Assessment of Gender-Specific COVID-19 Case Fatality Risk per Malignant Neoplasm Type.

Importance: While the characteristics of COVID-19 infection and mortality among patients with a malignant neoplasm have previously been examined, little data are available for gender-specific COVID-19 mortality. Objective: To examine the gender-specific COVID-19 case fatality risks among patients with a malignant neoplasm. Design, Setting, and Participants: In this cohort study using the Healthcare Cost and Utilization Project's National Inpatient Sample, patients admitted to the hospital from April to December 2020 with a diagnosis of COVID-19 infection were identified by the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code U07.1. Data analysis was performed from November 2022 to January 2023. Exposure: Diagnosis of malignant neoplasm, identified and classified according to the National Cancer Institute's definition. Main Outcome and Measure: COVID-19 in-hospital case fatality rate, defined as the number of deaths that occurred during index hospital admissions. Results: There were 1 622 755 patients who were admitted to the hospital from April 1 to December 31, 2020, with a diagnosis of COVID-19. The cohort-level COVID-19 in-hospital case fatality rate was 12.9% with a median time to death of 5 days (IQR, 2-11 days). Frequently reported morbidities among the patients with COVID-19 included pneumonia (74.3%), respiratory failure (52.9%), cardiac arrythmia or cardiac arrest (29.3%), acute kidney injury (28.0%), sepsis (24.6%), shock (8.6%), cerebrovascular accident (5.2%), and venous thromboembolism or pulmonary embolism (5.0%). In a multivariable analysis, gender (male vs female, 14.5% vs 11.2%; adjusted odds ratio [aOR], 1.28; 95% CI, 1.27-1.30) and malignant neoplasm (17.9% vs 12.7%; aOR, 1.29; 95% CI, 1.27-1.32) were both associated with increased COVID-19 in-hospital case fatality risk at the cohort level. Among the group of female patients, there were 5 malignant neoplasms in which the COVID-19 in-hospital case fatality risk was greater than 2-fold higher. These included anal cancer (23.8%; aOR, 2.94; 95% CI, 1.84-4.69), Hodgkin lymphoma (19.5%; aOR, 2.79; 95% CI, 1.90-4.08), non-Hodgkin lymphoma (22.4%; aOR, 2.23; 95% CI, 2.02-2.47), lung cancer (24.3%; aOR, 2.21; 95% CI, 2.03-2.39), and ovarian cancer (19.4%; aOR, 2.15; 95% CI, 1.79-2.59). Among the group of male patients, Kaposi sarcoma (33.3%; aOR, 2.08; 95% CI, 1.18-3.66) and malignant neoplasm in the small intestine (28.6%; aOR, 2.04; 95% CI, 1.18-3.53) had a greater than 2-fold increased COVID-19 in-hospital case mortality risk. Conclusions and Relevance: The results of this cohort study confirmed the substantial case fatality rate among patients with COVID-19 in the early pandemic experience in 2020 in the US. While COVID-19 in-hospital case fatality risks were lower among women compared with men, the associations of a concurrent malignant neoplasm with the COVID-19 case fatality were overall more substantial for women than for men.

Association between neighborhood socioeconomic status, built environment and SARS-CoV-2 infection among cancer patients treated at a Tertiary Cancer Center in New York City.

BACKGROUND: Racial and ethnic minority groups experience a disproportionate burden of SARS-CoV-2 illness and studies suggest that cancer patients are at a particular risk for severe SARS-CoV-2 infection. AIMS: The objective of this study was examine the association between neighborhood characteristics and SARS-CoV-2 infection among patients with cancer. METHODS AND RESULTS: We performed a cross-sectional study of New York City residents receiving treatment for cancer at a tertiary cancer center. Patients were linked by their address to data from the US Census Bureau's American Community Survey and to real estate tax data from New York's Department of City Planning. Models were used to both to estimate odds ratios (ORs) per unit increase and to predict probabilities (and 95% CI) of SARS-CoV2 infection. We identified 2350 New York City residents with cancer receiving treatment. Overall, 214 (9.1%) were infected with SARS-CoV-2. In adjusted models, the percentage of Hispanic/Latino population (aOR = 1.01; 95% CI, 1.005-1.02), unemployment rate (aOR = 1.10; 95% CI, 1.05-1.16), poverty rates (aOR = 1.02; 95% CI, 1.0002-1.03), rate of >1 person per room (aOR = 1.04; 95% CI, 1.01-1.07), average household size (aOR = 1.79; 95% CI, 1.23-2.59) and population density (aOR = 1.86; 95% CI, 1.27-2.72) were associated with SARS-CoV-2 infection. CONCLUSION: Among cancer patients in New York City receiving anti-cancer therapy, SARS-CoV-2 infection was associated with neighborhood- and building-level markers of larger household membership, household crowding, and low socioeconomic status. NOVELTY AND IMPACT: We performed a cross-sectional analysis of residents of New York City receiving treatment for cancer in which we linked subjects to census and real estate date. This linkage is a novel way to examine the neighborhood characteristics that influence SARS-COV-2 infection. We found that among patients receiving anti-cancer therapy, SARS-CoV-2 infection was associated with building and neighborhood-level markers of household crowding, larger household membership, and low socioeconomic status. With ongoing surges of SARS-CoV-2 infections, these data may help in the development of interventions to decrease the morbidity and mortality associated with SARS-CoV-2 among cancer patients.

Trends in Hysterectomy Rates Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: To compare nationwide trends in the rate of inpatient and outpatient hysterectomy between 2019 and 2020 during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Using weighted data from the National Inpatient Sample and the National Ambulatory Surgery Sample, we examined the number of hysterectomies performed by month from 2019 through 2020. Monthly trends were compared between years overall, stratified by the route of surgery (abdominal, laparoscopic, and vaginal) and by indication for surgery (benign, preinvasive, cancer). Trends analyses were conducted using Joinpoint regression and reported as average monthly percentage change (AMPC). Differences in demographic characteristics between the years were compared using χ 2 tests. RESULTS: From January 2019 through December 2020, after weighting, 1,029,792 hysterectomies were performed, including 548,802 (53.2%) in 2019 and 480,990 (46.7%) in 2020. Starting in January 2020, monthly cases declined significantly, from 40,240 to a nadir of 10,566 hysterectomies in April 2020 (AMPC -29.2%, 95% CI -39.8% to -16.8%) ( P <.001). The subsequent months saw a significant increase in cases, from the nadir in April 2020 to 40,023 cases in July 2020 (AMPC 39.4%, 95% CI 18.6-63.9%) ( P =.001), which then stabilized to the end of the year (AMPC -1.3%, 95% CI -4.8% to 2.4%) ( P =.46). In March 2020 there was a 24.0% decrease, in April 2020 a 74.2% decrease, and in May 2020 a 35.1% decrease compared with the respective months in 2019. The rates of vaginal hysterectomy declined more than the rates of other routes of surgery, and procedures performed for benign and preinvasive disease decreased more than those for cancer. CONCLUSION: The rate of hysterectomy in the United States decreased in 2020 compared with 2019, with the greatest decrease from March to May of 2020, corresponding with the initial wave of COVID-19.

Lessons from the Failure to Complete a Trial of Denosumab in Women With a Pathogenic BRCA1/2 Variant Scheduling Risk-Reducing Salpingo-Oophorectomy.

Female carriers of pathogenic/likely pathogenic (P/LP) BRCA1/2 variants are at increased risk of developing breast and ovarian cancer. Currently, the only effective strategy for ovarian cancer risk reduction is risk-reducing bilateral salpingo-oophorectomy (RR-BSO), which carries adverse effects related to early menopause. There is ongoing investigation of inhibition of the RANK ligand (RANKL) with denosumab as a means of chemoprevention for breast cancer in carriers of BRCA1 P/LP variants. Through the NCI Division of Cancer Prevention (DCP) Early Phase Clinical Trials Prevention Consortia, a presurgical pilot study of denosumab was developed in premenopausal carriers of P/LP BRCA1/2 variants scheduled for RR-BSO with the goal of collecting valuable data on the biologic effects of denosumab on gynecologic tissue. The study was terminated early due to the inability to accrue participants. Challenges which impacted the conduct of this study included a study design with highly selective eligibility criteria and requirements and the COVID-19 pandemic. It is critical to reflect on these issues to enhance the successful completion of future prevention studies in individuals with hereditary cancer syndromes.

COVID-19 outcomes of patients with gynecologic cancer in New York City: An updated analysis from the initial surge of the pandemic.

BACKGROUND: Despite significant increase in COVID-19 publications, characterization of COVID-19 infection in patients with gynecologic cancer remains limited. Here we present an update of COVID-19 outcomes among people with gynecologic cancer in New York City (NYC) during the initial surge of severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]). METHODS: Data were abstracted from gynecologic oncology patients with COVID-19 infection among 8 NYC area hospital systems between March and June 2020. Multivariable logistic regression was utilized to estimate associations between factors and COVID-19 related hospitalization and mortality. RESULTS: Of 193 patients with gynecologic cancer and COVID-19, the median age at diagnosis was 65.0 years (interquartile range (IQR), 53.0-73.0 years). One hundred six of the 193 patients (54.9%) required hospitalization; among the hospitalized patients, 13 (12.3%) required invasive mechanical ventilation, 39 (36.8%) required ICU admission. Half of the cohort (49.2%) had not received anti-cancer treatment prior to COVID-19 diagnosis. No patients requiring mechanical ventilation survived. Thirty-four of 193 (17.6%) patients died of COVID-19 complications. In multivariable analysis, hospitalization was associated with an age ≥ 65 years (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.11, 4.07), Black race (OR 2.53, CI 1.24, 5.32), performance status ≥2 (OR 3.67, CI 1.25, 13.55) and ≥ 3 comorbidities (OR 2.00, CI 1.05, 3.84). Only former or current history of smoking (OR 2.75, CI 1.21, 6.22) was associated with death due to COVID-19 in multivariable analysis. Administration of cytotoxic chemotherapy within 90 days of COVID-19 diagnosis was not predictive of COVID-19 hospitalization (OR 0.83, CI 0.41, 1.68) or mortality (OR 1.56, CI 0.67, 3.53). CONCLUSIONS: The case fatality rate among patients with gynecologic malignancy with COVID-19 infection was 17.6%. Cancer-directed therapy was not associated with an increased risk of mortality related to COVID-19 infection.

Association between definitive chemoradiotherapy wait-time and survival in locally-advanced cervical cancer: Implications during the coronavirus pandemic.

OBJECTIVE: The current coronavirus pandemic caused a significant decrease in cancer-related encounters resulting in a delay in treatment of cancer patients. The objective of this study was to examine the survival effect of delay in starting concurrent chemo-radiotherapy (CCRT) in women with locally-advanced cervical cancer. METHODS: This is a retrospective observational study querying the National Cancer Database from 2004 to 2016. Women with stage IB2-IVA squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix who received definitive CCRT with known wait-time for CCRT initiation after cancer diagnosis were eligible (N=13,617). Cox proportional hazard regression model with restricted cubic spline transformation was fitted to assess the association between CCRT wait-time and all-cause mortality in multivariable analysis. RESULTS: The median wait-time to start CCRT was 6 (IQR 4-8) weeks. In a multivariable analysis, older age, non-Hispanic black and Hispanic ethnicity, recent year of diagnosis, Medicaid and uninsured status, medical comorbidities, and absence of nodal metastasis were associated with longer CCRT wait-time (P<.05). Women with aggressive tumor factors (poorer differentiation, large tumor size, nodal metastasis, and higher cancer stage) were more likely to have a short CCRT wait-time (P<.05). After controlling for the measured covariates, CCRT wait-time of 6.1-9.8 weeks was not associated with increased risk of all-cause mortality compared to a wait-time of 6 weeks. Similar association was observed when the cohort was stratified by histology, cancer stage, tumor size, or brachytherapy use. CONCLUSION: An implication of this study for the current coronavirus pandemic is that in the absence of aggressive tumor factors, a short period of wait-time to start definitive CCRT may not be associated with increased risk of mortality in women with locally-advanced cervical cancer.

Care Delivery Impact of the COVID-19 Pandemic on Breast Cancer Care.

PURPOSE: COVID-19 has altered healthcare delivery. Previous work has focused on patients with cancer and COVID-19, but little has been reported on healthcare system changes among patients without COVID-19. METHODS: We performed a retrospective study of patients with breast cancer (BC) in New York City between February 1, 2020, and April 30, 2020. New patients were included as were patients scheduled to receive intravenous or injectable therapy. Patients with COVID-19 were excluded. Demographic and treatment information were obtained by chart review. Delays and/or changes in systemic therapy, surgery, radiation, and radiology related to the pandemic were tracked, along with the reasons for delay and/or change. Univariate and multivariable analysis were used to identify factors associated with delay and/or change. RESULTS: We identified 350 eligible patients, of whom 149 (42.6%) experienced a delay and/or change, and practice reduction (51.0%) was the most common reason. The patients who identified as Black or African American, Asian, or Other races were more likely to experience a delay and/or change compared with White patients (Black, 44.4%; Asian, 47.1%; Other, 55.6%; White, 31.4%; P = .001). In multivariable analysis, Medicaid compared with commercial insurance (odds ratio [OR], 3.04; 95% CI, 1.32 to 7.27) was associated with increased odds of a delay and/or change, whereas stage II or III BC compared with stage I (OR, 0.38; 95% CI, 0.15 to 0.95; and OR, 0.28; 95% CI, 0.08 to 0.092, respectively) was associated with decreased odds of a delay and/or change. CONCLUSION: Almost half of the patients with BC without COVID-19 had a delay and/or change. We found racial and socioeconomic disparities in the likelihood of a delay and/or change. Further studies are needed to determine the impact these care alterations have on BC outcomes.

Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures.

OBJECTIVE: To evaluate the perioperative morbidity and mortality of patients with COVID-19 who undergo urgent and emergent surgery. SUMMARY BACKGROUND DATA: Although COVID-19 infection is usually associated with mild disease, it can lead to severe respiratory complications. Little is known about the perioperative outcomes of patients with COVID-19. METHODS: We examined patients who underwent urgent and emergent surgery at 2 hospitals in New York City from March 17 to April 15, 2020. Elective surgical procedures were cancelled throughout and routine, laboratory based COVID-19 screening was instituted on April 1. Mortality, complications, and admission to the intensive care unit were compared between patients with COVID-19 detected perioperatively and controls. RESULTS: Among 468 subjects, 36 (7.7%) had confirmed COVID-19. Among those with COVID-19, 55.6% were detected preoperatively and 44.4% postoperatively. Before the routine preoperative COVID-19 laboratory screening, 7.7% of cases were diagnosed preoperatively compared to 65.2% after institution of screening (P = 0.0008). The perioperative mortality rate was 16.7% in those with COVID-19 compared to 1.4% in COVID-19 negative subjects [aRR = 9.29; 95% confidence interval (CI), 5.68-15.21]. Serious complications were identified in 58.3% of COVID-19 subjects versus 6.0% of controls (aRR = 7.02; 95%CI, 4.96-9.92). Cardiac arrest, sepsis/shock, respiratory failure, pneumonia, acute respiratory distress syndrome, and acute kidney injury were more common in those with COVID-19. The intensive care unit admission rate was 36.1% in those with COVID-19 compared to 16.4% of controls (aRR = 1.34; 95%CI, 0.86-2.09). CONCLUSIONS: COVID-19 is associated with an increased risk for serious perioperative morbidity and mortality. A substantial number of patients with COVID-19 are not identified until after surgery.

Inflammatory markers in gynecologic oncology patients hospitalized with COVID-19 infection.

OBJECTIVE: Elevated inflammatory markers are predictive of COVID-19 infection severity and mortality. It is unclear if these markers are associated with severe infection in patients with cancer due to underlying tumor related inflammation. We sought to further understand the inflammatory response related to COVID-19 infection in patients with gynecologic cancer. METHODS: Patients with a history of gynecologic cancer hospitalized for COVID-19 infection with available laboratory data were identified. Admission laboratory values and clinical outcomes were abstracted from electronic medical records. Severe infection was defined as infection requiring ICU admission, mechanical ventilation, or resulting in death. RESULTS: 86 patients with gynecologic cancer were hospitalized with COVID-19 infection with a median age of 68.5 years (interquartile range (IQR), 59.0-74.8). Of the 86 patients, 29 (33.7%) patients required ICU admission and 25 (29.1%) patients died of COVID-19 complications. Fifty (58.1%) patients had active cancer and 36 (41.9%) were in remission. Patients with severe infection had significantly higher ferritin (median 1163.0 vs 624.0 ng/mL, p < 0.01), procalcitonin (median 0.8 vs 0.2 ng/mL, p < 0.01), and C-reactive protein (median 142.0 vs 62.3 mg/L, p = 0.02) levels compared to those with moderate infection. White blood cell count, lactate, and creatinine were also associated with severe infection. D-dimer levels were not significantly associated with severe infection (p = 0.20). CONCLUSIONS: The inflammatory markers ferritin, procalcitonin, and CRP were associated with COVID-19 severity in gynecologic cancer patients and may be used as prognostic markers at the time of admission.

Racial disparities in patients with coronavirus disease 2019 infection and gynecologic malignancy.

BACKGROUND: Mounting evidence suggests disproportionate coronavirus disease 2019 (COVID-19) hospitalizations and deaths because of racial disparities. The association of race in a cohort of gynecologic oncology patients with severe acute respiratory syndrome-coronavirus 2 infection is unknown. METHODS: Data were abstracted from gynecologic oncology patients with COVID-19 infection among 8 New York City area hospital systems. A multivariable mixed-effects logistic regression model accounting for county clustering was used to analyze COVID-19-related hospitalization and mortality. RESULTS: Of 193 patients who had gynecologic cancer and COVID-19, 67 (34.7%) were Black, and 126 (65.3%) were non-Black. Black patients were more likely to require hospitalization compared with non-Black patients (71.6% [48 of 67] vs 46.0% [58 of 126]; P = .001). Of 34 (17.6%) patients who died from COVID-19, 14 (41.2%) were Black. Among those who were hospitalized, compared with non-Black patients, Black patients were more likely to: have ≥3 comorbidities (81.1% [30 of 37] vs 59.2% [29 of 49]; P = .05), to reside in Brooklyn (81.0% [17 of 21] vs 44.4% [12 of 27]; P = .02), to live with family (69.4% [25 of 36] vs 41.6% [37 of 89]; P = .009), and to have public insurance (79.6% [39 of 49] vs 53.4% [39 of 73]; P = .006). In multivariable analysis, among patients aged <65 years, Black patients were more likely to require hospitalization compared with non-Black patients (odds ratio, 4.87; 95% CI, 1.82-12.99; P = .002). CONCLUSIONS: Although Black patients represented only one-third of patients with gynecologic cancer, they accounted for disproportionate rates of hospitalization (>45%) and death (>40%) because of COVID-19 infection; younger Black patients had a nearly 5-fold greater risk of hospitalization. Efforts to understand and improve these disparities in COVID-19 outcomes among Black patients are critical.

Coronavirus Spectrum Infections (COVID-19, MERS, SARS) in Cancer Patients: A Systematic Review of the Literature.

BACKGROUND: Coronavirus 2019 (COVID-19) has spread rapidly around the world to become a global pandemic. There is limited data on the impact of COVID-19 among patients with cancer. METHODS: A systematic review was performed to determine outcomes of adult patients with cancer affected by coronavirus infections, specifically SARS, MERS, and COVID-19. Studies were independently screened by two reviewers and assessed for quality and bias. Outcomes measured included study characteristics, cancer type, phase of care at the time of diagnosis, and clinical presentation. Morbidity and mortality outcomes were analyzed to assess the severity of infection as compared to the general population. RESULTS: A total of 19 studies with 110 patients were included. Of these, 66.4% had COVID-19 infections, 32.7% MERS and only one patient with SARS. The majority of COVID-19 studies were based on studies in China. There was a 56.6% rate of a severe event, including ICU admission or requiring mechanical ventilation, with an overall 44.5% fatality rate. CONCLUSIONS: Patients with cancer with coronavirus infections may be more susceptible to higher morbidity and mortality.

COVID-19 outcomes of patients with gynecologic cancer in New York City.

BACKGROUND: New York City (NYC) is the epicenter of severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) in the United States. Clinical characteristics and outcomes of vulnerable populations, such as those with gynecologic cancer who develop COVID-19 infections, is limited. METHODS: Patients from 6 NYC-area hospital systems with known gynecologic cancer and a COVID-19 diagnosis were identified. Demographic and clinical outcome data were abstracted through a review of electronic medical records. RESULTS: Records for 121 patients with gynecologic cancer and COVID-19 were abstracted; the median age at the COVID-19 diagnosis was 64.0 years (interquartile range, 51.0-73.0 years). Sixty-six of the 121 patients (54.5%) required hospitalization; among the hospitalized patients, 45 (68.2%) required respiratory intervention, 20 (30.3%) were admitted to the intensive care unit, and 9 (13.6%) underwent invasive mechanical ventilation. Seventeen patients (14.0%) died of COVID-19 complications. No patient requiring mechanical ventilation survived. On multivariable analysis, hospitalization was associated with an age ≥64 years (risk ratio [RR], 1.73; 95% confidence interval [CI], 1.18-2.51), African American race (RR, 1.56; 95% CI, 1.13-2.15), and 3 or more comorbidities (RR, 1.43; 95% CI, 1.03-1.98). Only recent immunotherapy use (RR, 3.49; 95% CI, 1.08-11.27) was associated with death due to COVID-19 on multivariable analysis; chemotherapy treatment and recent major surgery were not predictive of COVID-19 severity or mortality. CONCLUSIONS: The case fatality rate among gynecologic oncology patients with a COVID-19 infection is 14.0%. Recent immunotherapy use is associated with an increased risk of mortality related to COVID-19 infection. LAY SUMMARY: The case fatality rate among gynecologic oncology patients with a coronavirus disease 2019 (COVID-19) infection is 14.0%; there is no association between cytotoxic chemotherapy and cancer-directed surgery and COVID-19 severity or death. As such, patients can be counseled regarding the safety of continued anticancer treatments during the pandemic. This is important because the ability to continue cancer therapies for cancer control and cure is critical.

Gynecologic surgical considerations in the era of COVID-19.

The goal of this chapter is to review the various considerations necessary to safely perform gynecologic surgery in the setting of a viral pandemic. The ability to triage surgical cases at a time of reduced resources is facilitated by both state and national societal guidelines in addition to various scoring systems. Concerns by health care personnel of viral transmission intra-operatively require appropriate use of PPE and pre-operative COVID-19 testing. Implementation of mitigation strategies around aerosol-generating procedures such as laparoscopy protects health care personnel involved in the surgical care of the patient.

When to Operate, Hesitate and Reintegrate: Society of Gynecologic Oncology Surgical Considerations during the COVID-19 Pandemic.

The COVID-19 pandemic has challenged our ability to provide timely surgical care for our patients. In response, the U.S. Surgeon General, the American College of Srugeons, and other surgical professional societies recommended postponing elective surgical procedures and proceeding cautiously with cancer procedures that may require significant hospital resources and expose vulnerable patients to the virus. These challenges have particularly distressing for women with a gynecologic cancer diagnosis and their providers. Currently, circumstances vary greatly by region and by hospital, depending on COVID-19 prevalence, case mix, hospital type, and available resources. Therefore, COVID-19-related modifications to surgical practice guidelines must be individualized. Special consideration is necessary to evaluate the appropriateness of procedural interventions, recognizing the significant resources and personnel they require. Additionally, the pandemic may occur in waves, with patient demand for surgery ebbing and flowing accordingly. Hospitals, cancer centers and providers must prepare themselves to meet this demand. The purpose of this white paper is to highlight all phases of gynecologic cancer surgical care during the COVID-19 pandemic and to illustrate when it is best to operate, to hestitate, and reintegrate surgery. Triage and prioritization of surgical cases, preoperative COVID-19 testing, peri-operative safety principles, and preparations for the post-COVID-19 peak and surgical reintegration are reviewed.