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RESEARCH 

Race is Related with Increased COVID-19 
Infection in Oncology Patients 
John Nakayama*a, Gino Cioffib,I, Sharanya Iyerc, Ravi Kumar Kyasaramd, John Shanahand, Paolo Caimie, 
Kristin A. Waiteb,I, Thomas A. Sellersf, Jill S. Barnholtz-Sloanb,g,h,i 

a Division of Gynecologic Oncology, Department of Obstetrics and Gynecology University Hospitals 
Cleveland Medical Center. Cleveland, Ohio. USA b Department of Population and Quantitative Health 
Sciences, Case Western Reserve University School of Medicine. Cleveland, Ohio. USA c Case Western 
Reserve University School of Medicine. Cleveland, Ohio. USA d Cancer Informatics, Seidman Cancer 
Center. Cleveland, Ohio. USA e Division of Hematology, Department of Medicine, University Hospitals 
Seidman Cancer Center. Cleveland, Ohio. USA f TAS Consulting. Tampa, Florida. USA g Case 
Comprehensive Cancer Center. Cleveland, Ohio. USA h Research and Education Division, University 
Hospitals of Cleveland. Cleveland, Ohio. USA i Cleveland Center for Health Outcomes Research (CCHOR). 
Cleveland, Ohio. USA 
Corresponding author: John Nakayama. Email: john.nakayama@ahn.org  

ABSTRACT 
We seek to assess racial disparities in oncology patients with COVID19 compared to appropriately 
matched controls with and without COVID19. All patients treated at the Seidman Cancer Center with a 
diagnosis of COVID19 and cancer were identified from the electronic medical record using ICD9/ICD10 
codes for cancer diagnoses and database of all patients diagnosed with COVID19. Two control groups, 
cancer patients without COVID19 and patients without cancer but with COVID19, were generated and 
matched 3:1 on age at date of data extraction, age at cancer diagnosis, and sex to COVID19 positive 
cancer cases. African Americans (AA) and Whites made up 8.6% vs. 76.9% of the baseline oncologic 
population without COVID19, respectively. AA representation (41.0%) was significantly increased in cancer 
patients positive for COVID19 compared to those negative for COVID19 (p<0.001). In the comparison of 
patients with COVID19 with or without cancer, the proportion of AA cases was greater in the non-
oncologic population (41.0% vs. 47.6%, p=0.014). AA are disproportionately affected with COVID19 in 
oncologic and benign populations. Despite similar rates of adverse outcomes to COVID19 in cancer 
patients by race, we found a 32.4% increase in the AA proportion compared to those without COVID19. 
These findings suggest COVID19 prevention policies and future studies should account for racial 
differences in the oncology population. 

KEYWORDS: COVID19, coronavirus 19, racial disparities, oncology, 

Citation: Nakayama J et al (2021) Race is Related with Increased COVID-19 Infection in Oncology Patients. 
Cancer Health Disparities 5:e1-e8.doi:10.9777/chd.2021.1004 
 
 

mailto:john.nakayama@ahn.org


 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e2 Cancer Health Disparities 

RESEARCH 

Introduction 
The novel coronavirus SARS-CoV-2 (COVID19) 
pandemic led to radical shifts in oncology care. New 
reports indicate that cancer patients have increased 
morbidity and mortality from COVID191–4. One 
study from New York, showed 40% of cancer 
patients with COVID19 required hospital admission. 
Older age (>65 years) and recent immunotherapy 
predicted admission and disease severity while 
chemotherapy or surgery did not5. These findings 
may not be generalizable given that the proportion 
of minority subjects was lower than other studies 
conducted in the same area3,6. In an attempt to 
overcome some of the limitations of prior studies,a 
case control study of Chinese COVID19 patients 
with and without cancer was performed. It showed 
oncology patients had a nearly significant increased 
risk of death (OR: 2.17, p= 0.06) and significantly 
more ICU admissions (OR: 3.13, p<0.01) or at least 
one severe symptom (OR: 1.99, p<0.01)7. 

Cancer patients are often obliged to continue care. 
During the COVID19 pandemic this can be 
dangerous for patients who lack the resources or 
ability to limit their exposure. While higher COVID19 
infection rates have been observed in minority 
communities through the lay press and editorials, a 
limited body of scientific literature is available3,8. A 
recent study using Veteran’s Affairs (VA) data 
showed a higher prevalence of COVID19 infection 
and hospitalization, but not mortality, in African 
Americans (AA)9. This data may not be 
generalizable due to the unique VA population. 

Given these realities and the racially diverse 
population of the University Hospitals Seidman 
Cancer Center (UHSCC), we investigated the 
dynamics of COVID19 infection in oncology patients 
in order to: (1) determine the demographic 
differences between cancer patients infected with 
COVID19 versus COVID19 infected patients without 
a cancer history, (2) compare the outcomes of 

cancer patients infected with COVID19 to patients 
without cancer who are infected with COVID19, and 
(3) compare characteristics and outcomes of cancer 
patients infected with COVID19 to cancer patients 
without COVID19 diagnosis. 

Materials and Methods 
After receiving approval by UHSCC institutional 
review board, a search from 3/16/2020 to 7/7/2020 
was performed of all patients treated at the 
Seidman Cancer Center. A cancer diagnosis was 
determined by searching the electronic medical 
record for a cancer ICD9/10 code and then 
manually verifying the cancer diagnosis. COVID19 
positive patients were identified using a database 
maintained by the hospital of all patients diagnosed 
with COVID19. Adult (>18years old), COVID19 
positive oncology patients were identified 
(CA+/COVID+). Two control groups, cancer 
patients without COVID19 (CA+/COVID-) and 
patients without cancer but with COVID19 (CA-
/COVID+), were generated. The CA+/COVID- 
group was matched based upon age at date of data 
extraction, age at cancer diagnosis, and sex at 3:1, 
and the CA-/COVID+ group was matched for age 
at data extraction at 3:1 (Figure 1). The weighted 
Elixhauser-comorbidity score was used to quantify 
the rate of comorbid medical conditions present in 
each group10,11. Descriptive statistics were generated 
using R software (version 3.6.3) to assess 
demographic and treatment differences between 
Cases and each control group. T-tests were 
performed to compare differences in mean and 
Chi-square tests assess differences in proportion. A 
p < 0.05 was considered statistically significant. 



 
 
 
 
 

 
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Figure 1. Flow diagram of included patients 

 

A total of 166 Cases were identified (Table 1). The 
median follow-up time was 53 days from COVID19 
diagnosis. Distribution of cancer differed between 
the CA+/COVID+ and CA+/COVID- groups 
(p=0.026), with a notably higher proportion of oral 
cavity and pharynx cancers in the CA+/COVID- 
population (0.6% compared to 4.2%, 
p=0.045). Cancer related treatment in 
CA+/COVID+ patients was uncommon with 7.2% 
and 0.6% of patients receiving chemotherapy or 
radiation, respectively, within 30 days of their 
COVID19 diagnosis. Only 4 CA+/COVID+ patients 
(2.4%) had a surgery in the year prior to their 
COVID19 diagnosis. 

Significant racial differences were identified 
between groups. The racial distribution of patients 
in the CA+/COVID- group was 8.6% AA vs. 76.9% 
White (Table 1). A significantly higher proportion of 
AA, 41.0%, was noted in patients with cancer and 

COVID19 (p<0.001). In the comparison of 
CA+/COVID+ to CA-/COVID+, the proportion of 
AA patients was greater in the non-oncologic 
population (41.0% vs. 47.6%, p=0.014). 

Measures associated with COVID19 severity were 
examined. A weighted Elixhauser Comorbidity 
score >5 was present in 91.6% of CA+/COVID+ 
patients compared to 82.3% (p=0.003) of 
CA+/COVID- and 52.3% (p<0.001) of CA-/COVID+ 
patients. Over 1 in 5 (22.3%) of the CA+/COVID+ 
patients were admitted to the ICU. This was not 
significantly greater than the CA-/COVID+ (16.3%, 
p= 0.101). There was no difference in ventilator use 
(p=0.999). The death rate from COVID19 was 3.0% 
in the CA-/COVID+ group versus 4.8% in the 
CA+/COVID- group, which was not statistically 
significant (p=0.391). 

The CA+/COVID+ group was further stratified by 
race (Table 2). There was no difference in types of 
cancer (p=0.394) and comorbidity score by race 
(p=.794). Outcomes were equivalent between racial 
groups in terms of ventilator use (94.7% vs. 95.6%, 
p=0.999), ICU admission (76.8% vs. 77.9%, 
p=0.999), and death (94.7% vs. 95.6%, p=0.999). 

 

 

 

 

 

 

 

 

 



 
 
 
 
 

 
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RESEARCH 

Table 1. Descriptive statistics of patients diagnosed with primary cancer and COVID19 with corresponding 
Cancer and COVID19 controls. 

 Patients with cancer 
and COVID19 

(Cancer+/COVID+) 

Patients with cancer 
without COVID19 

(Cancer+/COVID-) 

P* Patients with cancer 
without COVID19 

(Cancer-/COVID+) 

P* 

Overall n 166 498  498  

Age at Cancer 
Diagnosis, Mean 
(SD)[Range] 

63.5 (15.0) [19-91] 63.5 (15.0) [19-91] 0.99 -- -- 

Age at COVID 
Diagnosis, Mean 
(SD)[Range] 

68.2 (15.1) [26-97] -- -- 68.2 (15.1) [26-97] 0.86 

Gender, n (%) 

Female 97 (58.4%) 291 (58.4%) 0.999 303 (60.8%) 0.647 

Male 69 (41.6%) 207 (41.6%)  195 (39.2%)  

Race, n (%) 

White 95 (57.2%) 383 (76.9%) <0.001 218 (43.8%) 0.014 

African American 68 (41.0%) 43 (8.6%)  237 (47.6%)  

Other 2 (1.2%) 39 (7.8%)  20 (4.0%)  

 Unknown 1 (0.6%) 33 (6.6%)  23 (4.6%)  

Ethnicity, n (%) 

Hispanic 2 (1.2%) 5 (1.0%) 0.999 0 (0.0%) 0.137 

Non-Hispanic 160 (96.4%) 453 (91.0%)  418 (83.9%)  

Unknown 4 (2.4%) 40 (8.0%)  80 (16.1%)  

First Cancer, n (%) 

Bones and Joints 3 (1.8%) 6 (1.2%) 0.026 -- -- 

Brain and Other 
Nervous System 

3 (1.8%) 19 (3.8%)  --  

Breast 31 (18.7%) 96 (19.3%)  --  

Digestive System 20 (12.0%) 92 (18.5%)  --  

Endocrine System 8 (4.8%) 11 (2.2%)  --  

Female Genital 
System 

11 (6.6%) 30 (6.0%)  --  

Leukemia 10 (6.0%) 18 (3.6%)  --  

Lymphoma 8 (4.8%) 18 (3.6%)  --  



 
 
 
 
 

 
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RESEARCH 

Male Genital System 22 (13.3%) 52 (10.4%)  --  

Oral Cavity and 
Pharynx 

1 (0.6%) 21 (4.2%)  --  

Respiratory System 14 (8.4%) 39 (7.8%)  --  

Skin 5 (3.0%) 39 (7.8%)  --  

Urinary System 11 (6.6%) 20 (4.0%)  --  

Other/Unspecified 19 (11.4%) 37 (7.4%)  --  

Weighted Elixhauser Comorbidity Score, n (%) 

<0 3 (1.8%) 16 (3.2%) 0.003 122 (26.2%) <0.001 

0 2 (1.2%) 48 (9.6%)  60 (12.9%)  

1-4 9 (5.4%) 24 (4.8%)  40 (8.6%)  

>=5 152 (91.6%) 410 (82.3%)  243 (52.3%)  

Ventilator Use, n (%)      

No 158 (95.2%) -- -- 476 (95.6%) 0.999 

Yes 8 (4.8%) --  22 (4.4%)  

Admitted to ICU, n (%) 

No 129 (77.7%) -- -- 417 (83.7%) 0.101 

Yes 37 (22.3%) --  81 (16.3%)  

Died within 30 Days of COVID Diagnosis 

No 158 (95.2%) -- -- 483 (97.0%) 0.391 

Yes 8 (4.8%) --  15 (3.0%)  

*: p considered significant if <0.05, SD: standard deviation 

Table 2. Descriptive statistics of cases (Cancer+/COVID19+) stratified by Race. 

 Study Population (Cancer+/COVID19+)  

 White Black P* 

Overall n 95 68  

Age at Cancer Diagnosis, Mean (SD) 65.0 (13.7) 61.8 (15.5) 0.162 

Age at COVID Diagnosis, Mean (SD) 69.4 (14.3) 66.8 (15.6) 0.276 

Gender, n (%)    

Female 55 (57.9%) 40 (58.8%) 0.999 

Male 40 (42.1%) 28 (41.2%)  

Ethnicity, n (%)    



 
 
 
 
 

 
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RESEARCH 

Hispanic 2 (2.2%) 0 (0.0%) 0.609 

Non-Hispanic 89 (97.8%) 68 (100.0%)  

Unknown 0 (0.0%) 4 (4.2%)  

First Cancer, n (%)    

Bones and Joints 1 (1.1%) 2 (2.9%) 0.394 

Brain and Other Nervous System 2 (2.1%) 1 (1.5%)  

Breast 13 (13.7%) 17 (25.0%)  

Digestive System 13 (13.7%) 6 (8.8%)  

Endocrine System 3 (3.2%) 4 (5.9%)  

Female Genital System 8 (8.4%) 3 (4.4%)  

Leukemia 6 (6.3%) 4 (5.9%)  

Lymphoma 5 (5.3%) 3 (4.4%)  

Male Genital System 11 (11.6%) 11 (16.2%)  

Oral Cavity and Pharynx 1 (1.1%) 0 (0.0%)  

Respiratory System 10 (10.5%) 9 (13.2%)  

Skin 11 (11.6%) 3 (4.4%)  

Urinary System 5 (5.3%) 0 (0.0%)  

Other/Unspecified 6 (6.3%) 5 (7.4%)  

Weighted Elixhauser Comorbidity Score, n 
(%) 

   

<0 2 (2.1%) 1 (1.5%) 0.794 

0 1 (1.1%) 0 (0.0%)  

1-4 4 (4.2%) 4 (5.9%)  

>=5 88 (92.6%) 63 (92.6%)  

Ventilator Use, n (%)    

No 90 (94.7%) 65 (95.6%) 0.999 

Yes 5 (5.3%) 3 (4.4%)  

Admitted to ICU, n (%)    

No 73 (76.8%) 53 (77.9%) 0.999 

Yes 22 (23.2%) 15 (22.1%)  

Died within 30 Days of COVID Diagnosis    

No 90 (94.7%) 65 (95.6%) 0.999 

Yes 5 (5.3%) 3 (4.4%)   



 
 
 
 
 

 
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RESEARCH 

*: p considered significant if <0.05 

Discussion 
This study reflects the disproportionate effect of 
COVID19 on AA with and without cancer. AA 
normally make up 8.6% of the oncology patients at 
UHSCC as shown in the CA+/COVID- group. 
However, this increases over 4.5 times to 41.0% of 
oncology patients with COVID19 infections. Further 
studies evaluating socioeconomic factors that limit 
the ability to social distance or work remotely as well 
as other social determinants of health are needed 
to determine why this disparity exists. Interestingly, 
the proportion of AA is even greater (47.6%) in 
non-oncologic patients (CA-/COVID19+) than 
oncology patients (CA+/COVID19+). To our 
knowledge, this has not been previously reported. 
Cancer patients may be taking additional 
precautions that ameliorate identified factors 
predisposing this community to COVID198,12. 
Alternatively, the smaller proportion of AA among 
cancer patients could reflect impaired access to 
cancer care which would decrease the likelihood of 
COVID19 testing; such an investigation was beyond 
the scope of this report. 

There was no difference in ventilator use, ICU 
admission, or death in cancer patients with 
COVID19 versus patients without cancer. This 
finding remained true when stratified by race. This 
absence of difference in COVID19 related 
complications occurred despite cancer patients 
having a greater proportion of patients with 
elevated comorbidity scores and could be related 
to the low percentage of patients receiving active 
treatment, a known risk factor for worse outcomes 
4,7,13–15. 

This study has several limitations. Given its 
retrospective nature, it was not possible to control 
for rapidly evolving COVID19 care, however, the 
limited time frame of interest minimizes the effects 

of cancer care specifics to mortality and morbidity. 
The study population was that of a large urban 
academic center and may not represent other 
patient groups. 

This study illustrates the disproportionate effect of 
COVID19 on AA oncology patients. Despite similar 
rates of adverse outcomes to COVID19 amongst 
racial groups, the proportion of AA patients was 
significantly higher among cancer patients with 
COVID19 when compared with controls without 
COVID19. These findings suggest racial differences 
in COVID19 rates in the oncology population should 
inform infection control efforts like vaccination 
programs as well as future study designs to protect 
vulnerable populations. 

Acknowledgement 
None 

Conflicts of interest 
The authors declare no conflict of interest. 

Authors' contributions 
Design: Nakayama, Cioffi, Waite, Sellers, Barnholtz-
Sloan, Caimi, Sellers 

Data collection: Nakayama, Iyer, Kyasaram, 
Shanahan 

Analysis: Nakayama, Cioffi, Iyer, Caimi, Waite, 
Sellers, Barnholtz-Sloan  

Manuscript: Nakayama, Cioffi, Iyer, Caimi, Waite, 
Sellers, Barnholtz-Sloan 

 

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	Introduction
	Materials and Methods
	Results
	Discussion
	Acknowledgement
	Conflicts of interest
	Authors' contributions

