Clinical Challenges: Lung Cancer and COVID-19

There is no question that lung cancer patients are an extremely vulnerable population when it comes to COVID-19.

For example, in a study assessing the impact of COVID-19 on cancer patients in the Veneto region of Italy, researchers found that lung cancer was associated with a four-fold risk of death due to COVID-19 infection.

And in a study published in the Annals of Oncology in June, researchers from Memorial Sloan Kettering Cancer Center (MSKCC) reported that among 102 patients with lung cancer and COVID-19, 62% ended up being hospitalized, and 25% died. Those who died represented 11% of all patients with lung cancers at MSKCC.

“Our results [highlight] both the urgent vulnerability of patients with lung cancer during this pandemic as well as the persistently critical need to continue, and drive improvements in, optimal cancer care,” the authors of that study wrote.

“Most of the data suggests that patients on active treatment may be at risk,” said Brendan Stiles, MD. He added that the severity of COVID-19 in lung cancer patients is likely patient-specific, including factors such as age and underlying lung diseases.

“Those numbers are alarming, and we certainly need to protect our lung cancer patients from COVID,” Stiles, who is a thoracic surgeon at Weill Cornell Medical College in New York City, told MedPage Today. “At the same time we need to find safe ways to continue to treat them.”

With COVID-19 now surging nationwide, current efforts to screen, diagnose, and manage patients with lung cancer are like shooting at a moving target, Stiles said

“And that makes it challenging,” said Stiles, adding that this problem is “defined by rates of positivity, the resources in your hospital, and the strengths of different groups within your hospital.”

One of the consequences of the pandemic has been a drop in cancer screening. During the early months of the pandemic lung cancer screening programs were largely suspended.

Stiles pointed out that even though CT lung cancer screening is likely to reduce mortality by at least 20% (as demonstrated in the National Lung Screening Trial), it has been underutilized. A February 2020 report from the CDC found that only about one in eight adults who met U.S. Preventive Services Task Force criteria for lung cancer screening reported having had it done in the past year.

“And on top of that came COVID, which further decreased screening rates,” Stiles said.

“We know that screening decreases deaths from lung cancer – and we know it may find other medical issues, so we’ve got our lung cancer screening program [at Weill Cornell Medicine] back up and running,” Stiles said. “And we are doing it carefully, making sure to space out the waiting rooms and radiology facilities and that everyone wears masks.”

Furthermore, he said, some of the aspects of lung cancer screening, such as discussions with patients about the need for it, or the shared decision-making that accompanies results from it, can be done with telemedicine. “I think best practice is now to do that remotely, and that makes sense for a lot of patients,” Stiles said. “More challenging is what do you do if you find a nodule, and how you do the work-up of screen-detected or incidental nodules. Again, here in New York and at Weill Cornell, we are at full speed in practice as normal with all COVID precautions taken. However, in the heat of COVID that sometimes changes practice.”

There are studies suggesting that, for higher stage patients, as many as 60% may have some disruption or change in their treatment plan as a result of COVID, said Stiles. This involves anything from stopping therapy, changing dosing schedule, or changing therapy, to treatment more amenable to outpatient therapy.

“So, we’ve already seen that it’s dramatically affected the treatment of different kinds of lung cancer,” he said.

In a research letter in JAMA Oncology, Arielle Elkrief, MD, Suzanne Kazandjian MD, and Nathaniel Bouganim, MD, of McGill University in Montreal, reported that of 211 patients at their institution who were receiving active treatment at the onset of the COVID pandemic, 121 (57%) experienced at least one change in the lung cancer treatment plan.

Elkrief pointed out that most changes encompassed a delay or cessation of palliative chemotherapy. She and her colleagues also found that among patients on active therapy who experienced a treatment change, 2.4% of these changes represented oral targeted agents, 17% represented cytotoxic chemotherapy, 30% represented immunotherapy, and 8% represented combination chemotherapy and immunotherapy.

“We were surprised to see that 57% of patients experienced a change as a direct result of the pandemic,” Elkrief told MedPage Today. “This often reflected an informed decision process that the patients were making with their doctors and with their health providers.”

Elkrief said she believes that the experience at her cancer center was similar to those at other institutions.

“As cancer doctors we are sort of stuck, because we wanted to protect our patients from coming to the hospital [at the beginning of the pandemic], but at the same time we don’t want to compromise the quality of their care,” she said. “I think now we have a clearer idea on how to protect them when they come to the hospital – mask wearing, screening, avoiding visitors, handwashing, all of these things are strictly implemented. We have very strict controls over who comes in and out of our oncology center, so it is safe to say we can provide the same quality of care we were providing before the pandemic.”

Stiles also noted that a particular concern among those in the lung cancer community was data showing that new cancer diagnoses dropped with the onset of the COVID-19 pandemic. A report in JCO Clinical Cancer Informatics showed that in April 2020, the number of new lung cancer diagnoses was half the level in April 2019.

“We know the cases have not simply gone away – they are still there, they just hadn’t seen doctors and been diagnosed,” said Stiles. “We’ve made incredible progress against lung cancer, and there is a huge worry in the lung cancer community that delay in diagnoses, the ability to detect patients earlier, and the delay in starting treatment, may erase some of the incredible gains we’ve made in decreasing cancer mortality.”