International Academic Research Journal of Surgery
ISSN Print : 2789-6099 | ISSN Online : 2789-6102
Frequency : BI-Monthly
Language : English
Origin : Kenya
Website : https://www.iarconsortium.org/journal-info/iarjs
Research Article
The Impact of Covid on The Survival Rate of Cancer Patients.
Single Center Study At Moewardi Hospital Indonesia
Article History
Received: 10.01.2022
Revision: 18.01.2022
Accepted: 29.01.2022
Published: 10.02.2022
Author Details
Widyanti Soewoto*1, Ida Bagus Budhi Surya
Adnyana2, Muhammad Fahmi Salafuddin3,
Muhammad David Perdana Putra3, Galih
Santoso Putra3, Rizka Vinkan Septiani3,
Muhamad Muamar3, Ikhdin Radiamin
Saadhi3, Meirisa Ardianti3, Dea Alberta
Setiawati3, Rico Alfredo Hutabarat3 and
Dinar Kukuh Prasetyo3
Authors Affiliations
1Department
of
Surgery,
Oncology
Subdivision, Sebelas Maret University,
Indonesia
2Department
of
Surgery,
Digestive
Subdivision, Sebelas Maret University,
Indonesia
3Faculty
of Medicine, Sebelas Maret
University, Indonesia
Corresponding Author*
Widyanti Soewoto
How to Cite the Article:
Widyanti Soewoto, Ida Bagus Budhi Surya Adnyana
..& Dinar Kukuh Prasetyo. (2022). The Impact of
Covid on The Survival Rate of Cancer Patients.
Single Center Study At Moewardi Hospital
Indonesia. Int Aca Rea Jr Surg. 2(1) 36-44.
Copyright @ 2022: This is an open-access article
distributed under the terms of the Creative
Commons Attribution license which permits
unrestricted use, distribution, and reproduction
in any medium for non commercial use
(NonCommercial, or CC-BY-NC) provided the
original author and source are credited.
DOI:10.47310/iarjs.2022.v02i01.009
Abstract: Background: The novel coronavirus known as SARS-CoV-2 has
spread worldwide and caused the COVID-19 pandemic. In September 2020, more
than 32 million confirmed cases of COVID-19, with a death toll of more than
990,000. Among COVID-19 patients, those with cancer had worse outcomes than
those without malignancy, but in some studies, the mortality rates differed
significantly, ranging from 3.7% to 61.5%. Method: In this descriptive study,
survival analysis with the Kaplan Meier curve was used to determine the healing
rate of patients with cancer exposed to COVID-19 and undergoing treatment at dr.
Moewardi General Hospital Surakarta-Indonesia from February to December
2020, and the Log Rank test was used to analyze data on two related groups.
Results: The analysis using the Kaplan Meier method, female patients were found
to have a higher survival rate than females, paged <50 years had a higher survival
rate than those aged > 51 years, breast cancer had the lowest survival rate, and
comorbidity of anemia had a higher survival rate than those with other
comorbidities. The Log Rank test found a significant difference in the cumulative
survival rates of cancer patients with COVID-19 with a p-value of 0.010 for
comorbidity types. Meanwhile, from gender (p = 0.632), age (p = 0.672), type of
cancer (p = 0.472), there was no significant difference. Conclusion: COVID-19
female patients aged less than 50 years with types of malignancy other than breast
cancer and comorbidity of anemia have a higher survival rate.
Keywords: Survival Rate – Non-Solid Cancer – Solid Cancer – Comorbidity –
COVID -19.
INTRODUCTION
The coronavirus known as SARS-CoV-2 has spread worldwide,
resulting in more than 635,000 deaths as of July 2020 ( El Gohari et
al.,2020). Within two months, there was a spike of more than 32 million
confirmed cases of COVID-19, and more than 990,000 people died from
the virus. The mortality rate of COVID-19 patients is reported to be close
to 2%, leading to a drastic change in the world's life. The phenomena of
lockdown, social distancing, and setting curfews have become the new
norm in world life ( Ferrari et al., 2021; Assaad S et al., 2020).
Cancer is one of the most common diseases in the world. A total of
1,762,450 new cases were expected in the United States in 2019, with an
estimated death of 606,880 patients. Cancer affects multiple organs and
can weaken the immune system, controlling tumor cell growth and
regulating autoreactive responses. The effect of highly aggressive cancer treatment can temporarily weaken the immune
system and make cancer patients susceptible to contracting infections (Cavalcanti IDL,2019).
In Indonesia, based on Globocan 2020, from a total population of 273,523,621 million, there were 396,914 total cases
with breast cancer cases amounting to 65,858 (16.6%), cervical cancer 36,633 (9.2%), lung cancer 34,783 (8.8%),
colorectal cancer 34,189 (8.6%), liver cancer 21,392 (5.4%), and other cancers 204,059 (51.4%). Of this total, 234,511
deaths were recorded (IARC,2020).
Cancer patients are more at risk of COVID-19 infection with higher complication rates. Among those with COVID19, cancer patients have worse outcomes than those without malignancy, but some studies suggest that the mortality rate
differed significantly, ranging from 3.7% to 61.5% (Assaad, S. et al., 2020).
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Widyanti Soewoto et al., Int Aca Rea Jr Surg.; Vol-2, Iss- 1 (Jan-Feb, 2022): 36-44
Variability in mortality rates has been reported
across countries, which may be related to differences in
screening strategies and the effect of different
population susceptibility. The mechanism of cancer
patients may influence the risk of death from COVID19, whether this is related to the age group of cancer
patients, the underlying cause (smoking habits and
comorbidities). Cancer stage or recently applied
treatment remains unclear (Assaad S et al., 2020).
The lack of data on the number of cancer patients
who died from COVID-19 in Indonesia is an exciting
issue for conducting this research. This study took
samples from one center of an educational hospital,
namely dr. Moewardi Public Hospital SurakartaIndonesia.
MATERIAL AND METHOD
Patient Population
The research subjects were patients with solid and
non-solid cancers diagnosed with COVID-19,
undergoing treatment at dr. Moewardi General Hospital
Surakarta from February to December 2020 and
assessed in March 2021. The ethics committee has
approved this study of Sebelas Maret University no.
72/UN27.06.6.1/KEP/EC/2021.
The weakened immune system of cancer patients is
caused by various factors, including the level of
underlying malignancy and active cancer treatments
such as cytotoxic chemotherapy, radiotherapy, or even
from patients undergoing transplantation and the use of
immunosuppressants (Kalinsky, K. et al.,2020; Yang,
K. et al., 2020; Garassino, M. C., et al.,2020; Dai, M. et
al.,2020; Kim, H. I. et al.,2018; & Zahid, M. et
al.,2013). However, recent evidence suggests that the
death in cancer patients from COVID- 19 is driven
mainly by old age and comorbidities and is less likely to
use cytotoxic drugs. A study shows that most cancer
patients have a 25-28% risk of death when infected with
COVID-19 and other studies reported mortality rate
ranges from 18.2% in France 5.6%, in the USA, and
3,7% in Germany (Abdelhamid O et al.,2020; Vougant
P et al.,.2020).
Sample Collection
The data of this study are secondary (medical
records) and obtained from cancer patients exposed to
COVID-19, either with comorbidities or not, and
treated at dr. Moewardi General Hospital Surakarta
from February to December 2020.
Statistical Analysis
In this descriptive study, survival analysis with the
Kaplan Meier curve was used to determine the healing
rate of patients with cancer exposed to COVID-19 and
undergoing treatment at dr. Moewardi General Hospital
Surakarta from October 2020 to March 2021, the Log
Rank test was used to analyze the data on two related
groups.
This pandemic has had a profound and
unprecedented impact on the series of treatments for
cancer patients in terms of diagnosis, treatment
schedules, and follow-up. New and old patients lose
visitation time for routine control due to quarantine or
lockdown. Likewise, new patients may miss the early
diagnosis and patients with advanced cancer experience
delays or interruptions in regular care that lead to the
risk of disease progression.
RESULTS
Patient Characteristics
Table 1. Patient Characteristics
Characteristics
N
Gender
Male
Female
Age (Year)
< 51
≥ 51
Solid Tumor
Breast Cancer
Genitourinary Malignancy
Colorectal Malignancy
Gynecological Malignancy
Brain Malignancy
Lung Malignancy
Non-Solid Tumor
Acute myeloid leukemia (AML)
Chronic myeloid leukemia (CML)
Comorbidity
Hypertension
Diabetes Mellitus
Chronic Kidney Disease (CKD)
Anemia
Total
%
P-value
0.256
13
38
25.5
74.5
33
18
64.7
35.3
28
1
6
7
1
2
54.9
2.0
11.8
13.7
2.0
3.9
3
3
5.9
5.9
3
2
7
17
10.3
6.9
24.1
58.6
0.193
0.337
0.273
0.015
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Widyanti Soewoto et al., Int Aca Rea Jr Surg.; Vol-2, Iss- 1 (Jan-Feb, 2022): 36-44
Status
Survived
Dead
Cause of Death
COVID
Non-COVID
0.309
44
7
86.3
13.7
5
2
71.4
28.6
0.041
In this study, from February to December 2020, 51
cancer patients (25.5% men and 74.5% women) were
infected with COVID. A total of 33 people (64.7%)
aged less than 51 years, and 18 people (35.3%) were 51
years old and more. Based on the type of cancer, the
number of solid cancer patients is more than that of
non-solid cancer patients. The number of breast cancer
patients was 54.9%, patients with genitourinary
malignancy 2%, patients with colorectal malignancy
11.8%, patients with gynecological malignancy 13.7%,
patients with brain malignancy 2%, and patients with
lung malignancy 3.9%. In non-solid cancer, AML and
CML patients were 5.9%, respectively. Based on the
comorbidities, patients with hypertension were 10.3%,
diabetes mellitus 6.9%, CKD 24.1%, and the number of
patients with anemia was 58. 6%.
The results in the table above show no difference in
the survival rate of cancer patients with positive
confirmed COVID-19 in terms of gender, age, solid and
non-solid tumor types, and patient status (p > 0.05).
Then, based on comorbidities and cause of death, there
is a significant difference in comorbidities and survival
rates of cancer patients with confirmed positive
COVID-19 (p < 0.05).
Table 2. Causes of Death by Type of Cancer
Type of Cancer
Solid Cancer
Breast Cancer
Genitourinary Malignancy
Colorectal Malignancy
Gynecological Malignancy
Brain Malignancy
Lung Malignancy
Non-Solid Cancer
Acute myeloid leukemia (AML)
Chronic myeloid leukemia (CML)
In table 2, the results showed that 13.7% of the
research respondents' patients died, and 86.3% were
still alive. Based on the type of cancer, the number of
patients with breast cancer was 28.5%, gynecologic
malignancy 14.2%, lung malignancy 14.2%, and AML
14.2%.
Total
Mean (%)
Dead
28
1
6
7
1
2
54.9
2.0
11.8
13.7
2.0
3.9
2
2
1
1
3
3
5.9
5.9
1
-
The results showed that 71.4% of cancer patients
who died due to COVID-19 were two patients with
colorectal cancer, one with gynecological cancer, one
with lung malignancy, and one with AML, while 28.6%
died breast cancer.
Survival Rate
No
1
2
3
4
5
Characteristics
Gender
Age
Type of Cancer
Comorbidity
Death Status
Table 3. Log Rank Analysis
Significance
0.632
0.672
0.472
0.010
0.553
Statistically showed that gender (p 0.632), age (p
0,672), type of cancer (p 0.472), and death status (p
0.553) had no significant values (p > 0.05). There is no
significant difference in the cumulative chance of
survival of cancer patients affected by COVID-19 in
terms of gender, age, type of cancer, and death status
due to COVID-19 or not.
Remark
Insignificant
Insignificant
Insignificant
Significant
Insignificant
Meanwhile, based on comorbidities, the significance
value is 0.010 < 0.05, which means a significant
difference in the cumulative survival chances of cancer
patients with COVID-19 based on comorbidities.
Kaplan Meier Analysis
The following chart illustrates the estimated survival
rate of cancer patients affected by COVID-19.
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Widyanti Soewoto et al., Int Aca Rea Jr Surg.; Vol-2, Iss- 1 (Jan-Feb, 2022): 36-44
Figure 1. Kaplan Meier Analysis by Gender
It shows that the female chart is above the males. This means that female cancer patients with COVID-19 have a
higher chance of survival than females.
Figure 2. Kaplan Meier Analysis By Age
Based on the chart in figure 2, the graph of cancer patients with COVID-19 aged less than 51 is above that of those
aged 51 years and over. This means that patients with cancer affected by COVID-19 aged 50 years and under have a
higher survival rate than patients aged 51 years and over.
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Widyanti Soewoto et al., Int Aca Rea Jr Surg.; Vol-2, Iss- 1 (Jan-Feb, 2022): 36-44
Figure 3. Kaplan Meier Analysis by Type of Cancer
Patients who died from COVID-19 had AML,
breast, gynecological, colorectal, and lung cancer types.
Meanwhile, all patients with CML, genitourinary, and
nerve cancer survived. The chart shows that patients
with the fastest chance of dying are those with breast
cancer. It is indicated by the decrease in the number of
breast cancer patient charts earlier than the other charts.
It can be concluded that patients with breast cancer
exposed to COVID-19 have the lowest survival rates
than those with different types of cancer.
Figure 4. Kaplan Meier Analysis Based by Comorbidity
Based on comorbidities, the chart of cancer patients
with COVID-19 with comorbidity of anemia is above
that of cancer patients with other comorbidities. It
means that cancer patients with COVID-19 with
comorbidity of anemia have a higher survival rate than
comorbidities.
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Widyanti Soewoto et al., Int Aca Rea Jr Surg.; Vol-2, Iss- 1 (Jan-Feb, 2022): 36-44
Figure 5. Kaplan Meier Analysis by Cause of Death
Based on the chart of death from COVID or not, it is
known that COVID patients have a greater chance of
dying than non-COVID patients. This is shown by the
COVID chart above the non-COVID chart. It means
that COVID patients have lower survival rates than
non-COVID patients.
In this study, from 51 cancer patients with
confirmed COVID-19, 44 patients (86.3%) were
discharged alive, and seven patients (13.7%) died. Of
the 44 patients who lived, ten patients were male, and
34 were female. Of the seven patients who died, three
patients were male, and four were female. More
extensive studies have found significantly different
mortality rates; for example, a prospective
observational cohort study from the U.K. reported a
35.4% mortality rate (617 deaths among 1,743 patients
with COVID-19 and cancer) while the most recent
update of COVID-19 and the Cancer Consortium
(CCC-19) showed a mortality rate of 15.8% (433 deaths
in the cohort of 2,749 patients with both diseases)
(Yang K et al.,2020; Garassino et al.,.2020; Dai et
al.,2020)
Comorbidities presented play a role in our
human body's function to fight and survive the COVID19 virus. It weakened our immune system from the
disease and the management itself in many cases.
Especially, as per the chart, in those groups with a
history of cancer, cardiac disease, and anemia. Many
policies have been put in place to minimize this risk,
such as social distancing, wearing masker anywhere and
anytime, staying and working at home, washing and
cleaning your hands more often, and avoiding crowded
places. However, such policies may also limit cancer
patients to healthcare facilities. Their psychological
response could presume that they may have utmost risk
and be the most vulnerable group in this pandemic
situation, resulting in withdrawal from healthcare
management or hospitalized treatment.
The research results with 25.5% males and 74.5%
females, most aged below 51 years. Sex hormones may
contribute to the difference in cancer incidence between
men. Women. Estrogen is closely associated with
higher rates of thyroid cancer development in women.
Estrogen increases the proliferation of human papillary
thyroid carcinoma cell lines. It promotes the expression
of extra-large B-cell lymphoma (Bcl-XL), known as an
anti-apoptotic protein, compared to testosterone.
Endogenous female hormones such as progestins
increase bile acid excretion, which has been suggested
as a potential trigger for colon cancer. Exogenous
estrogens decrease secondary bile acid production,
responsible for inducing malignant changes in the
colonic epithelium. Therefore, female hormones may
play a protective role in developing colon cancer by
lowering bile acid levels ( Kim H,2018; Zahid M, 2013;
Derwahl M et al.,2014; Dong W,2013).
DISCUSSION
The coronavirus 2019 (COVID-19) pandemic,
caused by the beta-coronavirus, severe acute respiratory
syndrome, coronavirus 2 (SARS-CoV-2), has spread
globally and caused many deaths. This research was
carried out at dr. Moewardi General Hospital Surakarta
from February to December 2020, 51 cancer patients
with COVID-19 were found. Several studies have
concluded that among patients with COVID-19, cancer
patients cancer had worse outcomes than those without
malignancy, but mortality rates differed significantly
between studies, ranging from 3.7% to 61.5%
(Kalinsky,2020).
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Widyanti Soewoto et al., Int Aca Rea Jr Surg.; Vol-2, Iss- 1 (Jan-Feb, 2022): 36-44
In this study, many predictive risk factors for the
death of cancer patients affected by COVID-19 are like
data published by previous studies. A recent metaanalysis highlighted the association of chronic diseases
including hypertension (OR: 2.29), diabetes (OR: 2.47),
chronic obstructive pulmonary disease (COPD) (OR:
5.97), cardiovascular disease (OR: 2.93), and
cerebrovascular disease (OR: 3.89) with a risk of
developing severe COVID-19 infection among all
patients. Based on the cancer patient dataset in this
study, most patients had at least one risk factor. In a
univariate model, a survey by Mehta Vikas stated that
there was a significant relationship between death from
COVID-19 infection in patients with hypertension,
chronic lung disease, coronary heart disease, and
congestive heart failure (Mehta V et al., 2020).
Cancer patients affected by COVID-19 with breast
cancer have the highest chance of death than those with
other cancers. The solid chart indicates this above the
non-solid chart. It means that cancer patients affected
by COVID-19 with breast cancer have the lowest
survival rates than those with different types of cancer.
Severe COVID-19 and death in cancer patients were
significantly associated with age, disease severity,
multiple comorbidities, and habits such as smoking
status. A study conducted by Mehta et al. in 2018 on
cancer patients with SARS-CoV-2 infection showed
that older age was significantly associated with
increased mortality from COVID-19, aligned with some
other studies ( Pathania AS et al.,2020; Chen M et
al.,2020; Ho F.K. et al.,2020).
Patients with hematological malignancies, including
leukemia, lymphoma, and myeloma, had the highest
mortality rates, followed by patients with lung cancer
and esophageal cancer.70 Meanwhile, breast malignancy
ranks fifth regarding the mortality rate of cancer
patients affected by COVID-19. Patients with
hematological malignancies tend to have more extended
hospitalization and higher mortality than solid
tumors.71,72 These patients tend to be treated with
myelosuppressive therapy and are often severely
immunocompromised because of the underlying
disease.73,74 There were 3 sample patients with
hematology oncological malignancies; one of the three
treated patients died. There is accumulating evidence
that one of the main mechanisms of injury may be
cytokine-storm syndrome secondary to hyperinflammation, leading to lung damage. Patients with
hematological malignancies may be potentially more
susceptible to cytokine-mediated inflammation due to
disruption of the myeloid cell and lymphocyte
compartments (Shoumariyeh K et al..,2020; Vijenthira
A et al.,2020).
The analysis of the Kaplan Maier test based on
gender showed that female cancer patients with
COVID-19 had a higher chance of survival than male
cancer patients. A meta-analysis study by Biswas,
Mohitosh showed that male patients with COVID-19
were associated with a significantly increased risk of
death than female patients (RR 1.86: 95% CI 1.67–2.07;
p < 0.00001). Interestingly, when comparing gender
with a positive test for SARS-CoV-2, it was found that
male patients were associated with only a 28%
increased risk of infection confirmed by the SARSCoV-2 pandemic than female patients (RR1.28: 95% CI
1.11–1.47; p = 0.0006). Without appropriate
explanatory and confirmatory mechanisms, it may not
make sense to explain why mortality is significantly
higher in male COVID-19 patients than in females.
Based on the previous review, it has been suggested that
male patients may have higher expression of
angiotensin-converting enzyme 2 (ACE2), which can be
regulated by male hormones, making them more at risk
for SARS-CoV-2 infection and poor clinical outcome
(Biswas M et al.,2020).
Kaplan Maier's analysis of the effect of
comorbidities found that cancer patients with COVID19 and comorbidity of anemia had a higher survival rate
than patients with other comorbidities. Contrary to
previous studies, Covid 19 and Anemia are associated
with poor outcomes. In the U.S., the Centers for
Disease Control (CDC) uses COVID-Net in 14 states to
monitor the demographics of COVID-19 inpatients. As
of January 30, 2020, a total of 180 patients used
COVID-Net, 89.3% of whom had underlying
comorbidities. Of the 180 patients, 94.4% aged 65 years
and over had comorbidities. Several studies support the
most common comorbidities in Covid 19 patients are
obesity, hypertension, and diabetes mellitus (Dinevari
MF et al., 2021; Garg S et al., 2020; Kaur H et
al.,2020).
From Kaplan Maier's age analysis in this study,
patients with cancer affected by COVID-19 aged 50
years and under have a higher survival rate than patients
aged 51 years and over. A retrospective study of
middle-aged and elderly patients with COVID-19 found
that the elderly population is more susceptible to the
disease and more likely to be admitted to the ICU with
a higher mortality rate (Liu K et al., 2020). Age-related
changes in the geriatric population may be due to lung
anatomy and muscle atrophy resulting in altered
physiologic function, decreased lung reserve, decreased
airway clearance. There is a correlation between age
and innate immunity. Other studies have concluded that
the elderly are particularly vulnerable to more
infections because natural immunity decreases
gradually with older age. The elderly are also
susceptible to adverse drug reactions, partly due to
reduced organ function in older age or the use of
multiple drugs due to comorbidities (Sanyaolu A et
al.,2020).
From the cases that emerged, comorbidities were
observed to increase the likelihood of infection. In a
cohort study of 7,337 patients with COVID-19 with and
without type-2 diabetes mellitus, those with type-2
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diabetes mellitus required an increased intervention for
the hospital stay compared to those without diabetes
mellitus (Deng QS,2020).
put in place, which may implicate limited access for
cancer patients to healthcare.
CONFLICT OF INTEREST:
The authors declare no potential conflicts of interest
Based on the study by Biswas M, the effects of
various comorbidities such as hypertension, diabetes
mellitus, respiratory disease, cardiovascular disease,
cerebrovascular disease, kidney disease, liver, and
cancer were compared between the survivors and nonsurvivors with these comorbidities. All of these
comorbid conditions, except liver, were significantly
higher in non-survivors compared with survivors;
hypertension (RR 1.95: 95% CI 1.58–2.40; p <
0.00001), diabetes (RR 1.97: 95% CI 1.48–2.64; p <
0.00001), and respiratory disease (RR 2.74: 95% CI
2.04–3.67; p < 0.00001; cardiovascular disease (RR
3.05: 95% CI 2.20-4.25; p < 0.00001) and
cerebrovascular disease (RR 4.78; 95% CI 3.39-6.76; p
< 0.00001; renal disease (RR 4.90: 95% CI 3.04–7.88; p
< 0.00001), liver (RR 1.64: 95% CI 0.82–3.28; p =
0.16), and cancer (RR 1.89; 95% CI 1.25–2.84; p =
0.002).
FINANCIAL SUPPORT:
The authors received no financial support for this
article's research, authorship, and publication.
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comorbidities (except liver disease) have a significantly
increased risk of death, as per the study reported. 96 The
median prevalence of COVID-19-related deaths as
identified by the analysis was 5.1%. Since SARS-CoV2 is rapidly evolving and has an extreme capacity to
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CONCLUSION
COVID-19 patients with cancer have worse
outcomes compared to those without malignancy.
COVID-19 female patients aged less than 50 years with
breast cancer but without comorbidities have a higher
chance of survival. In this study, cancer patients
affected by COVID-19 were dominated by women.
Comorbidities also affect the outcome of cancer
patients with COVID-19. The mortality rate for cancer
patients affected by COVID is still high. In addition to
cancer progression, the high mortality rate is caused by
the patient's comorbidity.
As we may know, the Immunity level may play a
role in the outcome of the COVID-19 patient.
Supported from previous studies, this research
concluded that comorbidities, especially cancer in
COVID-19 patients, worsen the effect. Our body's
metabolic and systemic function also affected any of the
comorbidities that COVID-19 patients previously had,
weakening our body fighting response. To minimize the
spreading of COVID-19, policies such as social
distancing, lockdown, and work from home have been
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