Clinical characteristics, racial inequities, and outcomes in patients with breast cancer and COVID-19: a COVID-19 and cancer consortium (CCC19) cohort study
- Loma Linda University, United States
- Fred Hutchinson Cancer Research Center, United States
- Stanford University, United States
- Vanderbilt University Medical Center, United States
- University of Washington, United States
- Virginia Mason Institute, United States
- University of Hawaii, United States
- University of Cincinnati, United States
- Dana-Farber Cancer Institute, United States
- University of Kansas Cancer Center, United States
- Memorial Sloan Kettering Cancer Center, United States
- Thomas Jefferson University, United States
- Loyola University Medical Center, United States
- Emory University, United States
- Beth Israel Deaconess Medical Center, United States
- Northwest Medical Specialties, United States
- Columbia University, United States
- University of California, San Francisco, United States
- Inova Schar Cancer Institute, United States
- Mayo Clinic, United States
- ThedaCare, United States
- University of Illinois Hospital & Health Sciences System, United States
- St. Elizabeth Healthcare, United States
- University of Michigan-Ann Arbor, United States
- Icahn School of Medicine at Mount Sinai, United States
- Cleveland Clinic, United States
- The Ohio State University, United States
- Henry Ford Hospital, United States
- Mount Auburn Hospital, United States
- Penn State Health St Joseph Cancer Center, United States
- The University of Texas MD Anderson Cancer Center, United States
- Brown University, United States
- Loyola University, United States
- University of Minnesota, United States
- Baptist Cancer Center, United States
- Intermountain Healthcare, United States
- University of Miami, United States
- Albert Einstein College of Medicine, United States
- Kaiser Permanente Northwest, United States
- University of Florida, United States
- University of California, San Diego, United States
- George Washington University, United States
- Hartford HealthCare Cancer Institute, United States
- Roswell Park Comprehensive Cancer Center, United States
- University of California, Davis, United States
- Massachusetts General Hospital, United States
- Penn State Health St. Joseph Cancer Center, United States
- Virtua Health, United States
- National Cancer Institute, United States
- Stamford Hospital, United States
- METAvivor, United States
- ThedaCare Cancer Care, United States
- Advocate Aurora Health, United States
- Fred Hutchinson/University of Washington Cancer Consortium, United States
- Yale University, United States
Abstract
Background: Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations.
Methods: This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity.
Results: 1,383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32 -1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70 - 6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83 - 12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63 - 3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20 - 2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66 - 3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89 - 22.6]). Hispanic ethnicity, timing and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status.
Conclusions: Using one of the largest registries on cancer and COVID-19, we identified patient and BC related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to Non-Hispanic White patients.
Funding: This study was partly supported by National Cancer Institute grant number P30 CA068485 to Tianyi Sun, Sanjay Mishra, Benjamin French, Jeremy L. Warner; P30-CA046592 to Christopher R. Friese; P30 CA023100 for Rana R McKay; P30-CA054174 for Pankil K. Shah and Dimpy P. Shah; and the American Cancer Society and Hope Foundation for Cancer Research (MRSG-16-152-01 -CCE) and P30-CA054174 for Dimpy P. Shah. REDCap is developed and supported by Vanderbilt Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH). The funding sources had no role in the writing of the manuscript or the decision to submit it for publication.
Clinical Trial Number: CCC19 registry is registered on ClinicalTrials.gov, NCT04354701.
Data availability
All datasets (with restriction of time variables to protect patient confidentiality) and code associated with the article are available at: https://datadryad.org/stash/dataset/doi:10.5061/dryad.1g1jwsv10
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Covid-19 and Cancer Consortium (CCC19) breast cancer and racial disparities outcomes study [Dataset]Dryad Digital Repository, doi:10.5061/dryad.1g1jwsv10.
Article and author information
Author details
Funding
National Cancer Institute (P30 CA068485)
- Tianyi Sun
- Sanjay Mishra
- Benjamin French
- Jeremy L Warner
National Cancer Institute (P30-CA046592)
- Christopher R Friese
National Cancer Institute (P30 CA023100)
- Rana R McKay
National Cancer Institute (P30-CA054174)
- Pankil K Shah
- Dimpy P Shah
American Cancer Society (MRSG-16-152-01 -CCE)
- Dimpy P Shah
The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.
Reviewing Editor
- Jennifer Cullen, Case Western Reserve University, United States
Ethics
Human subjects: This study was exempt from institutional review board (IRB) review (VUMC IRB#200467) and was approved by IRBs at participating sites per institutional policy. CCC19 registry is registered on ClinicalTrials.gov, NCT04354701.
Version history
- Received: August 11, 2022
- Preprint posted: March 10, 2023 (view preprint)
- Accepted: September 18, 2023
- Accepted Manuscript published: October 17, 2023 (version 1)
- Version of Record published: November 10, 2023 (version 2)
Copyright
This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
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Clinical characteristics, racial inequities, and outcomes in patients with breast cancer and COVID-19: a COVID-19 and cancer consortium (CCC19) cohort study
eLife 12:e82618.
https://doi.org/10.7554/eLife.82618
Further reading
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- Epidemiology and Global Health
- Microbiology and Infectious Disease
Background: Few national-level studies have evaluated the impact of 'hybrid' immunity (vaccination coupled with recovery from infection) from the Omicron variants of SARS-CoV-2.
Methods: From May 2020 to December 2022, we conducted serial assessments (each of ~4000-9000 adults) examining SARS-CoV-2 antibodies within a mostly representative Canadian cohort drawn from a national online polling platform. Adults, most of whom were vaccinated, reported viral test-confirmed infections and mailed self-collected dried blood spots to a central lab. Samples underwent highly sensitive and specific antibody assays to spike and nucleocapsid protein antigens, the latter triggered only by infection. We estimated cumulative SARS-CoV-2 incidence prior to the Omicron period and during the BA.1/1.1 and BA.2/5 waves. We assessed changes in antibody levels and in age-specific active immunity levels.
Results: Spike levels were higher in infected than in uninfected adults, regardless of vaccination doses. Among adults vaccinated at least thrice and infected more than six months earlier, spike levels fell notably and continuously for the nine months post-vaccination. By contrast, among adults infected within six months, spike levels declined gradually. Declines were similar by sex, age group, and ethnicity. Recent vaccination attenuated declines in spike levels from older infections. In a convenience sample, spike antibody and cellular responses were correlated. Near the end of 2022, about 35% of adults above age 60 had their last vaccine dose more than six months ago, and about 25% remained uninfected. The cumulative incidence of SARS-CoV-2 infection rose from 13% (95% CI 11-14%) before omicron to 78% (76-80%) by December 2022, equating to 25 million infected adults cumulatively. However, the COVID-19 weekly death rate during the BA.2/5 waves was less than half of that during the BA.1/1.1 wave, implying a protective role for hybrid immunity.
Conclusions: Strategies to maintain population-level hybrid immunity require up-to-date vaccination coverage, including among those recovering from infection. Population-based, self-collected dried blood spots are a practicable biological surveillance platform.
Funding: Funding was provided by the COVID-19 Immunity Task Force, Canadian Institutes of Health Research, Pfizer Global Medical Grants, and St. Michael's Hospital Foundation. PJ and ACG are funded by the Canada Research Chairs Program.
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- Computational and Systems Biology
- Epidemiology and Global Health
The chemical composition of foods is complex, variable, and dependent on many factors. This has a major impact on nutrition research as it foundationally affects our ability to adequately assess the actual intake of nutrients and other compounds. In spite of this, accurate data on nutrient intake are key for investigating the associations and causal relationships between intake, health, and disease risk at the service of developing evidence-based dietary guidance that enables improvements in population health. Here, we exemplify the importance of this challenge by investigating the impact of food content variability on nutrition research using three bioactives as model: flavan-3-ols, (–)-epicatechin, and nitrate. Our results show that common approaches aimed at addressing the high compositional variability of even the same foods impede the accurate assessment of nutrient intake generally. This suggests that the results of many nutrition studies using food composition data are potentially unreliable and carry greater limitations than commonly appreciated, consequently resulting in dietary recommendations with significant limitations and unreliable impact on public health. Thus, current challenges related to nutrient intake assessments need to be addressed and mitigated by the development of improved dietary assessment methods involving the use of nutritional biomarkers.
