key: cord-0714611-yvp3m47o
authors: Cheruiyot, Isaac; Kipkorir, Vincent; Ngure, Brian; Misiani, Musa; Munguti, Jeremiah
title: Cancer is associated with coronavirus disease (COVID-19) severity and mortality: A pooled analysis
date: 2020-08-20
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.08.025
sha: bae06199b661c29d7e42d84e18efb2e28ade059a
doc_id: 714611
cord_uid: yvp3m47o

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a rapidly escalating pandemic that has spread to many parts of the world. As such, there is urgent need to identify predictors of clinical severity in COVID-19 patients. This may be useful for early identification of patients who may require life-saving interventions. In this meta-analysis, we evaluated whether malignancies are associated with a significantly enhanced odds of COVID-19 severity and mortality. METHOD: A systematic search of literature was conducted between November 1, 2019, to May 26th, 2020 on PubMed and China National Knowledge Infrastructure (CNKI) to identify studies reporting data on cancers in patients with or without severe COVID-19 were included. The primary outcome of interest was the association between malignancies and COVID-19 severity, while the secondary outcome was the association between malignancies and COVID-19 mortality. Data were pooled into a meta-analysis to estimate pooled odds ratio (OR) with 95% confidence interval (95% CI) for either outcome. RESULTS: A total of 20 studies (n = 4549 patients) were included. Overall, malignancies were found to be associated with significantly increased odds of COVID-19 severity (OR = 2.17; 95% CI 1.47–3.196; p < 0.001) and mortality (OR = 2.39; 95% CI 1.18–4.85; p = 0.016). No heterogeneity was observed for both outcomes (Cochran's Q = 6.558, p = 0.922, I(2) = 0% and Cochran's Q = 2.91, p = 0.71, I(2) = 0% respectively). CONCLUSION: Malignancies were significantly associated with a 2-fold increase in the odds of developing severe COVID-19 disease, as well as mortality. Larger studies are needed to corroborate these findings. These patients should be closely monitored for any signs of unfavorable disease progression.

following criteria: (1) observational cohort or case-control studies reporting malignancy frequency data in COVID-19 patients (>18 years old), (2) used appropriate definition of severe disease or compared survivors to non-survivors, (3) disease severity was monitored throughout the study, (4) clearly outlined the definition of "severe disease" and (5) sample size >10. A clinically valid definition of "severe disease" (i.e. a composite of (1) respiratory distress, respiratory rate ≥30 per min; (2) oxygen saturation on room air at rest ≤93%; (3) partial pressure of oxygen in arterial blood/fraction of inspired oxygen ≤300 mmHg; (4) patients requiring mechanical ventilation/vital life support/intensive care unit admission (ICU); (5) death/ mortality) was required for a study to be included. Reviews and studies with incomplete or irrelevant data were excluded. Any disagreements between reviewers arising during the eligibility assessment were settled through consensus.

Data extraction and quality assessment were conducted by three independent reviewers (I.C, B.N and V.K). For each study, the following information was extracted: the surname of the first author and the year of publication, the geographical region where the study was performed, the type of study, sample size, baseline demographic characteristics, proportion of cancer patients with severe and non-severe COVID-19/ survivors and non-survivors. Any variances were resolved by consensus. Quality assessment and analysis of risk of bias of all selected full-text articles were performed using the methodological index for non-randomized studies (MINORS) tool. The primary outcome of interest was the association between malignancies and COVID-19 severity, while the secondary outcome was the association between malignancies and COVID-19 mortality.

The statistical analysis was carried out using MetaXL (software version 5.3, EpiGear

International Pty Ltd., Sunrise Beach, Australia) and Meta-Analyst (software version 5.26.14, Center for Evidence-Based Medicine, Brown University, Providence, USA). The strength of association between malignancies and COVID-19 severity and mortality was estimated using the odds ratio (OR). A random-effects model was applied. The magnitude of heterogeneity among the included studies was assessed using the chi-squared test (Chi 2 ) and I-squared statistic (I 2 ).

For the Chi 2 test, a Cochrane"s Q p-value of <0.10 was considered significant. The values of the I 2 statistic were interpreted as follows at a 95% confidence interval: Thresholds of 25%, 50%, and 75% to designate low, moderate, and high heterogeneity were applied 4 . Random-effects meta-regression using log OR was performed to evaluate the impact of baseline characteristics (age and sex) on the study outcomes. Publication bias was assessed using funnel plots.

Additionally, a leave-one-out sensitivity analysis was performed to assess the robustness of the results and to further probe the sources of inter-study heterogeneity. Tables: Table 1 

Coronavirus disease 2019 (COVID-19) Situation Report -192 2020. Accessed 31 st

Risk factors of critical & mortal COVID-19 cases: A systematic literature review and metaanalysis

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Cochrane handbook for systematic reviews of interventions 4.2. 6

Clinical Characteristics of Coronavirus Disease 2019 in China

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Clinical features and shortterm outcomes of 221 patients with COVID-19 in Wuhan

Clinical features, laboratory characteristics, and outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19): Early report from the United States

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan

Clinical Features and Outcomes of 98 Patients Hospitalized with SARS-CoV-2 Infection in Daegu, South Korea: A Brief Descriptive Study

Risk factors for severity and mortality in adult COVID-19 inpatients in Wuhan

Clinical features of 69 cases with coronavirus disease 2019 in Wuhan, China. Clinical Infectious Diseases

COVID-19 with different severity: a multi-center study of clinical features. American journal of respiratory and critical care medicine

Clinical characteristics of coronavirus disease (COVID-19) early findings from a teaching hospital in Pavia

Clinical value of immuneinflammatory parameters to assess the severity of coronavirus disease 2019

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Clinical characteristics of 113 deceased patients with coronavirus disease 2019: Retrospective study