Correspondence
www.thelancet.com/oncology Published online March 3, 2020 https://doi.org/10.1016/S1470-2045(20)30150-9
1
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
cancer patients
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.
The incidence of COVID-19 in
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
of the whole population with
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
that generalise to all patients
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
invasive ventilation, or death)
from COVID-19. Evidence indicates
that overwhelming inflammation
and cytokine-associated lung
injury could be important in
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 status3 characterised by
overexpressed immunosuppressive
cytokines, suppressed induction
of proinflammatory danger
signals, impaired dendritic cell
maturation, and enhanced functional
immunosuppressive leukocyte
populations, which is contradictory
to the events believed to result
in severe events in patients with
COVID-19. Indeed, one of the
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
use significantly increases the
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
huahaoshen@zju.edu.cn
†Joint first authors
Lancet Oncol 2020
Published Online
March 3, 2020
https://doi.org/10.1016/
S1470-2045(20)30150-9