Risk, Racial Disparity, and Outcomes Among Patients With Cancer and COVID-19 Infection | Oncology | JAMA Oncology | JAMA Network
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Comment & Response
May 6, 2021

Risk, Racial Disparity, and Outcomes Among Patients With Cancer and COVID-19 Infection

Author Affiliations
  • 1Divisions of Hematology and Oncology, University of North Carolina at Chapel Hill
  • 2Division of Hematology and Oncology, Northwestern University, Chicago, Illinois
JAMA Oncol. 2021;7(7):1065. doi:10.1001/jamaoncol.2021.0768

To the Editor We read with great interest the much-needed real-world analyses by Wang and colleagues1 demonstrating the increased propensity for individuals with a recent cancer diagnosis to be infected with COVID-19 and the remarkable racial disparity in health outcomes. The authors’ commendable use of electronic health records, which are less susceptible to reporting biases seen in registry-based analyses, also provides key estimates of hospitalization rates (48%) and mortality (15%) among patients with cancer and COVID-19. Given the inherent limitations of observational data to identify causative factors, policy makers must now determine the best course of action to help address this worrying epidemiologic finding.

The increased risk for thrombotic complications among individuals infected with COVID-19 has been a consistent theme throughout the COVID-19 pandemic.2 Even prior to the pandemic, venous thromboembolism (VTE) was identified as the second leading cause of death among patients with cancer. Based on high-quality evidence, multiple guidelines, including those from the American Society of Clinical Oncology,3 recommend using the Khorana Risk Score (KRS) to identify ambulatory patients with cancer who should be considered for outpatient thromboprophylaxis. The KRS is a simple, user-friendly VTE prediction tool, which combines tumor site with hematologic parameters and body mass index. The numbers needed to treat to prevent 1 VTE event using a direct oral anticoagulant for outpatient thromboprophylaxis are 25 for KRS of 2 or greater and 17 for KRS of 3 or greater, comparing favorably to the corresponding numbers needed to harm of 1000 and 334.4 However, despite high-quality evidence and strong guideline recommendations for the implementation of existing thromboprophylactic strategies in ambulatory patients with cancer, the uptake is extremely low in clinical practice. In a single-center, pre–COVID-19 analysis of patients with KRS of 2 or greater,5 none received thromboprophylaxis, and a survey of oncology clinicians found that the majority were unaware of the KRS and did not routinely use VTE risk assessment or primary prophylaxis in clinical practice.

Knowing that ambulatory patients with cancer have, at baseline, an increased risk of VTE, it is reasonable to assume that infection with COVID-19 further elevates this risk and may be contributing to the observed poor outcomes demonstrated by Wang and colleagues.1 It is imperative that ambulatory patients with cancer undergo VTE risk assessment and be offered primary prophylaxis if deemed to be at elevated risk for VTE. Improving evidence-based guideline adherence offers a rare opportunity to mitigate a feared medical complication of the pandemic and also to leave a positive quality improvement legacy following the pandemic.

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Article Information

Corresponding Author: Karlyn A. Martin, MD, MS, Division of Hematology and Oncology, Northwestern University, 645 N Michigan Ave, Ste 1020, Chicago, IL 60611 (karlyn.martin@nm.org).

Published Online: May 6, 2021. doi:10.1001/jamaoncol.2021.0768

Conflict of Interest Disclosures: Dr Kumar reported receiving personal fees (honoraria for authoring a book chapter) from Diagnostica Stago. Dr Martin reported receiving grants from Janssen Scientific Affairs. No other disclosures were reported.

Wang  Q, Berger  NA, Xu  R.  Analyses of risk, racial disparity, and outcomes among US patients with cancer and COVID-19 infection.   JAMA Oncol. 2021;7(2):220-227. doi:10.1001/jamaoncol.2020.6178PubMedGoogle ScholarCrossref
Connors  JM, Levy  JH.  COVID-19 and its implications for thrombosis and anticoagulation.   Blood. 2020;135(23):2033-2040. doi:10.1182/blood.2020006000PubMedGoogle ScholarCrossref
Key  NS, Khorana  AA, Kuderer  NM,  et al.  Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update.   J Clin Oncol. 2020;38(5):496-520. doi:10.1200/JCO.19.01461PubMedGoogle ScholarCrossref
Bosch  FTM, Mulder  FI, Kamphuisen  PW,  et al.  Primary thromboprophylaxis in ambulatory cancer patients with a high Khorana score: a systematic review and meta-analysis.   Blood Adv. 2020;4(20):5215-5225. doi:10.1182/bloodadvances.2020003115PubMedGoogle ScholarCrossref
Martin  KA, Molsberry  R, Khan  SS, Linder  JA, Cameron  KA, Benson  A  III.  Preventing venous thromboembolism in oncology practice: use of risk assessment and anticoagulation prophylaxis.   Res Pract Thromb Haemost. 2020;4(7):1211-1215. doi:10.1002/rth2.12431PubMedGoogle ScholarCrossref
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