Valvi Nimish, Patel Hetvee, Bakoyannis Giorgos, Haggstrom David A, Mohanty Sanjay, Dixon Brian E
Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, United States.
Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States.
JMIR Cancer. 2022 Oct 6;8(4):e35310. doi: 10.2196/35310.
Prior studies, generally conducted at single centers with small sample sizes, found that individuals with cancer experience more severe outcomes due to COVID-19, caused by SARS-CoV-2 infection. Although early examinations revealed greater risk of severe outcomes for patients with cancer, the magnitude of the increased risk remains unclear. Furthermore, prior studies were not typically performed using population-level data, especially those in the United States. Given robust prevention measures (eg, vaccines) are available for populations, examining the increased risk of patients with cancer due to SARS-CoV-2 infection using robust population-level analyses of electronic medical records is warranted.
The aim of this paper is to evaluate the association between SARS-CoV-2 infection and all-cause mortality among recently diagnosed adults with cancer.
We conducted a retrospective cohort study of newly diagnosed adults with cancer between January 1, 2019, and December 31, 2020, using electronic health records linked to a statewide SARS-CoV-2 testing database. The primary outcome was all-cause mortality. We used the Kaplan-Meier estimator to estimate survival during the COVID-19 period (January 15, 2020, to December 31, 2020). We further modeled SARS-CoV-2 infection as a time-dependent exposure (immortal time bias) in a multivariable Cox proportional hazards model adjusting for clinical and demographic variables to estimate the hazard ratios (HRs) among newly diagnosed adults with cancer. Sensitivity analyses were conducted using the above methods among individuals with cancer-staging information.
During the study period, 41,924 adults were identified with newly diagnosed cancer, of which 2894 (6.9%) tested positive for SARS-CoV-2. The population consisted of White (n=32,867, 78.4%), Black (n=2671, 6.4%), Hispanic (n=832, 2.0%), and other (n=5554, 13.2%) racial backgrounds, with both male (n=21,354, 50.9%) and female (n=20,570, 49.1%) individuals. In the COVID-19 period analysis, after adjusting for age, sex, race or ethnicity, comorbidities, cancer type, and region, the risk of death increased by 91% (adjusted HR 1.91; 95% CI 1.76-2.09) compared to the pre-COVID-19 period (January 1, 2019, to January 14, 2020) after adjusting for other covariates. In the adjusted time-dependent analysis, SARS-CoV-2 infection was associated with an increase in all-cause mortality (adjusted HR 6.91; 95% CI 6.06-7.89). Mortality increased 2.5 times among adults aged 65 years and older (adjusted HR 2.74; 95% CI 2.26-3.31) compared to adults 18-44 years old, among male (adjusted HR 1.23; 95% CI 1.14-1.32) compared to female individuals, and those with ≥2 chronic conditions (adjusted HR 2.12; 95% CI 1.94-2.31) compared to those with no comorbidities. Risk of mortality was 9% higher in the rural population (adjusted HR 1.09; 95% CI 1.01-1.18) compared to adult urban residents.
The findings highlight increased risk of death is associated with SARS-CoV-2 infection among patients with a recent diagnosis of cancer. Elevated risk underscores the importance of adhering to social distancing, mask adherence, vaccination, and regular testing among the adult cancer population.
先前的研究一般在单中心进行，样本量较小，发现癌症患者因感染严重急性呼吸综合征冠状病毒2（SARS-CoV-2）而感染2019冠状病毒病（COVID-19）时会出现更严重的后果。尽管早期检查发现癌症患者出现严重后果的风险更高，但风险增加的程度仍不清楚。此外，先前的研究通常未使用人群水平的数据，尤其是美国的数据。鉴于针对人群有强有力的预防措施（如疫苗），因此有必要通过对电子病历进行强有力的人群水平分析，来研究SARS-CoV-2感染导致癌症患者风险增加的情况。
本文旨在评估SARS-CoV-2感染与近期确诊的成年癌症患者全因死亡率之间的关联。
我们对2019年1月1日至2020年12月31日期间新确诊的成年癌症患者进行了一项回顾性队列研究，使用与全州SARS-CoV-2检测数据库相关联的电子健康记录。主要结局是全因死亡率。我们使用Kaplan-Meier估计量来估计COVID-19期间（2020年1月15日至2020年12月31日）的生存率。我们在多变量Cox比例风险模型中进一步将SARS-CoV-2感染建模为随时间变化的暴露因素（不朽时间偏倚），并对临床和人口统计学变量进行调整，以估计新确诊成年癌症患者的风险比（HR）。在有癌症分期信息的个体中使用上述方法进行敏感性分析。
在研究期间，共识别出41924名新确诊癌症的成年人，其中2894人（6.9%）SARS-CoV-2检测呈阳性。人群包括白人（n=32867，78.4%）、黑人（n=2671，6.4%）、西班牙裔（n=832，2.0%）和其他种族背景（n=5554，13.2%），男性（n=21354，50.9%）和女性（n=20570，49.1%）均有。在COVID-19期间分析中，在调整年龄、性别、种族或民族、合并症、癌症类型和地区后，与COVID-19之前的时期（2019年1月1日至2020年1月14日）相比，调整其他协变量后死亡风险增加了91%（调整后HR 1.91；95%CI 1.76-2.09）。在调整后的随时间变化分析中，SARS-CoV-2感染与全因死亡率增加相关（调整后HR 6.91；95%CI 6.06-7.89）。与18-44岁的成年人相比，65岁及以上的成年人死亡率增加了2.5倍（调整后HR 2.74；95%CI 2.26-3.31），男性（调整后HR 1.23；95%CI 1.14-1.32）高于女性，有≥2种慢性病的患者（调整后HR 2.12；95%CI 1.94-2.31）高于无合并症的患者。农村人口的死亡风险比成年城市居民高9%（调整后HR 1.09；95%CI 1.01-1.18）。
研究结果突出了近期诊断为癌症的患者中，SARS-CoV-2感染与死亡风险增加相关。风险升高强调了成年癌症患者坚持社交距离、佩戴口罩、接种疫苗和定期检测的重要性。
