Since COVID-19 directly affects the lungs, clinicians should be extra cautious about patients undergoing lung irradiation. Stop treatment if a significant volume of lung is being irradiated, especially in contacts or suspects.

Dr Gomez: Our health system has instituted many changes to protect patients. The most important changes in the outpatient setting are: 

  • Mandatory COVID-19 testing and telephone health screening for all patients the day before administration of chemotherapy.
  • Widespread availability of personal protective equipment and hand sanitizer for patients coming to the center.
  • Health screening of patients on arrival to the center.
  • Continuous decontamination of patient waiting and treatment areas.
  • Limiting daily patient visit volumes in order to maintain adequate social distancing
  • Delaying treatments that are not critical in order to decrease COVID-19 exposure for individual patients.
  • Utilizing chemotherapy schedules that lengthen the interval between treatments.
  • Increasing utilization of telehealth visits for nontreatment encounters to minimize patient COVID-19 exposure.
  • Implementation of a community paramedic service where patients can be evaluated at home by trained paramedics who communicate with referring physicians during the visit. 

While these changes were not difficult to implement for a large academic institution, they may place a significant burden on smaller institutions and practices. They are all, however, important in order to protect our patients and providers. 

How are COVID-related disruptions expected to affect lung cancer treatment and outcomes in the long term?


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Dr Abhishek: An increased load of patients in cancer care settings may be seen in later months when patients resume visits for screening, diagnosis, treatment initiation and continuation, and follow-up for lung cancer. The COVID-19 crisis will eventually lead to disease progression in cancer patients and diagnosis at more advanced stages, thus adversely affecting their outcomes.

At present, no scientific data is available regarding the number of patients with lung cancer affected by the pandemic in many countries. One Chinese study showed the estimated infection rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients with cancer was double the cumulative incidence of all diagnosed COVID-19 cases. Lung cancer was most common cancer type with adverse outcomes, and 28.6% of patients with cancer who were COVID-19 positive were suspected to have acquired the infection from hospitals.8 

Apart from affecting patient care, the COVID-19 pandemic is severely disrupting cancer trials and research.8 The ongoing work or the trials which were ready to start are affected by the reduced availability of oncology staff and resources because of this global health emergency. Most of the ongoing studies have been put on hold to prioritize COVID-19-related trials. Delays in completion of ongoing trials will increase cost and negatively affect the development of new drugs and treatment standards for lung cancer.

What are the implications for future preparedness in similar crises?

Dr Abhishek: One lesson that we can learn from the ongoing COVID-19 pandemic is the need to build a platform for the future in which a cancer center is not wholly dependent on manpower and has the technology to run the diagnostic and treatment services to continue providing high-quality cancer care for patients.

Increased use of technology with telemedicine and remote review of results and consultations will partially mitigate the risk. The treatment should be tailored to have minimal toxicity, even if we must compromise on efficacy to balance the risk and patient safety. The treatment units will need to plan for impact on capacity to ensure social distancing and sanitization. At present, as well as beyond the pandemic, maximizing patient survival and quality of life should remain our ultimate goals.

Dr Gomez: The cumulative experience gained during the COVID-19 pandemic is a huge wealth of information. The ability of investigators throughout the world to come together to study COVID-19 in different populations has strengthened our understanding of this type of phenomenon and can serve as a template for future use. Studying the outcomes of the actions of local, regional, and national governments across the world can help us strengthen the practical control of future infectious diseases. 

What are some of the most important immediate and long-term needs to be addressed in this area?

Dr Abhishek: As a long-term management strategy, facilities to tackle COVID-19 should be strengthened but lung cancer care should not be ignored. There is a need to establish or strengthen government-run cancer centers to ensure patients’ access to uninterrupted lung cancer treatment near their homes at an affordable cost, during a crisis and beyond. In addition, screening measures and cancer awareness programs should be increased to facilitate detection at an early stage and to decrease lung cancer incidence.

Treatment plans in these situations should be in the best interest of society rather than that of physicians or patients, so we need to switch from an emphasis on the principle of patient autonomy to that of social justice.

Dr Gomez: One of the most urgent remaining needs for medical care is accurate rapid testing for COVID-19. The ability to triage patients and providers with a rapid test would greatly improve patient flow in our clinics while maintaining safety.

References

1. Shankar A, Saini D, Bhandari R, et al. Lung cancer management challenges amidst COVID-19 pandemic: hope lives here. Lung Cancer Manag. 2020;9(3):LMT33. doi:10.2217/lmt-2020-0012

2. Singh AP, Berman AT, Marmarelis ME, et al. Management of lung cancer during the COVID-19 pandemic. JCO Oncol Pract. Published online May 26, 2020. doi:10.1200/OP.20.00

3. Liao Z, Rivin Del Campo E, Salem A, Pang Q, Liu H, Lopez Guerra JL. Optimizing lung cancer radiation treatment worldwide in COVID-19 outbreak. Lung Cancer. 2020;146:230-235. doi:10.1016/j.lungcan.2020.05.029

4. Passaro A, Addeo A, Von Garnier C, et al. ESMO Management and treatment adapted recommendations in the COVID-19 era: Lung cancer. ESMO Open. 2020;5(Suppl 3):e000820.

5. Guckenberger M, Belka C, Bezjak A, et al. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radiother Oncol. 2020;146:223-229.

6. Dingemans AC, Soo RA, Jazieh AR, et al. Treatment guidance for patients with lung cancer during the coronavirus 2019 pandemic. J Thorac Oncol. 2020;15(7):1119-1136.

7. Raskin J, Lebeer M, De Bondt C, Wener R, Janssens A, van Meerbeeck JP. Cancer in the time of COVID-19: expert opinion on how to adapt current practice. Eur Respir J. 2020;55(5):2000959.

8. Saini KS, de Las Heras B, de Castro J, et al. Effect of the COVID-19 pandemic on cancer treatment and research. Lancet Haematol. 2020;7(6):e432-e435.

9. Zhang L, Zhu F, Xie L, et al. Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China. Ann Oncol. 2020;31(7):894-901.