We also wholly agree with Maitland et al that the association of older patients with lung cancer and COVID-19 is at best suggestive and requires validation in larger cohorts. Guidelines on contingency planning to adapt cancer treatment and infection control protocols have thus been proposed. Regarding the latter, it is widely recognized that repeated hospital visits for chemotherapy and radiotherapy pose a heightened risk of virus transmission to patients with cancer. The association of cigarette smoking would be difficult to ascertain without information on the number of pack-years and current cigarette smoking status moreover, the dose dependency of ACE2 upregulation by cigarette smoking is unclear. As raised by Dekker and Peng et al, cigarette smoking and repeat visitation to the hospital are potential risk factors for severe acute respiratory syndrome coronavirus 2 infection. The increased risk of infection is likely multifactorial. Nonetheless, in an age-matched case-control study, Dai and colleagues 3 observed that patients with cancer were more susceptible to in-hospital infection compared with patients without cancer (19.04% vs 1.49%). 2 To resolve this, one would need to perform an age-standardized comparison of incidence of COVID-19 cases between patients with cancer and patients without cancer. Compounding this conundrum, a study of 32 583 COVID-19 cases in Wuhan, China, from December 8, 2019, to March 8, 2020, revealed a positive association between the daily rate of cases and age (relative risk of 2.33 for patients aged 60-79 years compared with those aged 20-39 years). In our article, we had acknowledged that age is a confounder of our findings because most solid cancers tend to occur in older patients. We will attempt to respond to these points. Additionally, Maitland et al and Robinson et al queried our secondary observation that older patients with lung cancer represented a particularly susceptible subgroup. 1 These authors raised salient points on confounders, such as older age and cigarette smoking, on the higher incidence of coronavirus disease 2019 (COVID-19) in our cohort of patients with cancer. In Reply We thank Dekker, Peng et al, Maitland et al, and Robinson et al for their interest and insightful comments on our article. Shared Decision Making and Communication.Scientific Discovery and the Future of Medicine.Health Care Economics, Insurance, Payment.Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography.
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