Research has provided data on morbidity and mortality in patients with lung cancer and COVID-19, shown how the pandemic has disrupted lung cancer screening and clinical trials, and provided some insight into the efficacy of COVID-19 vaccination in patients with lung cancer.1-4

However, the underlying biology of SARS-CoV-2 infection in lung cancer patients is not well understood, and more research is needed to better understand how lung cancer patients respond to COVID-19 vaccines.

A recent review highlighted these knowledge gaps and summarized what is known to date about COVID-19 in the context of lung cancer.5 

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“[The review] is a call to action for our colleagues and information for the public and people with lung cancer,” explained senior author Fred Hirsch, MD, PhD, executive director of the Center for Thoracic Oncology at Mount Sinai Health System in New York, New York. 

“By answering the questions we raise in the review, we can hopefully find out how to prevent and manage COVID-19 in this patient population,” he added.

The review cited research suggesting that, compared with the general population, patients with lung cancer have a 7.7-fold higher risk of developing COVID-19. A separate study showed a 3.6-fold higher risk of hospitalization and a 5.7-fold higher risk of death among lung cancer patients. 

The review authors also cited meta-analysis data showing a 32.4% COVID-19 mortality rate for patients with lung cancer and a 25.4% COVID-19 mortality rate for all cancer patients studied.

“Among cancer patients, we know that those with hematologic malignancies are very vulnerable,” Dr Hirsch said. “But with regard to solid tumors, I believe lung cancer is at the top of the [most vulnerable] list, unfortunately.”

Explaining Vulnerability, Vaccine Response

Dr Hirsch and colleagues are conducting a study to investigate the biological factors that underlie the mechanisms of viral infection in lung cancer cells and susceptibility to SARS-CoV-2 infection in patients with lung cancer.6

“We don’t currently know what makes lung cancer patients so vulnerable,” Dr Hirsch said. “We know that there are receptors in the lung called ACE2, which are the gateway for the virus, and that ACE2 is often highly expressed in lung cancer, but whether that is a contributing factor or not is unknown.” 

Dr Hirsch and colleagues have theorized that patients with lung cancer have a weaker antibody response to both SARS-CoV-2 infection and COVID-19 vaccines. In their ongoing study, the researchers are comparing patients with lung cancer and control individuals to determine if differences in antibody response might be related to age, sex, smoking history, and race/ethnicity.

The high frequency of comorbidities in patients with lung cancer may make them more vulnerable, according to Jacob Sands, MD, a medical oncologist in the department of thoracic oncology at the Dana Farber Cancer Institute in Boston.

“We know that people with lung disease, those with limitations to their lung capacity, are at higher risk from COVID-19 infection,” Dr Sands said. “And the lung cancer population tends to include many patients like that, including those with chronic obstructive pulmonary disease, for example.” 

Dr Hirsch and colleagues have preliminary data from their study but hope that, after full recruitment, the results will reveal which patients are most vulnerable, which treatments may impact vaccine response, and how susceptible lung cancer patients are to breakthrough SARS-CoV-2 infections.

Other studies have shown that lung cancer patients tend to have lower antibody responses to COVID-19 vaccination, but booster shots appear to improve those responses.3,4 

“The good news is that most lung cancer patients mount an adequate antibody response to full vaccination,” Dr Hirsch said. “However, there are a few patients who do not mount sufficient antibody titers. We are trying to figure out why these patients don’t respond and how we can protect these patients.”