Among the various patient groups affected by the coronavirus disease 2019 (COVID-19) pandemic, the ongoing crisis has presented multiple challenges for patients with lung cancer. This population is considered high risk in terms of worse illness severity and complications related to COVID-19 infection, and patients who become infected must delay cancer treatment until they recover from the virus.1 Additionally, there may be difficulty differentiating between certain symptoms of lung cancer or treatment-induced pneumonitis2 and symptoms of pneumonia secondary to COVID-19, leading to diagnostic delays.1
Numerous articles and sets of guidelines1-7 have discussed issues affecting patients with lung cancer in the context of COVID-19, including a paper published in May 2020 in Lung Cancer Management.1 Abhishek Shankar, MD, assistant professor, Department of Radiation Oncology at Lady Hardinge Medical College and SSK Hospital in Delhi, India, and coauthors noted the risk of disease progression, reduced survival, and worse quality of life associated with delayed treatment for locally advanced and metastatic lung cancer.1
However, the authors acknowledged the need to weigh these risks against the increased risk of infection related to chemotherapy. “Targeted therapies are generally safe while the potential interaction between immunotherapy and COVID-19 remains unknown at present,” they wrote. “Therefore, such patients in the absence of any symptoms suggestive of COVID-19 should be considered for continuation of planned chemotherapy, immunotherapy or radiation.”1
To learn more about these issues and treatment implications in lung cancer, we interviewed Dr Shankar as well as Jorge Gomez, MD, assistant professor in the division of hematology and medical oncology and medical director of the Thoracic Oncology Program and the World Trade Center oncology clinic at Mount Sinai Hospital in New York City. Dr Gomez is also a national volunteer spokesperson for the American Lung Association and member of the organization’s Lung Cancer Expert Medical Advisory Panel.
How has the COVID-19 pandemic affected the care and quality of life of patients with lung cancer?
Dr Abhishek: Most lung cancer patients are older, active smokers with concurrent respiratory problems like chronic obstructive pulmonary disease (COPD), asthma, or interstitial lung disease, and the majority of these individuals are on chronic inhaled or oral steroid/immunosuppressant therapies.4 The current challenge is to balance the risk of COVID-19 infection and potential harm as a result of delayed treatment to patients with lung cancer.
Patients with lung cancer often present for treatment at advanced stages and require frequent visits, but the cancer care delivery system has been adversely affected because of lockdown. At one point, chemotherapy, radiotherapy, palliative care, and follow-ups for patients with lung cancer were in standstill mode. While the situation is improving overall, diagnosis is delayed as bronchoscopy and other interventional procedures have been deferred.
In addition, nationwide lockdown has restricted access to transportation and flight services. Patients in rural areas are suffering as they are unable to access the cancer centers that are primarily located in urban areas. Delays and changes in treatment are causing anxiety and distress among patients with lung cancer. Limited availability of intensive care facilities because of the needs of patients with has further strained the care of patients with lung cancer when aggressive curative treatment in the form of surgical resection is required.8
Dr Gomez: The COVID-19 pandemic has affected the care and quality of life of our patients in many ways. During the pandemic, we were forced to limit the number of patients in our clinics in order to maintain patient safety. This caused delays in treatment for some patients. Other patients were forced to delay treatment because of poor health and high risk of complications from COVID-19. Diagnosis was also delayed as our transthoracic computed tomography (CT)-guided biopsy and bronchoscopic biopsy services were temporarily suspended. During the height of the pandemic, all elective surgeries were suspended, including lung cancer surgeries because of the extremely high risk for perioperative complications.
As the incidence of COVID-19 has decreased in our area, the services have resumed, although below previous capacity. Surgical capacity has decreased in order to minimize patient exposure to COVID-19. Chemotherapy infusion capacity has decreased in order to maintain safe social distancing. Clinic visit capacity has decreased for the same reason. The one positive result of all of these changes is that the lower volumes have decreased visit and infusion wait times because of increased efficiency, and this has had a significant positive effect on quality of life for patients.
What are some ways in which these issues are being addressed in practice in terms of both treatment and patient safety?
Dr Abhishek: Various lung cancer associations have issued guidelines on lung cancer care during the pandemic which depend on therapeutic intent and treatment benefits, considering the patient’s age, various comorbidities, and patient preferences. While there is some variation in guidelines, such recommendations include the following points.7
- For small cell lung cancer, 4 cycles of cisplatin and etoposide chemotherapy may be preferred instead of 6 cycles in stages I to III. Replacement of etoposide from intravenous to oral administration can help limit the frequency of hospital visits.
- In stage I, surgical resection of the tumor followed by chemotherapy can be considered.
- Radiotherapy with accelerated hyperfractionation 2 times per day can also limit hospital visits.
- For stage IV patients, in selected cases, palliative chemotherapy with platinum and etoposide can be considered along with other supportive care.
- In patients at risk for febrile neutropenia, dose reduction in chemotherapy can be considered with supplemental granulocyte colony-stimulating factor therapy.
- Immune checkpoint inhibitors (durvalumab or atezolizumab) can be omitted, considering the triweekly clinic visits during the maintenance phase.
- In non-small cell lung cancer, for small tumors having stable growth, surgery can be delayed with follow-up chest CT.
- Adjuvant chemotherapy can be omitted or stopped early in elderly patients with significant comorbidity, preferably after 3 cycles.
- The cisplatin/docetaxel regimen reduces frequent hospital admission and stays compared to vinorelbine or gemcitabine which require 8 days of administration but have the same efficacy.
- In non-squamous non-small cell lung cancer, the cisplatin and pemetrexed regimen is an efficacious alternative to limit hospital visits.
- For positive epidermal growth factor (EGFR) mutation, oral EGFR-tyrosine kinase inhibitor (TKI) for 1 year on a daily basis is the preferred alternative to adjuvant chemotherapy.
- For small tumors having stable growth, curative radiotherapy can be delayed with follow-up chest CT.
- Durvalumab every 4 weeks with a dose of 20 mg/kg-1 is equally efficacious to a dose of 10 mg/kg-1 every 2 weeks, ultimately limiting hospital visits.
- For asymptomatic patients with indolent disease, chemotherapy or immunotherapy could be delayed.
- Triweekly chemotherapy is preferred over weekly regimens in the case of docetaxel to reduce hospital visits.
- Palliative chemotherapy can be restricted to 4 cycles, and maintenance therapy with pemetrexed can be omitted.
- Pembrolizumab as a first-line monotherapy is preferred in patients with programmed death-ligand 1 expression of >50%.
- Nivolumab every 4 weeks with a dose of 480 mg is preferred and is equally efficacious to 240 mg every 2 weeks, ultimately limiting hospital visits as well.
Chemotherapy, TKIs, or immune checkpoint inhibitors can cause pneumonitis because of toxicity, which could be confused with COVID-19 pneumonia or interstitial lung disease. This should be addressed aggressively with appropriate [strategies] like chest CT and proper treatment.
Guckenberger et al have recently used a modified Delphi process to publish consensus guidelines for treating lung cancer with stereotactic body radiation therapy in 1 to 5 fractions.5