The coronavirus 2019 (COVID-19) pandemic has transformed lung cancer management on several fronts at many cancer centers — from screening, to diagnosis, to treatment. Indeed, clinicians from the University of Cincinnati recently reported in a retrospective review that lung cancer screening procedures at their institution were temporarily suspended in the spring of 2020 and remained at relatively low levels through last summer.1 The investigators expressed concern that new lung cancer cases are going undiagnosed or are caught at more advanced stages, partly due to delays in diagnostic procedures and the reluctance of people with early symptoms to seek medical care out of fear of contracting the virus.

The problem seems to be global: a retrospective study in Spain, for instance, documented 38% fewer lung cancer diagnoses in the first half of 2020 compared with the same period in 2019, and an increase in the number of patients diagnosed with symptomatic and severe non-small cell lung cancer (NSCLC).2 Data from the United Kingdom, gathered in a Cancer Research UK survey, suggest that urgent referrals by general practitioners to specialists for patients with suspected lung cancer fell by 34% between March 2020 and March 2021.3

Studies indicate that the COVID-19 pandemic has also heavily disrupted lung cancer treatment itself. Because patients with lung cancer who become infected with SARS-CoV-2 tend to experience more severe COVID-19 symptoms and higher associated mortality — likely due to underlying comorbidities, especially pulmonary conditions — there have been widespread efforts to minimize the exposure to SARS-CoV-2 of not only patients with thoracic cancers but also the healthcare providers and other staff that patients encounter in the course of treatment.4 These new approaches to the dual management of lung cancer and SARS-CoV-2 have manifested as treatment delays, changes to therapeutic regimens, and shifts to telemedicine in order to minimize clinic visits, creating a new treatment landscape with an uncertain impact on clinical outcomes.

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“We’re seeing these patterns across different patient populations [and] different stages of cancer — even [including] the prevention of cancer,” remarked Arielle Elkrief, MD, fellow in oncology at McGill University Health Centre in Canada. “The pandemic has severely affected the way that cancer care is provided throughout the world.”

During the initial phases of the pandemic, cancer surgeries were temporarily suspended in many locations to preserve hospital resources needed to manage the influx of COVID-19 patients and limit the exposure to SARS-CoV-2 of patients with other diseases. COVID-19 patients with lung cancer are considered especially vulnerable to severe adverse events after surgery.5 As operating rooms reopened at fluctuating capacity, several organizations, including the American College of Surgeons, published guidelines on triaging lung cancer patients for surgeries.6 For instance, for certain patients, the guidelines advised offering stereotactic body radiation therapy (SBRT) when timely access to surgery was unavailable, as echoed by joint recommendations on lung cancer radiotherapy by the European Society for Radiotherapy and Oncology (ESTRO) and the American Society for Radiation Oncology (ASTRO).7

Radiation therapy dosing has also been adjusted to minimize patient visits, in line with several recommendations from groups in Europe and the United States that advise modifying regimens to administer higher doses across as few treatments as possible.7,8 For instance, in certain patients with bone metastases, “it’s just as effective to give 1 treatment vs 10 treatments. That situation is where we’re very commonly doing those 1-fraction treatments to really minimize the [number of] patients coming in,” noted Kristin Higgins, MD, associate professor in the department of radiation oncology at Emory University School of Medicine; medical director of radiation oncology of the Emory Clinic at Winship Cancer Institute’s Clifton campus, Atlanta, Georgia; and a co-author of the ESTRO-ASTRO joint statement.

Of course, “we’re not forgoing curative radiation,” Dr Higgins added. “If a patient has a stationary lung cancer and needs 6 weeks of radiation with chemotherapy at the same time, they’re still going to get that [regimen] in the pandemic . . .  We aren’t deviating from the standard of care if there’s not a shorter treatment alternative, but if there is, . . .  we consider [such alternatives] more now.”