|Year : 2022 | Volume
| Issue : 1 | Page : 21-24
Mortality audit of 19 patients with cancer and SARS-CoV-2 positivity
Kaberi Kakati1, Tashnin Rahman1, Debabrata Barman2, Mouchumee Bhattacharyya3, Bibhuti Bhusan Borthakur4, Rashmisnata Barman5, Apurba Kalita3, Amal Chandra Kataki2, Manigreeva Krishnatreya6
1 Department of Head and Neck Surgery, Dr B Borooah Cancer Institute, Guwahati, Assam, India
2 Department of Gynecological Oncology, Dr B Borooah Cancer Institute, Guwahati, Assam, India
3 Department of Radiation Oncology, Dr B Borooah Cancer Institute, Guwahati, Assam, India
4 Department of Surgical Oncology, Dr B Borooah Cancer Institute, Guwahati, Assam, India
5 Department of Microbiology, Dr B Borooah Cancer Institute, Guwahati, Assam, India
6 Department of Cancer Registry and Epidemiology, Dr B Borooah Cancer Institute, Guwahati, Assam, India
|Date of Submission||10-May-2022|
|Date of Decision||30-May-2022|
|Date of Acceptance||03-Jun-2022|
|Date of Web Publication||02-Sep-2022|
Dr. Manigreeva Krishnatreya
Room3, OPD Building, Dr. B Borooah Cancer Institute, Guwahati 781016, Assam
Source of Support: None, Conflict of Interest: None
Introduction: Coronavirus disease-2019 (COVID-19) has disrupted cancer care services globally. The main objective of this study was to review the cause of deaths in admitted patients with cancer with positive report for severe acute respiratory syndrome coronavirus – 2 (SARS-CoV-2). Materials and Methods: The present review of the cause of deaths was conducted in a tertiary care cancer center in the North East India. In our institute, all cancer patients requiring admission for surgery, chemotherapy, and other daycare procedures require testing for SARS-CoV-2. Results: From 9 July 2020 to 16 May 2021, 119 cancer patients with SARS-CoV-2 positive report or COVID-19 have been admitted to our institute COVID ward. A total of 19 cancer patients with COVID-19 succumbed. Of 19 deaths, 13 (68.4%) patients were men and 6 (31.6%) patients were women. The age range was from 27 years to 74 years (median =55 years). Vomiting alone or with diarrhea was the most common symptom requiring admission after testing (4/19, 21.0%), followed by bleeding from the primary tumor site (3/19, 15.7%). Conclusion: The antecedent and underlying cause of deaths in 19 (100%) patients was cancer. SARS-CoV-2 infection should not be a hindrance to cancer treatment and management.
Keywords: Cancer, COVID-19, death, mortality, SARC-CoV-2
|How to cite this article:|
Kakati K, Rahman T, Barman D, Bhattacharyya M, Borthakur BB, Barman R, Kalita A, Kataki AC, Krishnatreya M. Mortality audit of 19 patients with cancer and SARS-CoV-2 positivity. J Curr Oncol 2022;5:21-4
| Introduction|| |
The coronavirus disease-2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus – 2 (SARS-CoV-2) virus, has caused significant disruption in the healthcare system in India. In India, the deaths due to COVID-19 have crossed 500,000 as of February 26, 2022. According to the World Health Organization (WHO), death due to COVID-19 is defined for surveillance purposes as, “a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma).” A study has shown that acute respiratory failure and sepsis were the main causes of death in 77 cases based on patients’ clinical characteristics and laboratory results. The reason for deaths in COVID-19 is suspected to be the “cytokine storm” or the systemic inflammatory response syndrome (SIRS). Excessive production of pro-inflammatory cytokines leads to acute respiratory distress syndrome aggravation and widespread tissue damage resulting in multiorgan failure and death. We conducted a review of cause of deaths in admitted patients with cancer with positive report of real-time polymerase chain reaction (RT-PCR) or rapid antigen test (RAT) for SARS-CoV-2.
| Materials and Methods|| |
This study has been done with approval from the Institutional Ethics Committee along with consent waiver (BBCI-TMC/Misc-01/MEC/11/2021 dated July 12, 2021). In our institute, all patients with cancer requiring admission for surgery, chemotherapy, and other daycare procedures require testing for SARS-CoV-2. A molecular virology laboratory was established for the same in July 2020. In case the person is tested positive for SARS-CoV-2, he or she is admitted to the COVID ward, which has 37 beds. From July 9, 2020 to May 16, 2021, 119 patients with cancer with SARS-CoV-2 positive reports admitted to our institute’s COVID ward. None of our cohort of 119 patients presented with typical symptoms of COVID-19 and presented for their underlying cancers. All the patients with cancer in this study presented to our hospital for symptoms due to their underlying cancer and some for surgeries. All patients were tested for SARS-CoV-2 after their admission for trivial influenza-like illnesses like 1-day fever, sore throat, and occasional cough, as per the protocol of testing and isolation to a separate COVID-19 ward. Of them, 19 (15.9%) patients with cancer with SARS-CoV-2 positive report succumbed to their illness. In the first wave, from July 9, 2020 to September 30,2020 (more than 2 months), 10 patients with cancer with SARS-CoV-2 positive report died. However, in the second wave, from April 28, 2021 to May 16, 2021, nine patients with cancer with SARS-CoV-2 positive report died in a span of 18 days. The first and second waves were considered based on months preceding and after the peak number of infections that occurred in the country. In the present review of the death audit, we examined median age, gender, main symptom that required admission, primary site of cancer, presence of comorbidities, duration of admission before death, and presence of fever or influenza-like illness. The causes of death statements were recorded according to the guidelines of the WHO into immediate causes of death, antecedent cause of death, and underlying cause, and further relevant conditions that may have contributed to fatal outcome. The death report of each of these 19 cases was forwarded to the chairperson of the state COVID-19 death audit board formed by the State government, and reporting of all COVID-19 deaths to the audit board was a statutory requirement. Patient 1 was the first patient with cancer with SARS-CoV-2 positive report who succumbed at our COVID ward.
| Results|| |
Of 19 deaths, 13 (68.4%) patients were men and 6 (31.6%) patients were women. The age range varied from 27 years to 74 years (median was 55 years with interquartile range [IQR] = 52 [38–62]). Vomiting alone or with diarrhea was the most common symptom requiring admission after testing (4/19, 21.0%), followed by bleeding from the primary tumor site (3/19, 15.7%) [Table 1]. Vomiting and/or diarrhea were due to gastric outlet obstruction or intestinal obstruction. One patient with symptoms of severe vomiting was on active chemotherapy. Three (15.7%) patients with cancer were admitted for surgical procedures as seen in [Table 1]. Two patients turned out to be positive after admission for emergency procedures. One patient who had post-traumatic (surgery) lung collapse developed fever (one day) on ninth postoperative day and was tested positive for SARS-CoV-2. These three were considered asymptomatic SARS-CoV-2 positive patients with cancer. The antecedent and underlying cause of deaths in 19 (100%) patients was tentatively marked as cancer. One (5.2%) patient had renal insufficiency as the contributing cause of death [Table 2]. Four (21%) patients had a history of fever (patients 13, 14,15, and 16). Their fever lasted for 1–2 days only. In the present mortality review, five patients presented were with oral cavity/oro-pharyngeal cancer as the primary site, and eight patients were with gastrointestinal cancer as the primary site [Table 3]. Four patients had other comorbidities like hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and interstitial lung disease as shown in [Table 3]. Deaths occurred within 1 day following admission to up to 30 days following postoperative complications. The median time of death following hospitalization was 12 days.
|Table 1: Gender distribution and main presenting symptoms of patients with cancer detected with COVID-19 or SARS-CoV-2 positive report|
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|Table 2: Various immediate, antecedent, and underlying cause of death and presence of other significant conditions of patients with SARS-CoV-2 positive report and cancer|
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|Table 3: Primary site of cancer and presence of comorbidly (ies) in patients with SARS-CoV-2 positive report and cancer|
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In our mortality review, patients with cancer with unrelated symptoms with COVID-19 like bleeding from the primary cancer site and vomiting secondary to gastric outlet obstruction were predominant, and that lead to death. In the mortality review, we observed that 21% of deceased patients with cancer and with SARS-CoV-2 positivity had comorbidities. Hypertension was seen in 50% of patients with comorbidities. Four patients with cancer have had respiratory insufficiency as presentation. In one patient with supra-glottic cancer, the respiratory insufficiency was due to stridor or upper airway obstruction. One patient had disseminated lung cancer; one with lung cancer had a long history of interstitial lung disease and in one patient with cancer, the respiratory insufficiency was due to lung collapse secondary to surgical trauma.
| Discussion|| |
After reviewing the history and clinical presentations in the present mortality review, it showed that cause of death of all patients admitted to our institute with COVID-19 was due to cancer. In the present mortality audit, the most common immediate cause of death was cancer cachexia (21%) followed by respiratory insufficiency in the absence of typical symptoms of COVID-19 pneumonia or ARDS. Though there are opposing views regarding cancer cachexia as the cause of death and whether this is rather an epiphenomenon, it is postulated that an increase in platelet number and activation pathways, and arrhythmias appear to be the cause of sudden cardiovascular events leading to death in cancer cachexia. One of the parameters we looked at was the history of fever. Typically, in deaths due to COVID-19 and SIRS, fever is seen to last for more than 7 days, and typical ground-glass opacities involving bilateral lungs are seen. The short duration (maximum 2 days) of fever in our cohort of cancer patients with COVID-19 favored death due to underlying cancer and not due to COVID-19. In addition, anecdotal evidences from larger centers treating patients with ARDS due to COVID-19 suggest severe body ache and weakness with long-lasting fever (more than 7 days) as early signs of worsening of COVID-19 requiring ventilator support. It is worthwhile to note that COVID-19 has a very wide spectrum of clinical presentations and many may not have the classic 7-day fever. None of the patients with cancer with SARS-CoV-2 positivity or mild COVID-19 in our study developed typical acute respiratory distress syndrome (SARS) or had features of systemic inflammatory response syndrome (SIRS) to fit in the WHO definition of COVID-19 death (chain of events). The present review found cancer as the underlying cause of death in the study cohort. However, more justification of the same will be required by means of autopsy. A study has shown that in patients with severe COVID-19, a multisystemic pathology leads to death typically in those with comorbidities. There are no pathophysiological explanations of “hastening” of death by COVID-19 in patients with cancer or any other diseases like acute renal failure, and myocardial infarction.
Case fatality rate of COVID-19 in patients with cancer is of order of 21% and hence precautions must be taken to protect patients with underlying cancer from contracting COVID-19. With vaccination efforts being ramped up, patients with cancer being in the vulnerable age group should get the vaccine shots without any hesitation, and on priority. This type of mortality audits helps to quantify the actual mortality due to COVID-19.
Limitation of the study
The assessment of the cause of death was purely based on history and clinical presentation, and serum pro-inflammatory biomarkers like ferritin, D-Dimer, troponin-I, pro-calcitonin, and IL-6 were not tested. We justify the lack of pro-inflammatory biomarkers testing in the absence of fever in over 84% of the patient cohort or fever lasting not more than 2 days in three patients.
| Conclusion|| |
Catching SARS-CoV-2 infection while coming for cancer treatment and further management should not be viewed as a devastating outcome for cancer patients. We should encourage cancer treatment despite an ongoing ravaging pandemic. This type of mortality audits helps to quantify the actual mortality due to COVID-19 and shall guide in framing a sound public health policy to combat future viral pandemics, if any.
The authors thank Jamil Ahmed Barbhuiya and Tarun Sonowal, medical social workers of the institute for helping families of deceased cancer patients with COVID-19 in their cremation or burial by following the COVID death protocol mandated by the government. The authors greatly acknowledge the support of the National Health Mission of the Government of Assam and the Assam Covid Death Audit Board.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
2019 Novel Coronavirus Visual Dashboard operated by the Johns Hopkins University Center for Systems Science and Engineering. Available from: https://github.com/CSSEGISandData/COVID-19
. [Last accessed on 2022 Feb 26].
Guidance for appropriate recording of COVID-19 related deaths in India. National Center for Disease Informatics and Research, Indian Council of Medical Research. Available from: https://health.odisha.gov.in/pdf/Guidance-for-recording-of-Covid19-related-deaths.pdf
. [Last accessed on 2022 Jun 15].
Wang K, Qiu Z, Liu J, Fan T, Liu C, Tian P, et al
. Analysis of the clinical characteristics of 77 COVID-19 deaths. Sci Rep 2020;10:16384.
Tang Y, Liu J, Zhang D, Xu Z, Ji J, Wen C Cytokine storm in COVID-19: The current evidence and treatment strategies. Front Immunol 2020;11:1708.
Ragab D, Salah Eldin H, Taeimah M, Khattab R, Salem R The COVID-19 cytokine storm; what we know so far. Front Immunol 2020;11:1446.
Kalantar-Zadeh K, Rhee C, Sim JJ, Stenvinkel P, Anker SD, Kovesdy CP Why cachexia kills: Examining the causality of poor outcomes in wasting conditions. J Cachexia Sarcopenia Muscle 2013;4:89-94.
Ng DHL, Choy CY, Chan YH, Young BE, Fong SW, Ng LFP, et al
; National Centre for Infectious Diseases COVID-19 Outbreak Research Team. Fever patterns, cytokine profiles, and outcomes in COVID-19. Open Forum Infect Dis 2020;7:ofaa375.
Elsoukkary SS, Mostyka M, Dillard A, Berman DR, Ma LX, Chadburn A, et al
. Autopsy findings in 32 patients with COVID-19: A single-institution experience. Pathobiology 2021;88:56-68.
Tagliamento M, Agostinetto E, Bruzzone M, Ceppi M, Saini KS, de Azambuja E, et al
. Mortality in adult patients with solid or hematological malignancies and SARS-cov-2 infection with a specific focus on lung and breast cancers: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2021;163:103365.
[Table 1], [Table 2], [Table 3]