key: cord-0869972-c8g7b4ot authors: Sahin, Mustafa; Haymana, Cem; Demirci, Ibrahim; Tasci, Ilker; Rıfat, Emral; Unluturk, Ugur; Satman, Ilhan; Demir, Tevfik; Cakal, Erman; Ata, Naim; Ertugrul, Derun; Salman, Serpil; Sahin, Ibrahim; Dagdelen, Selcuk; Celik, Osman; Caglayan, Murat; Atmaca, Aysegul; Sonmez, Alper title: The clinical outcomes of COVID‐19 infection in patients with a history of thyroid cancer: A nationwide study date: 2021-05-03 journal: Clin Endocrinol (Oxf) DOI: 10.1111/cen.14486 sha: 5b9b9a53f58c9f2e0fb00070a5d5c47fab1e1ebe doc_id: 869972 cord_uid: c8g7b4ot BACKGROUND: There are scarce published data in differentiated thyroid cancer patients about new coronavirus disease 2019 (COVID‐19) disease outcomes and mortality. Here, we evaluated COVID‐19 infection outcomes and mortality in thyroid cancer patients with COVID‐19 infection. DESIGN AND METHODS: We included a cohort of patients with thyroid cancer with PCR‐confirmed COVID‐19 disease from 11 March to 30 May 2020 from the Turkish Ministry of Health database in our nationwide, retrospective study. We compared the mortality and morbidity of COVID patients with or without thyroid cancer. Univariate and multivariate analyses were used to assess the independent factors for mortality, length of hospital stay and intensive care unit (ICU) admission and mechanical ventilation. We also analysed the effect of radioiodine treatment on severity and death rate of COVID‐19 disease. RESULTS: We evaluated 388 COVID‐19 patients with thyroid cancer [median age: 54 years, interquartile range (IQR) 18 years, males: 23%] and age and gender‐matched 388 COVID‐19 patients without thyroid cancer. Patients with thyroid cancer had a similar mortality ratio compared with the non‐cancer group. Among patients with thyroid cancer, age, presence of diabetes mellitus, asthma/COPD, heart failure, chronic kidney disease, prior coronary artery disease, RAS blocker usage and low lymphocyte count were associated with mortality. Radioactive iodine (RAI) treatment and cumulative radioactive iodine dosage did not negatively affect the severity and mortality of COVID‐19 disease in our patient group. CONCLUSIONS: Our study indicated that history of thyroid cancer did not have an increased risk of mortality or morbidity in COVID‐19 disease. Besides, RAI therapy history and doses of radioactive iodine did not affect mortality or outcome. The new coronavirus disease 2019 (COVID-19) pandemic has caused serious social and health problems. So far, nearly 2 million people have died. There is a diverse clinical course of COVID-19. Many patients are asymptomatic but some develop acute respiratory failure, which leads to ICU admission and even death. Those who are diagnosed with diabetes mellitus, obesity, hypertension and the elderly are more likely to be affected by COVID-19. 1 Patients with cancer are considered a vulnerable subgroup of the population, and they have an increased risk of coronavirus disease 2019 (COVID-19) severity and mortality. 2 Patients with cancer are heterogeneous and divided into different groups, especially according to cancer type and stages. Cancer patients with metastatic disease or using systemic immunosuppressive therapies have a more severe clinical course and poor prognosis. 3 Patients with malignant tumours have impaired immune response to infections and increased thromboembolic and cardiac complications. 4 Both impaired immunity and thromboembolism may affect the course of COVID-19. Cancer types may affect morbidity and mortality in patients with COVID-19 differently. 2, 3 There are no sufficient data currently to evaluate the COVID-19 morbidity and mortality in patients with thyroid cancer. Generally, the prognosis in differentiated thyroid cancer is excellent. However, a small percentage of patients may have increased morbidity and mortality. It is unclear whether some thyroid cancer patients are more vulnerable to COVID-19 infection. Zhang et al reported low mortality rates of patients with thyroid cancer in COVID-19 but the number of thyroid cancer patients in this study was very low. 2 Thyroid cancer management has become a more personalized therapy approach. Thyroid cancer patients are diverse within themselves. They have different stages and prognostic factors, and some of them may receive radioactive iodine with different doses. Cancer type, stages and risk stratification may help optimizing initial therapy. Some patients receive ablation radioactive iodine (RAI) treatment, while others do not receive it. Also, few receive radioactive therapy for metastasis. In addition to these, RAI treatment may also affect the course. Also, thyroid hormones may affect immune cell function and inflammation. 5 Significantly increased thyroid hormone levels increase the pro-inflammatory cytokine release. 6 It is obscure whether thyroid suppression therapy may affect COVID-19 morbidity and mortality. We aimed to evaluate whether the diagnosis of thyroid cancer and therapy modalities are associated with a higher risk of poor outcome in patients with COVID-19. In this study, among PCR-positive COVID-19 patients from the Turkish National Database between March 2019 and May 2020, we evaluated the differences in clinical characteristics, prognosis and mortality between COVID-19infected thyroid cancer and without thyroid cancer patients. Also, it was investigated how specific factors related to thyroid cancer (RAI therapy, suppressed thyroid-stimulating hormone (TSH) level, tyrosine kinase inhibitors, etc) affect COVID-19 outcomes. We believe that the data in this study may help to understand the impact of thyroid cancer on the outcomes of COVID-19 disease and give recommendations to the physicians who follow these patients. We used the Turkish Ministry of Health National Electronic Database to design a multi-centre, retrospective cohort study. Our study was conducted according to the Declaration of Helsinki. Ministry of Health Ethical Board approved our study (95741342020/27112019). 388 COVID-19 patients without thyroid cancer. Patients with thyroid cancer had a similar mortality ratio compared with the non-cancer group. Among patients with thyroid cancer, age, presence of diabetes mellitus, asthma/COPD, heart failure, chronic kidney disease, prior coronary artery disease, RAS blocker usage and low lymphocyte count were associated with mortality. Radioactive iodine (RAI) treatment and cumulative radioactive iodine dosage did not negatively affect the severity and mortality of COVID-19 disease in our patient group. Conclusions: Our study indicated that history of thyroid cancer did not have an increased risk of mortality or morbidity in COVID-19 disease. Besides, RAI therapy history and doses of radioactive iodine did not affect mortality or outcome. COVID-19, mortality, radioactive iodine therapy, thyroid cancer Data included age, gender, smoking history, education history and body mass index (BMI) as a demographic and patient's characteristics. Comorbid diseases and medication usage were also evaluated. In our data set, laboratory test results on fasting serum samples, including TSH, glucose, lipid profile (total cholesterol, HDL and LDL cholesterol, and triglycerides), creatinine, liver function tests (aspartate and alanine aminotransferase; AST and ALT), C-reactive protein (CRP), procalcitonin, lactate dehydrogenase, white blood cell count, lymphocyte count, fibrinogen, ferritin, D-dimer value and thyroglobulin levels. The history of RAI intake was also evaluated. Chest computerized tomography (CT) results were evaluated for the presence of COVID-19 pulmonary findings. Clinical definitions are given as follows. Smoking was defined as current smoking, higher education as receiving more than formal education (nine years and more). Body mass index (BMI) was calculated as the ratio of weight to the square of height (kg/m 2 ). Thyroid cancer was defined based on the International Classification of Disease (ICD-10) codes. Thyroid cancer patients were divided into two groups according to the administration of RAI therapy. We grouped RAI therapy, according to I-131 doses (30, 50, 75, 100, 125, 150 and 200 mCi). Comorbidities such as diabetes mellitus, coronary artery disease (CAD), heart failure, stroke, hypertension, peripheral artery disease, dyslipidaemia, chronic obstructive pulmonary disease (COPD) and asthma were defined based on ICD-10 codes. Chronic kidney disease (CKD) was determined as an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m 2 . 7 Definition of CVD included CAD, stroke and peripheral artery disease. Data on drug use such as RAS, acetylsalicylic acid and statins were collected. The primary endpoint was all-cause mortality. The secondary outcomes were the length of stay in the hospital and admitted to the intensive care unit (ICU) or mechanical ventilation need during hospitalization. All variables were assessed with descriptive statistics. The normality of data distribution was checked with the Kolmogorov-Smirnov test. mIU/L; P = .046). There was no significant difference in the comorbidity rates and the laboratory parameters between the RAI therapy group and the non-RAI group. Also, there was no difference in COVID-19 severity or mortality rates between the non-RAI and RAI groups ( Table 2) . Doses of RAI administered to patients were given in Table 1 . COVID-19 mortality and outcomes are given in table 3. The clinical and demographic properties of patients who survived and died for COVID-19 were compared in Table S2 . Significant variables associated with all-cause mortality were age, lymphopenia, diabetes mellitus, asthma/chronic obstructive pulmonary disease (COPD), heart failure, CKD and renin-angiotensin system (RAS) blocker usage in the thyroid cancer group (Table 4) . RAI treatment or high-dose RAI treatment history was not found to be associated with a prolonged hospital stay, ICU admission, mechanical ventilation or mortality (Table 4 ). In the whole group, multivariate analysis for predictors of hospitalization revealed three independent risk factors ( (30 to 50 The results of the present study show that the risk of mortality in Thyroid cancer is the most common form of endocrine cancers, and its incidence rate is increasing. 15 Authors would like to thank to all of our healthcare professionals in COVID-19 crisis, treating and monitoring patients, and ensuring these data were collected. We would like to extend our deepest gratitude, respect and appreciation in front of the memories of all healthcare heros who have lost their lives during Covid-19. All authors were involved in the interpretation, critically reviewed the first draft, and approved the final version. The authors have no conflict of interest. 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