Cancer is considered a risk factor for COVID-19 mortality, yet several countries have reported that deaths with a primary code of cancer remained within historic levels during the COVID-19 pandemic. Here, we further elucidate the relationship between cancer mortality and COVID-19 on a population level in the US. We compared pandemic-related mortality patterns from underlying and multiple cause (MC) death data for six types of cancer, diabetes, and Alzheimer's. Any pandemic-related changes in coding practices should be eliminated by study of MC data. Nationally in 2020, MC cancer mortality rose by only 3% over a pre-pandemic baseline, corresponding to ~13,600 excess deaths. Mortality elevation was measurably higher for less deadly cancers (breast, colorectal, and hematological, 2-7%) than cancers with a poor survival rate (lung and pancreatic, 0-1%). In comparison, there was substantial elevation in MC deaths from diabetes (37%) and Alzheimer's (19%). To understand these differences, we simulated the expected excess mortality for each condition using COVID-19 attack rates, life expectancy, population size, and mean age of individuals living with each condition. We find that the observed mortality differences are primarily explained by differences in life expectancy, with the risk of death from deadly cancers outcompeting the risk of death from COVID-19.
Keywords: COVID-19; cancer; cancer biology; epidemiology; excess mortality; global health; none.
Establishing the true death toll of a pandemic like COVID-19 is difficult, as laboratory testing is generally too limited to directly count the number of deaths that can be attributed to a particular pathogen. To overcome this, researchers analyse excess mortality – that is, they compare the observed number of deaths with the expected level based on trends in prior years. These techniques have been used for over 100 years to estimate the burden of pandemic influenza and became a popular way to estimate deaths due to the COVID-19 pandemic. Excess mortality can also reveal the impact of COVID-19 on sub-populations with chronic conditions. For example, previous studies showed that deaths with diabetes, heart disease and Alzheimer’s disease listed as the primary cause of death increased during waves of COVID-19. Cancer deaths did not show such a pattern, however, despite some epidemiological studies identifying cancer as a risk factor for COVID-19 mortality. To understand why this may be the case, Hansen et al. reviewed death certificates from different states in the United States during the first year of the pandemic. Their analyses of multiple-cause death records (listing cancer anywhere on the death certificate, not just as the primary cause of death) showed that death certificate coding practices during the pandemic did not explain the absence of excess cancer mortality. While a low level of excess mortality was detectable for cancers with longer life expectancy (breast cancer, for example), no elevation was observed for cancers with lower life expectancy, such as pancreatic cancer. The analyses demonstrate that the lack of excess mortality for especially deadly cancers can be explained through competing risks – in other words, the high risk of dying from the cancer itself vastly outweighs the additional risk posed by COVID-19. These findings shed light on how competing mortality risks might mask the true impact of COVID-19 on cancer mortality and explain the apparent discrepancy between cohort studies and excess mortality studies. To fully comprehend the impact of COVID-19 on patients living with cancers, future research should look at the possibility of longer-term increases in cancer mortality due to late diagnosis during pandemic lockdowns, and an elevated risk of severe illness.