The impact of covid on cancer patients

Correspondence

www.thelancet.com/oncology Vol 21 April 2020 e180

Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine (YX, RJ, WL, HS) and Department of Medical Oncology (JZ), Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, China

1 Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020; published online Feb 14. http://dx.doi.org/10.1016/ S1470-2045(20)30096-6.

2 Xu Z, Shi L, Wang Y, Zhang J, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020; published online Feb 18. https://doi.org/10.1016/ S2213-2600(20)30076-X.

3 Schreiber RD, Old LJ, Smyth MJ. Cancer immunoediting: integrating immunity’s roles in cancer suppression and promotion. Science 2011; 331: 1565–70.

4 Cai G. Bulk and single-cell transcriptomics identify tobacco-use disparity in lung gene expression of ACE2, the receptor of 2019-nCov. medRxiv 2020; DOI:10.1101/2020.02.05.20020107 (preprint).

5 Guan W-J, Ni Z-Y, Hu Y, et al. Clinical characteristics of 2019 novel coronavirus infection in China. medRxiv 2020; DOI:10.1101/2020.02.06.20020974 (preprint).

Risk of COVID-19 for patients with cancer We read the excellent Comment by Wenhua Liang and colleagues1 in The Lancet Oncology with great interest. Of 1590 cases with confirmed coronavirus disease 2019 (COVID-19), 18 patients had a history of cancer. The authors concluded that patients with cancer had a higher risk of COVID-19 and with a poorer prognosis than those without cancer.

First, the data in the Comment by Liang and colleagues1 showed a higher percentage of patients with cancer in the COVID-19 cohort than in the overall population. However, this observation is not sufficient to conclude that patients with cancer had a higher risk of COVID-19. T h e i n c i d e n c e o f C OV I D - 1 9 i n patients with cancer would be more informative in assessing whether or not patients with cancer have an increased risk of COVID-19. Second, we reviewed the cancer history of the 18 individuals discussed in Liang and colleagues’ Comment.1 We are concerned that such a small sample size with a large amount of heterogeneity, presenting as various cancer types with different biological behaviours, highly variable disease courses (from 0–16 years), and diverse treatment strategies, might be filled with contingency and thus not ideally representative o f t h e w h o l e p o p u l a t i o n w i t h cancer. Notably, half of the patients with cancer had a disease course of more than 4 years, indicating that a substantial proportion of these patients might be clinically cured. Therefore, any conclusions t h a t g e n e r a l i s e t o a l l p a t i e n t s with cancer should be interpreted with caution. Third, 13 (72%) of 18 patients with cancer had a history of surgical resection; the prolonged effects induced by surgery including immunosuppression should not be neglected. Comparison of patients with COVID-19 and surgical history

with and without cancer would be of interest.

Additionally, the authors reported that patients with cancer were prone to severe events (admission to the intensive care unit requiring i n v a s i v e v e n t i l a t i o n , o r d e a t h ) from COVID-19. Evidence indicates that overwhelming inflammation a n d c y t o k i n e - a s s o c i a t e d l u n g i n j u r y c o u l d b e i m p o r t a n t i n instigating these severe events in patients with COVID-19.2 However, accumulated evidence has shown that development of cancer is usually associated with a blunted immune status 3 characterised by overexpressed immunosuppressive cytokines, suppressed induction o f p r o i n f l a m m a t o r y d a n g e r s i g n a l s , i m p a i r e d d e n d r i t i c c e l l maturation, and enhanced functional i m m u n o s u p p r e s s i v e l e u k o c y t e populations, which is contradictory to the events believed to result in severe events in patients with C OV I D - 1 9 . I n d e e d , o n e o f t h e potential explanations for differing susceptibility and prognosis is the higher rate of smoking history in the 18 patients with cancer. Data have shown that tobacco u s e s i g n i f i c a n t l y i n c r e a s e s t h e gene expression of angiotensin- converting enzyme 2, the binding receptor for severe acute respiratory syndrome coronavirus 2, which could explain the elevated susceptibility to COVID-19 in smokers.4 Furthermore, cigarette smoking is the leading cause of chronic obstructive pulmonary disease, which has been identified as an independent risk factor in severe COVID-19 cases.5

Overall, current evidence remains insufficient to explain a conclusive association between cancer and COVID-19. We declare no competing interests.

Yang Xia†, Rui Jin†, Jing Zhao†, Wen Li, *Huahao Shen [email protected]

†Joint first authors

Published Online March 3, 2020 https://doi.org/10.1016/ S1470-2045(20)30150-9