SARS-CoV-2 Transmission in Patients With Cancer at a Tertiary Care Hospital in Wuhan, China

In December 2019, an outbreak of 2019 novel coronavirus disease (COVID-19) occurred in Wuhan, Hubei, which has been linked to the severe adult respiratory syndrome coronavirus 2 (SARS-CoV-2). It is characterized by rapid human-to-human transmission from droplet contamination.^1,2 A report of 138 hospitalized patients from a single institution (Zhongnan Hospital of Wuhan University) indicated that hospital-acquired transmission accounted for 41.3% of these admitted patients, thus implicating the hospital environment as a source of spread of the virus.³ Patients with cancer are often recalled to the hospital for treatment and monitoring, and hence, they may be at risk of contracting COVID-19. Moreover, cancer treatments such as chemotherapy and radiotherapy are immunosuppressive. Here, we report the incidence and outcomes of SARS-CoV-2 infection in cancer patients who were treated at a tertiary cancer institution in Wuhan.

We reviewed the medical records, including demographic, clinical, and treatment data of 1524 patients with cancer who were admitted to the Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, from December 30, 2019, to February 17, 2020 (data cutoff date). COVID-19 pneumonia was diagnosed based on the updated COVID-19 Diagnostic Criteria, 5th Edition (Supplement). Outcomes of COVID-19 among patients with cancer were reported.

This retrospective study was approved by the Zhongnan Hospital of Wuhan University ethics committee (2020039). Waiver of informed consent was approved for the aggregated data; verbal informed consent was obtained from the living patients with COVID-19.

We estimated the infection rate of SARS-CoV-2 in patients with cancer from our single institution at 0.79% (12 of 1524 patients; 95% CI, 0.3%-1.2%). This was higher than the cumulative incidence of all diagnosed COVID-19 cases that was reported in the city of Wuhan over the same time period (0.37%; 41 152 of 11 081 000 cases; data cutoff on February 17, 2020). Clinical details on the cancer diagnoses and treatment history are summarized in Table 1. The median age of infected patients was 66 years (range, 48 to 78 years); 8 of 12 patients (66.7%) were older than 60 years. Seven of 12 (58.3%) patients had non–small cell lung carcinoma (NSCLC). Five (41.7%) were being treated with either chemotherapy with or without immunotherapy (n = 3) or radiotherapy (n = 2). Three patients (25.0%) developed SARS; 1 patient required intensive-level care. As of March 10, 2020, 6 patients (50.0%) had been discharged, whereas 3 deaths (25.0%) were recorded.

We also interrogated the association of SARS-Cov-2 infection with age and concurrent NSCLC diagnosis. Of the 1524 patients with cancer who were screened, 228 had NSCLC. We found that patients with NSCLC older than 60 years had a higher incidence of COVID-19 than those aged 60 years or younger (4.3% vs 1.8%) (Table 2).

It is hypothesized that patients with cancer may be susceptible to an infection during a viral epidemic owing to their immunocompromised status.⁴ This study highlights the following observations: patients with cancer from the epicenter of a viral epidemic harbored a higher risk of SARS-CoV-2 infection (OR, 2.31; 95% CI, 1.89-3.02) compared with the community. However, fewer than half of these infected patients were undergoing active treatment for their cancers. Next, we observed that older patients (>60 years) and patients with NSCLC may be at risk of COVID-19. Nonetheless, a population study of 1099 patients with COVID-19 did not indicate that age was associated with susceptibility to infection.⁵ A larger sample size in patients with cancer will resolve these potential associations. Finally, our findings imply that hospital admission and recurrent hospital visits are potential risk factors for SARS-CoV-2 infection.

We propose that aggressive measures be undertaken to reduce frequency of hospital visits of patients with cancer during a viral epidemic going forward. For patients who require treatment, proper isolation protocols must be in place to mitigate the risk of SARS-CoV-2 infection.

Corresponding Authors: Conghua Xie, MD, Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan 430071, People’s Republic of China (chxie_65@whu.edu.cn); Melvin L. K. Chua, MBBS, PhD, Division of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610 (melvin.chua.l.k@singhealth.com.sg).

Accepted for Publication: March 11, 2020.

Published Online: March 25, 2020. doi:10.1001/jamaoncol.2020.0980

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Yu J et al. JAMA Oncology.

Author Contributions: Drs Xie and Chua had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Yu and Ouyang contributed equally as co–first authors. Drs Chua and Xie contributed equally as co–senior authors.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Yu, Chua.

Critical revision of the manuscript for important intellectual content: Yu, Ouyang, Xie.

Statistical analysis: Yu, Chua.

Administrative, technical, or material support: All authors.

Study supervision: Yu, Chua, Xie.

Funding/Support: Dr Chua is supported by the National Medical Research Council Clinician-Scientist Award (CSA/0027/2018).

Role of the Funder/Sponsor: The National Medical Research Council had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Conflict of Interest Disclosures: No conflicts are reported.

Additional Contributions: We thank all the patients who consented to this study, and the frontline healthcare professionals who are involved in patient care during this pandemic.