COVID-19 and Cancer
Cancer patients and immunocompromised hosts are particularly susceptible
to lung infection. The spectrum of various infectious etiologies ranges
widely from viral, bacterial, and fungal pathogens; however, patients’
unique treatment regimens and resulting immunologic deficits predispose
patients to particular infections.10-14 In the setting
of SARS-CoV-2 and the COVID-19 pandemic, increased emphasis is being
placed upon the treatment and protection of those with cancer who may be
at increased risk to develop severe and potentially life-threatening
respiratory infections.15
Following the COVID-19 outbreak, the Italian National Institute of
Health established a surveillance program to collect information on all
patients with reverse transcriptase-polymerase chain reaction (RT-PCR)
confirmed SARS-CoV-2 infection. Among the Italian population, the
overall case fatality rate (CFR) was 7.2% (1625 deaths/22,512 cases) as
of March 15, 2020.16 In a subsample of 355 patients,
20.3% were noted to have active cancer in addition to multiple
comorbidities.17 Although a higher mean age (79.5 ±
8.1 years) was observed within this cohort, separate analyses have
reported a fatality rate approximating 20% in patients aged 80 and
older.18 While CFR estimates and degrees of morbidity
may vary based upon testing strategies and population demographics,
cancer patients and elderly individuals appear at higher risk for
adverse outcomes from COVID-19 infection.
Early reports from China indicate that infected cancer patients have a
3.5 times higher risk of requiring ICU admission, mechanical
ventilation, or death compared to individuals without
cancer.1 Zhang et al. noted a strong association
between anti-cancer therapy and risk of severe effects from COVID-19
infection (HR 4.079, p = 0.037) with 6 of 28 (21.4%) COVID-19
patients having received immunosuppressive treatment within the last 14
days.2 In a separate prospective analysis of 1,590
patients with laboratory-confirmed COVID-19 disease, Liang et al.
discovered that 18 (1%) patients had a history of cancer, a rate which
appears to be higher than the overall cancer incidence within the
Chinese population (0.29%) according to 2015 epidemiologic
data.1 Of the 16 patients with a known oncologic
treatment, 25% underwent surgery or received chemotherapy within the
past month. Compared to patients without cancer in this study, oncology
patients were older (mean 63.1 years vs. 48.7 years) and more likely to
have a history of smoking (22%). Notably, these characteristics are
also shared among a large proportion of patients with HNSCC. In a
multivariable model, cancer history was associated with the highest risk
for severe events (OR 5.4, p < 0.01). Older age, while
not significant, was the only risk factor associated with increased risk
for severe events in the cancer group (OR 1.43). Critics of this
analysis argue that exposure to an infectious source, rather than an
association with cancer, is the most important comorbid factor given
that 12 of the 18 patients had recovered from their initial cancer
treatments (e.g. surgery or chemotherapy) and were without obvious
immunosuppression.19 The response, by Wang and Zhang,
further notes that a higher median patient age of those with cancer
(63.1 vs. 48.7) in addition to increased comorbidities, remain
significant factors associated with worse COVID-19 outcomes. These
findings have been supported by prior COVID-19
analyses.20-22
Although data regarding the impact of prior viral outbreaks on patients
with HNSCC is lacking, the decision to proceed with anti-cancer therapy,
including surgery, in the current context of COVID-19 should be
carefully considered given the risk of severe respiratory complications,
immunosuppression, and death within this cohort. A recent review of 34
asymptomatic patients who underwent various elective surgeries during
the COVID-19 incubation period exemplifies these
risks.23 All 34 patients went on to develop COVID-19
pneumonia shortly after surgery (median time to COVID-19 onset, 3.5
days), with 15 (44%) requiring ICU admission. Ultimately, half of those
(7/15) patients died in the ICU. The risks of treatment delay and impact
on tumor progression should be carefully weighed given the potential for
devastating outcomes should surgery be pursued, even among asymptomatic
patients. Strategies to temporize tumor growth, such as induction
chemotherapy, may also predispose to severe COVID-19 complications
following immunosuppression. Further, treatment of HNSCC must be
balanced with the current local operational environment and resources to
achieve maximum patient and staff safety while minimizing morbidity.