key: cord-0702682-copk06je authors: Mangone, Lucia; Gioia, Francesco; Mancuso, Pamela; Bisceglia, Isabella; Ottone, Marta; Vicentini, Massimo; Pinto, Carmine; Giorgi Rossi, Paolo title: Cumulative COVID‐19 incidence, mortality and prognosis in cancer survivors: A population‐based study in Reggio Emilia, Northern Italy date: 2021-04-27 journal: Int J Cancer DOI: 10.1002/ijc.33601 sha: fe37622df94ae42d0c97b42ce98097e736e54761 doc_id: 702682 cord_uid: copk06je The aim of this population‐based study was to evaluate the impact of being a cancer survivor (CS) on COVID‐19 risk and prognosis during the first wave of the pandemic (27 February 2020 to 13 May 2020) in Reggio Emilia Province. Prevalent cancer cases diagnosed between 1996 and 2019 were linked with the provincial COVID‐19 surveillance system. We compared CS' cumulative incidence of being tested, testing positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), being hospitalized and dying of COVID‐19 with that of the general population; we compared COVID‐19 prognosis in CS and in patients without cancer. During the study period, 15 391 people (1527 CS) underwent real‐time polymerase chain reaction for SARS‐CoV‐2, of whom 4541 (447 CS) tested positive; 541 (113 CS) died of COVID‐19. CS had higher age‐ and sex‐adjusted incidence rate ratios (IRR) of testing (1.28 [95% confidence interval, CI = 1.21‐1.35]), of positive test (IRR 1.06 [95% CI = 0.96‐1.18]) and of hospitalization and death (IRR 1.27 [95% CI = 1.09‐1.48] and 1.39 [95%CI = 1.12‐1.71], respectively). CS had worse prognosis when diagnosed with COVID‐19, particularly those below age 70 (adjusted odds ratio [OR] of death 5.03; [95% CI = 2.59‐9.75]), while the OR decreased after age 70. The OR of death was higher for CS with a recent diagnosis, that is, <2 years (OR = 2.92; 95% CI = 1.64‐5.21), or metastases (OR = 2.09; 95% CI = 0.88‐4.93). CS showed the same probability of being infected, despite a slightly higher probability of being tested than the general population. Nevertheless, CS were at higher risk of death once infected. tient, primary and preventive care to the entire population residing in the province. The following measures were adopted throughout northern Italy to contain the spread of the SARS-CoV-2 virus: on 22 February, schools were closed, and social restrictions were imposed; on 8 March, mobility and travel restrictions were imposed and on 11 March, only essential services were permitted to remain open. During this phase, all cases with suspicious symptoms (fever, cough, dyspnea) were tested. The first case of SARS-CoV-2 disease (COVID- 19) in the Reggio Emilia Province was diagnosed on 27 February 2020. As of 13 May, the end of the study recruitment period, there were more than 4500 confirmed cases in the province; the epidemic was still spreading at that point, but at a slower rate, and cumulative incidence reached about 9 per 1000. The Reggio Emilia Cancer Registry, set up 2000, registers all new cancer diagnoses occurring in people residing in the Reggio Emilia Province. The main information sources of the RE-CR are the anatomic pathology reports, the hospital discharge records and mortality data. The RE-CR has registered all incident cases from 1996 to 2019, with active follow-up for deaths and residence of all prevalent cases updated to 31 December 2019. It collects information on site, morphology, partial staging (presence of metastases), mode of diagnosis and survival. 9 All RT-PCR SARS-CoV-2 tests performed in Italy must be recorded in the national case-based integrated COVID- 19 The whole resident population registered on 1 January 2020 was classified as CS or not having had a cancer through a linkage with cancer registry. This cohort was then linked with the list of cases tested for SARS-CoV-2 (positive and negative) from late February up to 13 May 2020. From the COVID-19 surveillance system data, we report the cumulative incidence up to 13 May 2020 of being tested for SARS-CoV Pearson's chi-square test was used to examine differences in the proportions of subjects with and without cancer and tested/not tested for SARS-CoV-2. We report age-and sex-adjusted incidence rate ratios (IRR), with relative 95% confidence intervals (95% CIs) using Poisson regression, for cumulative incidences. The outcomes of interest for this analysis were cancer survivors' being tested for SARS-CoV-2, having a positive test, being hospitalized and dying of COVID-19, compared with the same outcomes of those who had never had a cancer diagnosis. Multivariable analysis was performed using a logistic regression model to measure the odd ratios, with relative 95% CI, of hospitalization and death for COVID-19 patients with cancer, adjusting for age and sex. STATA v. 13.0 (StataCorp LP, College Station, TX) was used for all analyses. T A B L E 1 Distribution of 15 391 patients who tested for SARS-CoV-2, were positive for SARS-CoV-2, COVID-19 hospitalization, and death, by sex, age and cancer history Our data suggest that the SARS-CoV-2 control measures adopted in the oncology and diagnostic departments, together with public awareness and the specific measures implemented by the Italian Government to protect people with chronic diseases (eg, exemption from any work involving social contact), allowed cancer survivors to control their risk of infection even when they were in an active phase of care or in follow-up. This is an important message for the policy makers, physicians and patients who are trying to better manage cancer during this public health emergency. 22 The main strength of this study is its population-based design, which eliminates any selection bias occurring in case series. Furthermore, the assessment of exposure, that is, a previous diagnosis of cancer, was conducted through the linkage with a cancer registry with 25 years of prevalence data and timely registration of incident cases (to 31 December 2019). It is worth noting that this information was acquired before the onset of the pandemic and is thus completely independent of outcome occurrence. The main limitation of our study is that we do not have any information on treatment or on comorbidities, which could have influenced outcomes. Furthermore, because we could not include cancer patients with a diagnosis occurring in 2020, we could not observe the phase of diagnosis and disease assessment, which for many cancer sites involves intensive access to health care facilities. Our population-based study showed that during the peak of the COVID-19 epidemic in northern Italy, the cumulative incidence of COVID-19 in cancer survivors was similar to that in the general population, despite the former's having a slightly higher probability of being tested. On the other hand, cancer survivors had a greater risk of hospitalization and of death once infected, especially in the age group <70 years or in those with a recent diagnosis. The authors declare no potential conflict of interest. Researchers who would like to access individual data should present their request, together with a study protocol, to the Area Vasta Emilia Nord Ethics Committee for approval (cereggioemilia@ausl.re.it). The study was approved by the Area Vasta Emilia Nord Ethics Committee (no. 2020/0045199). The Ethics Committee authorized the use of patient data, even in the absence of consent, if all reasonable efforts had been made to contact that patient. 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