Patients with cancer who were diagnosed with COVID-19 demonstrated high rates of hospitalization and/or respiratory illness, with immune checkpoint inhibitor (ICI) use or older age particularly associated with an increased risk, according to data from a single-center observational study published in Nature Medicine.

“Reports from outside the United States raise the possibility that patients with cancer on active therapy have a higher risk of COVID-19–related severe events,” the authors wrote.

This study characterized the outcomes of 423 patients with cancer from the Memorial Sloan Kettering Cancer Center diagnosed with COVID-19 between March 2020 and May 2020. The median age of the cohort was 60 and the most common cancer types were breast cancer (20%), lymphoma (11%), colorectal cancer (9%), and lung cancer (8%).

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There was 1 or more known high-risk comorbid conditions present in 59% of the patients, including diabetes, hypertension, chronic kidney disease, and cardiac disease. Within the cohort, 45% of patients had received systemic chemotherapy within 30 days (191 individuals) and 7% received an ICI (31 individuals).

The COVID-19–associated hospitalization rate was 40%. Severe respiratory illness developed in 20% of patients, with 11% requiring high-flow oxygen and 9% who required mechanical ventilation. The case fatality rate was 12%.

There were 7 pediatric patients, all of whom developed mild symptoms without complications.

In a multivariate analysis, hospitalization was significantly and independently associated with non-white race (odds ratio [OR], 1.62; 95% CI, 1.05-2.51; P =.029), hematologic malignancy (OR, 2.49; 95% CI, 1.35-4.67; P =.003), a composite of chronic lymphopenia and/or corticosteroid use (OR, 1.85; 95% CI, 1.05-3.24; P =.030), or use of immune checkpoint inhibitors (ICIs; OR, 2.84; 95% CI, 1.24-6.72; P =.013).

Severe respiratory illness, defined as need for high-flow oxygen or mechanical ventilation, was significantly associated with an age of older than 65 years (hazard ratio [HR], 1.67; 95% CI, 1.07-2.60; P =.024) and the use of ICIs (HR, 2.74; 95% CI, 1.37-5.46; P=.004).

The association with ICI use and hospitalization or severe respiratory illness was independent of lung cancer or other solid tumor types.

Previous studies had not found an association between ICI use and poorer outcomes with COVID-19. The authors postulated that this discrepancy may be because “these studies had few patients on immunotherapy and examined death as an endpoint.” This study focused on oxygen requirement, which occurs in a greater proportion of patients than death.

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There was no association between hospitalization or severe respiratory illness and presence of metastatic cancer, recent receipt of chemotherapy, or recent major surgery.

Several laboratory markers were predictors for severe respiratory illness, including levels of procalcitonin, lymphopenia, interleukin-6, D-dimer, and lactate dehydrogenase.

The authors concluded that “until further evidence is available, it is prudent not to alter treatment decisions but to consider increased vigilance with SARS-CoV-2 testing in patients initiating or continuing treatment with ICIs, irrespective of symptoms.”


Robilotti EV, Babady NE, Mead PA, et al. Determinants of COVID-19 disease severity in patients with cancer [published online June 24, 2020]. Nat Med. doi: 10.1038/s41591-020-0979-0