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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 11-18

Outcome of COVID-19 on Indian patients with cancer: A multicenter, retrospective study


1 Departments of Medical Oncology, Dr GVN Cancer Institute, Tiruchirappalli, Tamil Nadu, India
2 Meenakshi Mission Hospital and Research Center, Madurai, Tamil Nadu, India
3 Madras Cancer Care Foundation, Chennai, Tamil Nadu, India
4 Mangalore Institute of Oncology, Mangaluru, Karnataka, India
5 Department of Hematology, Apollo Hospital, Bengaluru, Karnataka, India
6 Columbia Asia Hospital, Bengaluru, Karnataka, India
7 Manipal Hospital, Vijayawada, Andhra Pradesh, India
8 Department of Surgical Oncology, Silverline Speciality Hospital, Tiruchirappalli, Tamil Nadu, India
9 Department of Psycho Oncology, Fenivi Research Solutions, Chennai, Tamil Nadu, India

Date of Submission31-Aug-2021
Date of Decision16-Feb-2022
Date of Acceptance17-Feb-2022
Date of Web Publication31-Mar-2022

Correspondence Address:
Arun Seshachalam
M.D., D.M., Head of Dept.of Medical Oncology, Dr GVN Cancer Institute, 46, Near Super Bazar, Singarathope, Tiruchirappalli, Tamil Nadu – 620 008; Associate. Prof. Dept. Of Medical Oncology, Dhanalakshimi Srinivasan Medical College, Keelakanavai - Siruvachur Rd, Perambalur, Tamil Nadu - 621 212
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_212_21

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  Abstract 


Background: Managing patients with cancer during the coronavirus disease 2019 (COVID-19) pandemic has been challenging. Disruptions in cancer management have been observed due to cancellation of treatment, issues related to commuting, and dearth of health-care workers.
Objectives: This study was conducted during the first wave of the COVID-19 pandemic and was aimed at evaluating the 30-day all-cause mortality among patients with cancer and COVID-19 infection and the factors affecting it.
Materials and Methods: In this retrospective study, we collected secondary data from nine tertiary care centers in South India over a period of 10 months from March to Dec 2020. Patients across all age groups with histopathologically confirmed diagnosis of cancer who were affected by COVID-19 during their evaluation or treatment were included in the study. The primary outcome variables of the present study were 30-day all-cause mortality, cancer outcomes, and COVID-19 outcomes.
Results: A total of 206 patients were included. Median age of the cohort was 55.5 years, and the male-to-female ratio was 1:1.03. The 30-day mortality rate was 12.6%. Twenty-two patients (10.7%) had severe COVID-19 infection at the initial presentation. Predictors for severe pneumonia at the initial presentation were incomplete remission at the time of COVID-19 diagnosis and palliative intent of treatment. Severe pneumonia at the initial presentation, diagnosis of COVID-19 on or before August 2020, and need for ventilator support were associated with increased mortality.
Conclusion: Severity of infection at the initial presentation, cancer status, and the intent of cancer treatment impact COVID-19 outcomes in patients with cancer.

Keywords: COVID-19, mortality, oncology


How to cite this article:
Seshachalam A, Saju S V, Raju HS, Rathnam K, Janarthinakani M, Prasad K, Patil C, Anoop P, Reddy N, Anumula SK, Golamari KR, Bodepudi SK, Danthala M, Malipatil B, Senthilkumar G, Niraimathi K, Raman S G. Outcome of COVID-19 on Indian patients with cancer: A multicenter, retrospective study. Cancer Res Stat Treat 2022;5:11-8

How to cite this URL:
Seshachalam A, Saju S V, Raju HS, Rathnam K, Janarthinakani M, Prasad K, Patil C, Anoop P, Reddy N, Anumula SK, Golamari KR, Bodepudi SK, Danthala M, Malipatil B, Senthilkumar G, Niraimathi K, Raman S G. Outcome of COVID-19 on Indian patients with cancer: A multicenter, retrospective study. Cancer Res Stat Treat [serial online] 2022 [cited 2022 May 28];5:11-8. Available from: https://www.crstonline.com/text.asp?2022/5/1/11/341235




  Introduction Top


The coronavirus disease 2019 (COVID-19) pandemic caused significant disruption in the treatment of non-communicable diseases (NCDs) such as cardiovascular conditions, cancer, and diabetes.[1],[2] Specific to cancer, treatment disruption was reported in 42% of patients due to cancellation of treatment, issues related to commuting, and dearth of health-care workers.[3],[4],[5],[6] India, a low-income country, was also severely impacted by the pandemic as its health-care sector had to remodel itself based on screening principles and social distancing rules, thereby posing challenges and difficulties in cancer management.[7],[8] Sudden changes in health-care infrastructure and shortage of resources hindered the routine care of patients with cancer.[9],[10] Constraints created by the pandemic also led to the adoption of the prioritization approach for treatment decision-making, with curable cancers being given high priority while the palliative care services were deferred.[7]



Available data show variable presentation and outcomes of COVID-19–affected patients with cancer globally, with a paucity of data from the Indian subcontinent. Until December 31, 2020, India reported 1,02,66,674 cases and 1,48,738 deaths (21,821 new cases and 299 deaths on that day) due to COVID-19. India has approximately 19,00,000 hospital beds. 95,000 intensive care unit (ICU) beds, and 48,000 ventilators. Most of the beds and ventilators in India are concentrated in 7 states, namely, Uttar Pradesh (14.8%), Karnataka (13.8%), Maharashtra (12.2%), Tamil Nadu (8.1%), West Bengal (5.9%), Telangana (5.2%), and Kerala (5.2%). Among various states affected by COVID-19, Maharashtra, Delhi, Gujarat, Madhya Pradesh, Andhra Pradesh, Uttar Pradesh, and West Bengal are reported to be severely affected; Tamil Nadu, Rajasthan, Punjab, and Bihar are moderately affected; whereas in Kerala, Haryana, Jammu and Kashmir, Karnataka, and Telangana, the disease is under control.[11–13] The baseline socioeconomic profile, health-care facilities, and demographics are not uniform across different parts of India. Most of the available data on the effects of COVID-19 among patients with cancer are from the northern parts of India.[5],[6],[7],[14],[15]

Patients with cancer receiving treatment are immunocompromised and prone to adverse outcomes due to COVID-19.[16] Few studies from India have shown increased susceptibility of patients with cancer to COVID-19, with a case fatality rate (CFR) ranging between 10% and 15.6%.[7],[14],[15] The final decision on cancer care of individuals had to be made by balancing the risk of contracting COVID-19 against poor cancer outcomes due to delayed treatment.[7] Increased COVID-19–related mortality in patients with cancer is significantly associated with age, presence of more than one comorbidity, diabetes, and the severity of infection.[15] The rise in COVID-19 incidence among patients with cancer led to cancer centers being saturated and overwhelmed, which resulted in non-availability of hospital beds for cancer care.[17] Several studies had reported a very high 30-day all-cause mortality ranging from 10% to 28% among patients with cancer affected by COVID-19.[18] If this issue is not tackled, cancer-related morbidity, delays in treatment, and cancer mortality will continue to increase.[19]

Considering the scarcity of Indian data on the outcome of COVID-19 in patients with cancer, we conducted a multicenter study to evaluate the 30-day all-cause mortality and the factors affecting it among patients with cancer affected by COVID-19.


  Materials and Methods Top


General Study Details

In this study, we employed a retrospective cohort design, involving the collection and analysis of secondary data from nine select tertiary care centers in three states of South India: Tamil Nadu, Andhra Pradesh, and Karnataka. These nine tertiary care centers are located in Chennai, Bangalore, Madurai, Mangalore, Trichy, and Vijayawada [Supplementary Appendix 1]. The present study was conducted over a period of 10 months from March to December 2020, during the first wave of the COVID-19 pandemic.

Approval to conduct this study was obtained from the Institutional Ethics Committee of Dr. GVN Cancer Institute, Tiruchirappalli, India on November 6, 2020 [Supplementary Appendix 2]. The need for obtaining written informed consent was waived off because of the retrospective study design. The study was conducted according to the ethical guidelines established by the Declaration of Helsinki and other guidelines like Good Clinical Practice guidelines and those established by the Indian Council of Medical Research. No funding was obtained for this study. This study was not registered in any clinical trials registry.

Participants

Patients across all age groups with histopathologically confirmed diagnosis of cancer who tested positive for COVID-19 during their evaluation or treatment were included in the study. For a patient to be considered as COVID-19 positive, they had to have a positive result from the reverse transcription-polymerase chain reaction (RT-PCR) or computer tomography (CT) scan findings suggestive of COVID-19 pneumonia.

Variables

The primary outcome variables of the present study were 30-day all-cause mortality, cancer outcomes, and COVID-19 outcomes including the need for ventilator support and recovery.

Study Methodology

Treating physicians were responsible for retrospective data collection from the patients' files and filling the information in Google Forms. Local privacy and data de-identification were ensured by not entering patient details that could reveal their identity. Confidentiality was maintained at each hospital by ensuring that only the treating physicians had access to the information.

The following variables were recorded in Google Forms:

  • Age of patients grouped as <18 years, 18–60 years, and >60 years
  • Number and type of comorbidities experienced by the patients, such as diabetes, hypertension, or ischemic heart disease
  • Intent of treatment: curative versus palliative
  • Type of cancer: solid tumors or hematolymphoid malignancies based on the histopathology report
  • Cancer status of malignancy at the time of COVID-19 diagnosis was grouped as under evaluation, complete response or stable disease (SD), partial response (PR), and progressive disease (PD)
  • The peak of COVID-19 cases during the first wave of the COVID-19 pandemic was noted in the month of August 2020 and a decreasing trend was observed from September 2020. The period of COVID-19 diagnosis was grouped as diagnosed before August 2020 and diagnosed after August 2020
  • COVID-19 symptoms including fever, myalgia, headache, fatigue, diarrhea, cough, breathlessness, and anosmia
  • CT reporting and severity of COVID-19 were graded as per the World Health Organization recommendations as mild, moderate, and severe[7]
  • Organ systems involved due to the infection were grouped as lungs/heart/kidneys/central nervous system and others
  • Treatment-related details such as place of quarantine and observation and the type of therapy used (steroids alone, remdesivir, favipiravir, tocilizumab, plasma exchange, respiratory support in the form of mechanical ventilation or non-invasive ventilation or oxygen supplementation)


Clinical and demographic details such as comorbidities, cancer type, histology, stage, treatment, clinical presentation of COVID-19, treatment received for COVID-19, course and severity of COVID-19, outcome of COVID-19 and cancer, and swab status at recovery were included in the proforma.

Patients paid for the treatment either out of their own pockets, through health insurance schemes, or were covered under the state funds in these tertiary care centers.

Statistical Analysis

Being a retrospective study, the sample size was not estimated; all patients who tested positive for COVID-19 and were registered during the study period were included. After filling the information in Google Forms, the data were exported to Microsoft Excel and subsequently analyzed using the Statistical Package for the Social Sciences (SPSS; IBM SPSS Statistics, Chicago, IL, USA; August 2009, version 19). Descriptive statistics like median, interquartile range, and percentage were computed. Multivariable binary logistic regression analyses were used to assess the association between different variables and the severity of the disease. The odds ratio (OR) along with the 95% confidence interval (CI) were reported. Univariate and multivariate analyses to identify factors associated with death due to COVID-19 in patients with cancer were performed by Cox proportional hazards regression model. The factors included age, sex, treatment center, comorbidities, cancer group, cancer status, treatment category, severity, need for ventilator support, period of COVID-19, and organ involvement.


  Results Top


Patient demographics:

A total of 206 patients with cancer who were diagnosed with COVID-19 during various phases of their cancer treatment were included in the study [Figure 1]. Of these, 184 (89.3%) patients were diagnosed with COVID-19 by RT-PCR and 22 (10.7%) by CT chest. Among patients diagnosed with COVID-19 by chest CT, RT-PCR was negative in 19 (86.4%) and not done in 3 (13.6%) patients.
Figure 1: Flowchart for patient selection for the study evaluating the outcome of COVID-19 infection in patients with cancer

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A total of 122 (59.2%) patients had received chemotherapy less than 4 weeks before the diagnosis of COVID-19 [Table 1].
Table 1: Profile of patients with cancer diagnosed with COVID-19 treated at nine tertiary care centers across South India

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Similar numbers of COVID-19 cases were diagnosed before and after August 2020. Approximately 87 (42%) patients were asymptomatic at presentation, 54 (26%) had breathlessness, 25 (12%) had cough, and 27 (13%) had fever. Other reported symptoms were headache, myalgia, diarrhea, and anosmia. After the respiratory system, heart was the most commonly affected organ. Around half of the patients had mild infection, and only 23 (11%) had severe infection requiring treatment; approximately 52 (25%) patients required either remdesivir or favipiravir, 8 (4%) required tocilizumab, 5 (2.2%) required plasma treatment, and 126 (61%) did not require any form of respiratory support.

Severity of infection at presentation:

Of the 22 (10.7%) patients with severe infection, 15 (68.2%) died. Predictors for severe COVID-19 infection at the initial presentation were incomplete remission at COVID-19 diagnosis (OR, 0.127; 95% CI, 0.015–1.067) and palliative intent of cancer treatment (OR, 2.461; 95% CI, 0.299–20.243) [Table 2]. Death rate was significantly higher (15 [57.7%] out of 26 patients) among severe cases in comparison to mild and moderate cases (unadjusted hazard ratio, 0.298; 95% CI, 0.139–0.0635, P < 0.05); likewise, the death rate was also higher among cases diagnosed until August 2020 compared to those diagnosed after August 2020 (unadjusted hazard ratio, 1.743; 95% CI, 1.278–2.378; P < 0.05).
Table 2: Profile of patients with cancer diagnosed with COVID-19 treated at nine tertiary care centers across South India

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Predictors of death due to COVID-19 and 30-day mortality:

In the unadjusted model, sex, comorbidities, intent of treatment, severity of COVID-19 at the initial presentation, need for ventilator support, multiorgan involvement, and time of diagnosis (until August 2020 or after August 2020) were found to be significant predictors of death due to COVID-19. In the adjusted model, only the time of diagnosis was a significant predictor [Table 3]. Death was attributable to COVID-19 in 21 (10.2%) patients and to cancer progression in 4 (2%) patients. Among 87 asymptomatic patients, only 2 (7.7%) died.
Table 3: Predictors of 30-day mortality in patients with cancer diagnosed with COVID-19

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Outcome

Rate of 30-day all-cause mortality in our cohort was 12.6% (n = 26). A total of 15 (68.1%) patients among 22 with severe pneumonia at the initial presentation and 11 (5.9%) patients among 184 with mild to moderate pneumonia died. Delay in reinitiation of cancer treatment for more than 4 weeks was observed in 39 (n = 19%) patients, and 13 (6.3%) patients had cancer progression while on treatment for COVID-19.


  Discussion Top


Ours is the first multicenter study from South India to document the outcome and various factors predicting the outcome of COVID-19–infected patients with cancer. The 30-day all-cause mortality rate in our cohort of patients with cancer and COVID-19 was 12.6%. Patients who were asymptomatic at presentation and pediatric patients fared well, while those with severe infection at the initial presentation and those receiving palliative treatment had worse outcomes. Additionally, incomplete remission status for the underlying malignancy at the time of COVID-19 diagnosis and palliative intent of treatment were found to be predictors for severe pneumonia at the initial presentation. Severe pneumonia at the initial presentation, diagnosis of COVID-19 on or before August 2020, and need for ventilator support were associated with increased higher. The median age of our cohort was 55 years, and nearly 5% comprised pediatric patients; 1 among them died due to COVID-19. A study conducted in the Tata Memorial Hospital, Mumbai, India reported a higher proportion (14%) of pediatric patients with no mortality.[20],[21] Similarly, excellent outcomes among pediatric patients were reported by the Memorial Sloan Kettering cancer center group.[22]

In our study, the 30-day all-cause mortality rate was 12.6%. A similar study from India reported a CFR of 15.6%,[14] while the study from Tata Memorial Hospital reported a mortality rate of 10%.[23] This is less than the mortality rate reported from western countries. One study from the United Kingdom and another from New York city reported a CFR of 28% among COVID-19–affected patients with cancer.[18],[24] The reasons for the lower mortality in our study may be the lower median age (55 years) of the cohort, small sample size, and the fact that the majority of patients in our cohort had mild to moderate disease and were probably infected by a less virulent strain. Initial data from China showed a very high mortality rate of 25% among COVID-19–affected patients with cancer.[25] Most of the published data have confirmed increased mortality among patients with cancer in comparison to the general population.[14],[18],[20],[26],[27]

In our study, the median age was 55 years; in the study from the Tata Memorial Hospital, it was 42 years.[23] The median age reported in studies from western countries is relatively higher.[18],[24],[28] This may be attributed to variations in the distribution of populations between developing and developed nations. The most common cancer type in our cohort was breast cancer (20%), followed by lung cancer (11%). Kuderer et al. reported breast and prostate cancers as the most common cancer types in the Clinical impact of COVID-19 on patients with cancer (CCC19) study,[14] while the study from the Tata Memorial Hospital reported acute leukemia and gastrointestinal cancers as the predominant cancer types.[27]

Additionally, 54% of the patients had mild, 35% had moderate, and 11% had severe COVID-19. In the study from the Tata Memorial Hospital, 85% of the cases had mild, 5% had moderate, and 10% had severe COVID-19.[13] In contrast, the The UK Coronavirus Cancer Monitoring Project (UKCCMP) study showed a higher incidence (22%) of severe infection.[14] This might be one of the reasons for the low mortality rate reported in Indian studies in comparison to western studies. This also explains the regional differences in the severity of COVID-19 infection within India and also globally.

Age and sex were not found to be predictors of severe infection. Despite these findings, it has been reported that male patients with cancer diagnosed with COVID-19 may be at a greater risk of severe symptoms and fatality, compared to female patients.[27],[28] Although comorbidities did impact on mortality in our study, other studies have shown that comorbidities significantly influence the outcome of COVID-19 among patients with cancer.[14],[24],[27] The failure to find an association between comorbidities and COVID-19 outcomes in our study could be due to the small sample size of our study. Patients who required mechanical ventilator support had an increased chance of death due to the severity of their condition, with a severe COVID-19 infection at diagnosis being a strong predictor of mortality. Patients diagnosed with COVID-19 after August 2020 had better outcomes than those diagnosed before August 2020. This could be because of the improved understanding of the disease (lesser use of invasive ventilation and increased use of high-flow oxygen), more testing facilities, and treatment centers becoming available after August 2020.

A study performed to understand how patients with cancer perceived cancer care during the COVID-19 pandemic illustrated that they experienced modifications in their treatment, primarily in the form of delays in chemotherapy. Additionally, individuals with metastatic disease reported that COVID-19 had negatively impacted their cancer care, as opposed to those who had non-metastatic cancers.[27] This highlights the need to focus on finding methods whereby the care of patients with cancer can remain undisrupted even during medical emergencies and pandemics.

Ours is the first multicenter study from South India to document the outcome and various factors predicting the outcome of COVID-19–affected patients with cancer. Considering the prevailing situation, our study provides vital information regarding the management of COVID-19 in patients with cancer. Nevertheless, the study had some limitations, including its retrospective nature and small sample size. Additionally, we did not provide details of the biochemical and radiological findings, which would have helped us categorize the disease better. Short-term and long-term impact of COVID-19 on the cure rate of cancer was also not captured.

To enhance the knowledge, awareness, and empirical evidence for health-care professionals in this field, it is crucial that more research is conducted on patients with cancer affected with COVID-19 to equip the health-care system with the necessary information for future pandemics. This can also help to determine the optimal approach for the management of these patients without compromising on cancer treatment.


  Conclusion Top


The mortality of patients with cancer diagnosed with COVID-19 is principally driven by the severity of infection at the initial presentation, which in turn is associated with the cancer status and intent of cancer treatment. Therefore, increased testing to identify minimally symptomatic or asymptomatic infection should be a priority.

Data sharing statement

As the study is a record review study, the data collected from the participating centers will be shared on request. The study protocol and the data documentation sheet are provided as supplementary appendices with this manuscript. The data will be made available starting 9 months after the date of publication of the article and up to 24 months on request. Extensions will be considered on a case-by-case basis. Access to the data can be requested by qualified researchers engaging in independent scientific research and will be provided following review and approval of a research proposal and Statistical Analysis Plan and execution of a Data Sharing Agreement. Requests for data should be directed to Dr. Arun Seshachalam ([email protected])

Acknowledgement

We acknowledge the COVID-19 Action Teams of all affiliated institutions who have contributed to this venture.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.




  Supplementary Appendix 2: Study Protocol Top



  Outcome of COVID-19 in patients with cancer: A multicenter, retrospective study – study protocol Top


Introduction

Managing cancer patients during the coronavirus disease 2019 (COVID-19) pandemic is challenging and requires a thorough understanding of the interaction of cancer, cancer treatment, as well as COVID-19 infection. This mandated oncologists to strike a fine balance between the increased mortality associated with COVID-19 infection following cancer treatment with the decreased cure rates associated with delays in cancer management. The effects of the changes in cancer management during the COVID-19 pandemic on the long-term cure rates of cancer patients remain unknown. This study was performed to provide real-world evidence on the impact of COVID-19 infection in the management and treatment outcomes of cancer patients.

Materials and Methods

  1. Study design and participants: Retrospective data is collected from various tertiary care centers in South India. Cancer patients diagnosed with COVID-19 during evaluation or treatment are included in the study.
  2. Sample characteristics: Cancer patients diagnosed with COVID-19 during their evaluation or treatment phase are to be included in the study. Patient data are eligible only if they were from histopathologically confirmed cancer patients. For a patient to be considered as COVID-19 positive, they need to have a positive result from the reverse transcription-polymerase chain reaction (RT-PCR) or computer tomography (CT) scan findings suggestive of COVID-19 pneumonia.
  3. Data collection and entry: Data collection is done by treating physicians using Google Forms. Patient demographics, comorbidities, details of cancer type, histology, stage, treatment details, clinical presentation of COVID-19 infection, treatment received for the same, course and severity of COVID-19, outcome of the infection as well as the cancer, and swab status at recovery are included in the proforma.
  4. Data collection: Treating physicians were responsible for retrospective data collection from the patients' files and then respectively inserting the information into Google Forms. The following variables were required when inputting into Google Forms:


    • Comorbidities the patients were experiencing, such as diabetes, hypertension, or ischemic heart disease, or even more than one comorbidity
    • The intent of treatment: curative versus palliative
    • Cancer group to which the cancer belonged: either solid organs or hematolymphoid systems, based on the histopathology report
    • Cancer status at the time of COVID-19 diagnosis: whether under evaluation, in complete response, and others (stable disease [SD]/partial response [PR]/progressive disease [PD])
    • Treatment category: whether under evaluation, on chemotherapy, and others (radiotherapy/surgery/immunotherapy/targeted therapy)
    • Period of COVID-19 diagnosis: those diagnosed before August 2020 and those diagnosed after August 2020
    • COVID-19 symptomology including fever, myalgia, headache, fatigue, diarrhea, cough, breathlessness, and anosmia
    • Evaluation of CT report to determine the severity graded as per the World Health Organization (WHO) recommendations into mild, moderate, severe, and very severe disease groups
    • Organ systems involved due to the infection: lungs/heart/kidneys/central nervous system (CNS) and others


    • Treatment details for COVID-19: home isolation and observation, steroids alone, remdesivir, favipiravir, tocilizumab, plasma exchange, or respiratory support in the form of mechanical ventilation or Non invasive ventilation (NIV) or oxygen supplementation
    • Patient demographics, comorbidities, details of cancer type, histology, stage, treatment details, clinical presentation of COVID-19 infection, treatment received for the same, course and severity of COVID-19, the outcome of the infection as well as the cancer, and swab status at recovery


Endpoints

Major endpoints to be analyzed are 30-day mortality, cancer outcome, and COVID-19 outcome. Other endpoints are COVID death predictors like age, sex, center, comorbidities, cancer group, curative versus palliative intent, prior treatment response, mode of recent therapy, COVID risk at presentation, and COVID peak.

Planned Data Analysis Method

After inputting the information on Google Forms, the data will be exported to Microsoft Excel and Statistical Package for the Social Sciences (SPSS) version 20. Descriptive statistics, median and interquartile range, and proportion and percentage are to be analyzed. Multivariable binary logistic regression analyses are used to assess the association of selected factors on the dependent variable of the severity of the disease. The odds ratio (OR) along with the 95% confidence interval (CI) is calculated for select factors will be reported. Univariable and multivariable analyses to identify factors associated with death from COVID-19 in cancer patients will be performed by Cox proportional hazards regression model.

Study Sites

Nine tertiary care centers located in Chennai, Bangalore, Madurai, Mangalore, Trichy, and Vijayawada across three states in South India (Tamil Nadu, Andhra Pradesh, and Karnataka) are selected for the study. Patients either pay on their financial terms, health insurance schemes, or are covered under the state funds in these tertiary care centers.

Details of 12 private tertiary care centers across South India



Dr. GVN Cancer Institute = Dr. G. Viswanathan Cancer Institute; MMHRC = Meenakshi Mission Hospital and Research Center

Definitions

Mild COVID – with or without any COVID-19–related symptom, without pneumonia or hypoxia, and respiratory rate <24/min

Moderate COVID – pneumonia (clinical or radiological), or hypoxia and respiratory rate ≤30/min, SpO2 ≥90% on room air and no respiratory distress

Severe COVID – pneumonia and ≥1 of respiratory rate >30/min, severe respiratory distress, or SpO2 <90% on room air



 
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