constituting 30% of the area's insured population [5]. We describe the outcomes of those affected by COVID‐19 with cancer within KPNC.

Methods

We included adults with a positive lab test for COVID‐19 between February 25, 2020, and June 8, 2020, in this retrospective cohort study. All data were collected from the electronic medical record. Using an internally developed algorithm and chart review, we identified patients who had active treatment for cancer (including infusion chemotherapy, oral chemotherapy, or radiation) in the 180 days prior to COVID‐19 diagnosis, patients with a history of cancer documented in the KPNC cancer registry but no active treatment, and patients with no cancer history.

Outcomes included emergency department visit, inpatient hospitalization, ICU stay, mechanical ventilation, noninvasive ventilation, and mortality between COVID‐19 diagnosis and the first of 45 days after diagnosis or June 9, 2020. We used logistic regression to calculate odds ratios (ORs) and confidence intervals (CIs) of outcomes, adjusting for demographic and clinical characteristics, as well as the week of COVID‐19 diagnosis to account for changing testing and treatment guidelines. We completed chart review of patients with active cancer treatment and a COVID‐19 diagnosis.

The Research Determination Committee for KPNC determined this project does not meet the regulatory definition of research involving human subjects per 45 CFR 46.102(d).

Results

Of the 4,627 patients diagnosed with COVID‐19 from February 25, 2020, to June 8, 2020, 33 (0.7%) had active cancer treatment within 180 days, 214 (4.6%) had a history of cancer, and 4,380 (94.7%) had no diagnosis of cancer. Of the patients with cancer receiving active treatment, the most common cancer diagnoses were breast (n = 9) and hematologic (n = 7). The most common treatments were targeted (n = 14), chemotherapy (n = 12), and hormonal (n = 11).

Patients with active cancer treatment or a history of cancer were older and more likely to be white, had higher Charlson comorbidity scores and lower body mass index, and were more likely to have hypertension and diabetes and to have ever smoked than patients without cancer (Table 1). Patients with active cancer treatment had a higher risk of requiring noninvasive ventilation (OR, 2.57; CI, 1.10–6.01) than those without cancer. There was a non–statistically significant trend toward higher risk of death (OR, 2.78; CI, 0.92–8.43) in patients with active cancer. Those with a history of cancer had comparable outcomes to those without any cancer history (Table 2).

Table 1

Characteristics of 4,627 Kaiser Permanente Northern California patients

Characteristics	Active cancer treatment (n = 33)	History of cancer with no active treatment (n = 214)	No active cancer treatment or history (n = 4,380)
Age, years
18–59	39	29	77
60–69	24	22	13
70+	36	49	10
Sex
Male	45	48	48
Female	55	52	52
Race/ethnicity
Black	—	7	7
Asian	—	17	18
Hispanic	36	29	44
White	33	42	19
Missing/other	—	6	12
Body mass index a
Underweight	—	3	1
Healthy weight	30	29	20
Overweight	36	36	29
Obese	30	33	41
Unknown	0	0	10
Charlson comorbidity index
0	0	19	67
1–4	21	56	28
5+	79	25	5
Hypertension
Yes	42	29	13
No	58	71	87
Diabetes
Yes	18	28	13
No	82	72	87
Smoking status a
Ever	39	46	25
Never	61	54	64
Unknown	0	0	11
Neighborhood deprivation index
Quartile 1, least deprived	39	37	24
Quartile 2	27	29	24
Quartile 3–4, most deprived	33	34	50
Unknown	0	0	2

Data are presented as %.

Includes information for up to 10 years prior to diagnosis.

Abbreviation: —, indicates cell size is 5 patients or fewer.

Table 2

Adjusted odds ratios and 95% confidence intervals of clinical outcomes among 4,627 COVID‐19–positive patients diagnosed between February 25, 2020, and June 8, 2020

Characteristics	Any outcome (n = 1,829) a	ED (n = 1,767)	IP (n = 931)	ICU (n = 308)	Invasive ventilator (n = 212)	Noninvasive ventilator (n = 1,104)	Death (n = 150)
Cancer history
Active treatment for cancer (n = 33)	1.96 (0.85–4.50)	1.44 (0.65–3.19)	1.55 (0.67–3.59)	1.30 (0.41–4.08)	0.81 (0.18–3.75)	2.57 (1.10–6.01)	2.78 (0.92–8.43)
History of cancer with no active treatment (n = 214)	1.23 (0.89–1.69)	1.00 (0.73–1.38)	1.06 (0.75–1.50)	1.21 (0.76–1.95)	1.14 (0.66–1.96)	1.25 (0.89–1.75)	0.92 (0.54–1.57)
No cancer (n = 4,380)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
Age, years
18–29	0.56 (0.44–0.71)	0.55 (0.43–0.70)	0.26 (0.18–0.39)	0.16 (0.07–0.36)	0.18 (0.07–0.46)	0.25 (0.18–0.36)	0.22 (0.08–0.59) b
30–39	0.62 (0.50–0.77)	0.64 (0.51–0.80)	0.40 (0.30–0.55)	0.36 (0.22–0.60)	0.19 (0.09–0.41)	0.40 (0.31–0.53)
40–49	0.96 (0.78–1.18)	0.99 (0.81–1.22)	0.63 (0.49–0.81)	0.64 (0.43–0.94)	0.42 (0.25–0.70)	0.58 (0.45–0.74)
50–59	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
60–69	1.08 (0.86–1.35)	1.08 (0.86–1.36)	0.99 (0.76–1.28)	0.94 (0.64–1.36)	1.01 (0.66–1.54)	1.05 (0.82–1.35)	1.42 (0.71–2.83)
70–79	1.87 (1.35–2.59)	1.86 (1.35–2.57)	2.24 (1.59–3.14)	1.82 (1.16–2.85)	1.69 (1.02–2.81)	2.29 (1.64–3.20)	5.42 (2.74–10.73)
80+	2.85 (1.98–4.10)	2.67 (1.87–3.81)	3.78 (2.60–5.49)	1.15 (0.67–1.98)	1.05 (0.56–1.97)	3.75 (2.59–5.44)	15.94 (7.90–32.17)
Sex
Male	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
Female	0.74 (0.65–0.85)	0.72 (0.63–0.83)	0.60 (0.51–0.71)	0.48 (0.37–0.63)	0.45 (0.33–0.62)	0.60 (0.50–0.70)	0.58 (0.39–0.85)
Race/ethnicity
Black	1.49 (1.12–2.00)	1.58 (1.18–2.11)	1.19 (0.85–1.69)	1.29 (0.77–2.15)	1.33 (0.74–2.39)	1.15 (0.82–1.60)	0.74 (0.39–1.42)
Asian	1.10 (0.88–1.37)	1.19 (0.96–1.49)	1.57 (1.20–2.07)	2.06 (1.36–3.11)	1.90 (1.17–3.09)	1.37 (1.06–1.78)	1.15 (0.66–2.01)
Hispanic	1.50 (1.23–1.83)	1.63 (1.33–1.99)	1.56 (1.22–2.01)	1.75 (1.20–2.56)	1.72 (1.10–2.68)	1.44 (1.14–1.82)	0.90 (0.53–1.54)
White	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
Missing/other	0.81 (0.62–1.06)	0.85(0.65–1.11)	1.29 (0.92–1.82)	1.66 (1.01–2.73)	1.59 (0.88–2.88)	1.19 (0.86–1.65)	0.82 (0.39–1.73)
Body mass index c
Underweight	2.00 (0.95–4.19)	1.56 (0.77–3.15)	1.21 (0.59–2.48)	1.31 (0.46–3.78)	0.67 (0.14–3.17)	2.01 (0.97–4.16)	1.56 (0.57–4.24)
Healthy weight	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
Overweight	1.04 (0.85–1.27)	1.03 (0.84–1.25)	1.11 (0.87–1.43)	1.50 (1.03–2.19)	1.33 (0.85–2.07)	1.04 (0.82–1.32)	1.33 (0.81–2.20)
Obese	1.19 (0.98–1.45)	1.16 (0.96–1.42)	1.49 (1.17–1.91)	1.67 (1.14–2.45)	1.71 (1.09–2.67)	1.49 (1.18–1.89)	2.14 (1.27–3.60)
Charlson comorbidity index
0	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
1–2	1.31 (1.09–1.56)	1.31 (1.10–1.57)	1.19 (0.95–1.49)	1.26 (0.90–1.78)	1.66 (1.10–2.49)	1.22 (0.98–1.50)	2.56 (1.31–5.00)
3–4	1.18 (0.85–1.65)	1.22 (0.87–1.69)	1.18 (0.82–1.70)	1.37 (0.84–2.25)	1.62 (0.91–2.90)	1.08 (0.76–1.55)	2.57 (1.18–5.60)
5+	1.28 (0.89–1.83)	1.11 (0.78–1.59)	1.00 (0.68–1.47)	0.85 (0.49–1.47)	1.08 (0.57–2.03)	1.05 (0.72–1.53)	2.65 (1.19–5.90)
Hypertension
Yes	2.19 (1.74–2.75)	2.32 (1.85–2.90)	3.15 (2.50–3.96)	2.74 (1.99–3.76)	2.74 (1.90–3.96)	3.15 (2.51–3.96)	1.71 (1.13–2.60)
No	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
Diabetes
Yes	1.36 (1.07–1.73)	1.27 (1.00–1.61)	1.54 (1.20–1.99)	1.41 (1.00–1.99)	1.17 (0.79–1.73)	1.53 (1.19–1.97)	1.27 (0.81–2.00)
No	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
Smoking status c
Ever	1.11 (0.95–1.31)	1.13 (0.97–1.33)	1.09 (0.90–1.33)	1.10 (0.83–1.46)	1.02 (0.73–1.44)	1.13 (0.94–1.36)	1.15 (0.76–1.73)
Never	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
Neighborhood deprivation index
Quartile 1, least deprived	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)	1.00 (Ref)
Quartile 2	1.12 (0.93–1.36)	1.11 (0.91–1.34)	0.90 (0.71–1.15)	0.89 (0.62–1.29)	0.95 (0.62–1.47)	0.94 (0.75–1.18)	1.10 (0.67–1.80)
Quartile 3	1.26 (1.03–1.53)	1.27 (1.05–1.55)	1.18 (0.93–1.51)	1.24 (0.87–1.78)	1.30 (0.85–2.00)	1.24 (0.99–1.57)	1.01 (0.59–1.73)
Quartile 4, most deprived	1.65 (1.35–2.02)	1.61 (1.31–1.97)	1.31 (1.01–1.69)	1.37 (0.94–1.99)	1.58 (1.01–2.48)	1.37 (1.08–1.75)	1.43 (0.81–2.53)

Includes outcomes up to the first of either 45 days after COVID‐19 diagnosis or June 9, 2020.

All models are adjusted for all variables in the table (cancer history, age, sex, race/ethnicity, body mass index, Charlson comorbidity index, hypertension, diabetes, smoking status, and neighborhood deprivation index) and week of COVID‐19 diagnosis.

Any outcome includes any of emergency department visit, inpatient hospitalization, ICU stay, mechanical ventilation, noninvasive ventilation, or mortality.

Patients aged <50 years were grouped owing to small number of events in lower age groups.

Includes information for up to 10 years prior to diagnosis; also adjusts for missing and unknown status.

Abbreviations: ED, emergency department; ICU, intensive care unit; IP, inpatient hospitalization; Ref, reference.

Conclusion

There was an increased risk of requiring noninvasive ventilation and a non–statistically significant increased risk of death, consistent with prior data demonstrating an increased risk of complications from COVID‐19 for patients on active cancer therapy [3, 6]. Patients with a history of cancer appear to have similar outcomes to those without a history of cancer. This supports questions around whether treatment, with its impact on the immune system and additional touchpoints with the medical center, may pose significant risk for patients with an active diagnosis of cancer. Evaluating these factors in a larger population may further answer these questions.

Disclosures

The authors indicated no financial relationships.