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Table 1.  Clinical Characteristics and Outcomes of Patients With Cancer With SARS-CoV-2 Infection
Clinical Characteristics and Outcomes of Patients With Cancer With SARS-CoV-2 Infection
Table 2.  COVID-19 Pneumonia in Patients With NSCLC of Different Age Groups Treated at the Zhongnan Hospital of Wuhan University
COVID-19 Pneumonia in Patients With NSCLC of Different Age Groups Treated at the Zhongnan Hospital of Wuhan University
1.
Chen  N, Zhou  M, Dong  X,  et al.  Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.  Lancet. 2020;395(10223):507-513. doi:10.1016/S0140-6736(20)30211-7PubMedGoogle ScholarCrossref
2.
Wu  YC, Chen  CS, Chan  YJ.  The outbreak of COVID-19: an overview.  J Chin Med Assoc. 2020;83(3):217-220. doi:10.1097/JCMA.0000000000000270PubMedGoogle ScholarCrossref
3.
Wang  D, Hu  B, Hu  C,  et al.  Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.  JAMA. Published online February 7, 2020. doi:10.1001/jama.2020.1585PubMedGoogle Scholar
4.
Kamboj  M, Sepkowitz  KA.  Nosocomial infections in patients with cancer.  Lancet Oncol. 2009;10(6):589-597. doi:10.1016/S1470-2045(09)70069-5PubMedGoogle ScholarCrossref
5.
Guan  WJ, Ni  ZY, Hu  Y,  et al; China Medical Treatment Expert Group for Covid-19.  Clinical characteristics of coronavirus disease 2019 in China.  N Engl J Med.Published online February 28, 2020. doi:10.1056/NEJMoa2002032PubMedGoogle Scholar
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    6 Comments for this article
    EXPAND ALL
    Estimated Infection rate among Italian Cancer Patients
    Raffaele Giusti, MD | Medical Oncology Unit, Sant'Andrea Hospital of Rome
    Dear Author,
    The reported data are very interesting and underline a particular problem that we are observing among Italian cancer patients population.
    At today, We do not have retrospective analysis, but, according to the reported data from ISS (Istituto Superiore di Sanità, https://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_20_marzo_eng.pdf, accessed on march 25) in the 19.5% the Most common comorbidities observed in COVID-19 positive deceased patients were cancer.
    So my question is that maybe we're doing something wrong?
    Thank you.
    RG
    CONFLICT OF INTEREST: None Reported
    COVID-19, Flu, and Comorbidities of Cancer Patients
    Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
    The informative and prescriptive paper suggests that the number of visits to hospitals should be minimized for immunocompromised cancer patients during the COVID-19 epidemic.

    The results seem to suggest that COVID-19 positive patients should be carefully separated from cancer patients currently undergoing chemotherapy or radiotherapy treatments, and that "proper isolation protocols must be in place to mitigate the risk of SARS-CoV-2 infection".

    However, such salient recommendations might not be feasible for cancer patients undergoing immunosuppressive chemo or radio treatments on a regular basis, as they are typically administered in hospitals.

    If possible, it would have
    been useful to determine:

    (1) the types of cancer of the COVID-19 positive patients, including those other than, or in addition to, non–small cell lung carcinoma (NSCLC);
    (2) how long the patients had been undergoing such treatments, if at all; and
    (3) whether the cancer was primary, secondary, or tertiary.

    The types of cancer treatments would also have been a useful conditioning factor, as would the prevalence of seasonal flu, either contemporaneously or sequentially, in either order.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Error in Results
    Kate Anderton, Degree | AZONETWORK
    "..... (0.37%; 41 152 of 11 081 000 cases; data cutoff on February 17, 2020)" .... is incorrect, should be 41,081 cases if 0.37 percent = 152 patients not over 11 million.
    CONFLICT OF INTEREST: None Reported
    Response to: Estimated Infection rate among Italian Cancer Patients
    Melvin Chua, MBBS, PhD | National Cancer Centre Singapore
    Dear RG,

    Thank you for the comment on our paper.

    Indeed, your observation would be consistent with our preliminary data suggesting a higher mortality among patients with cancer, albeit in a small cohort of patients. It is unclear what could be the contributing factors to the severity but these patients were treated with high-level supportive care as per management of severe atypical pneumonia. We believe that the key is still to mitigate the risk of infection in these susceptible patients.

    Best
    All the authors
    CONFLICT OF INTEREST: None Reported
    Response to: Error in Results
    Melvin Chua, MBBS PhD | National Cancer Centre Singapore
    Dear Kate,

    To clarify, there is no error in the data. 41 152 of 11 081 000 equates to 0.3714%.

    Kind regards
    Melvin
    CONFLICT OF INTEREST: None Reported
    Special attention and priority should be paid to cancer survivor in this pandemic disease
    XINGLI WU, MD. | Institute of Geriatric cardiology, Chinese PLA General Hospital
    In this study, Dr Jing at Zhongnan Hospital of Wuhan University in China estimated the infection rate of SARS-CoV-2 in patients with cancer was 0.79% (12 of 1524 patients), which was higher than the 0.37% in general population. Dr Wang at the same hospital reported earlier 7.2% (10 of 138) of malignancy among the 138 hospitalized patients with confirmed 2019 novel coronavirus-infected pneumonia (Wang et al. 2020). Dr. Liang disclosed 1.13% (18 of 1590 patients) had a history of cancer, which seems to be higher than the incidence of cancer in the overall Chinese population (0.29%) ( Liang et al. 2020). undoubtedly,all the data demonstrated a higher ratio of cancer patients suffering from this pandemic disease.
    Furthermore, the higher case mortality in cancer patients has been documented in virus pneumonia as in a retrospective report from Korea (Youn-Jung Kim et al. 2019), which showed that the 30-day mortality was higher in cancer patients than non-cancer patients for the parainfluenza (12.3% vs. 3.8%, p <0 .05) and coronavirus (not SARS-CoV-2) (24.4% vs. 3.0%, p <0.01) infections.
    The higher mortality was also recognized in this vulnerable group of COVID-19 patients. As listed in this article by Dr Jing, three patients were died (25.0%), which was higher than the 0.6% in the early reported 17 cases of cancer death (Wang et al. 2020), the 11% reported by the Chinese national health commission and 14% estimated by Dr Wu et al in the general population during early stage of the epidemic (Wu et al. 2020).
    However the data of 1,099 patients with laboratory-confirmed COVID-19 in China showed that there were no correlation in both severity (0.8% vs. 1.7%, P=0.199) and composite endpoint (1.5% vs. 0.9%, P=0.468) between the cancer and no cancer group (Guan,et al. 2019). This discrepancy may be explained by relatively smaller sample of only 10 stable cancer patients were included in the series. As pointed out by Prof. Battegay from swiss, the case fatality rates may truly differ among different regions, because differences in medical care and susceptibilities to the 2019-Novel Coronavirus in different regions of China as well as different regions of the world (Battegay et al.2020).
    Nowadays, the extra risk is really there for the cancer survivors, especially for the active patients who are undergoing chemotherapy or radiation regimens. There for, the strict protective measures to keep patients from cross infection of COVID-19 and the rational arrangement of anticancer treatment should be carried out, and this strategy has been proved effective in some hospital in China. As reported by Dr. Wang on this April on this journal, they received a total of 2944 patients, including 2795 outpatients and 149 inpatients, not a single patient or staff member had been diagnosed with COVID-19 infection.
    Most importantly, attention and priority should be paid to development of effective vaccines, and diagnosis and treatment of viral infections in high-risk cancer patients with this pandemic disease.
    Additionally, because 3 patients of the total 12 patients are still in the hospital, the outcome of them will consummate information, best wishes for them!
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    March 25, 2020

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

    Author Affiliations
    • 1Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
    • 2Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
    • 3Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People’s Republic of China
    • 4Division of Radiation Oncology, Division of Medical Sciences, National Cancer Centre Singapore, Singapore
    • 5Oncology Academic Programme, Duke-NUS Medical School, Singapore
    JAMA Oncol. Published online March 25, 2020. doi:10.1001/jamaoncol.2020.0980

    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.

    Methods

    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.

    Results

    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).

    Discussion

    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.

    Back to top
    Article Information

    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.

    References
    1.
    Chen  N, Zhou  M, Dong  X,  et al.  Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.  Lancet. 2020;395(10223):507-513. doi:10.1016/S0140-6736(20)30211-7PubMedGoogle ScholarCrossref
    2.
    Wu  YC, Chen  CS, Chan  YJ.  The outbreak of COVID-19: an overview.  J Chin Med Assoc. 2020;83(3):217-220. doi:10.1097/JCMA.0000000000000270PubMedGoogle ScholarCrossref
    3.
    Wang  D, Hu  B, Hu  C,  et al.  Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.  JAMA. Published online February 7, 2020. doi:10.1001/jama.2020.1585PubMedGoogle Scholar
    4.
    Kamboj  M, Sepkowitz  KA.  Nosocomial infections in patients with cancer.  Lancet Oncol. 2009;10(6):589-597. doi:10.1016/S1470-2045(09)70069-5PubMedGoogle ScholarCrossref
    5.
    Guan  WJ, Ni  ZY, Hu  Y,  et al; China Medical Treatment Expert Group for Covid-19.  Clinical characteristics of coronavirus disease 2019 in China.  N Engl J Med.Published online February 28, 2020. doi:10.1056/NEJMoa2002032PubMedGoogle Scholar
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