Administration of systemic therapies has also been affected by the pandemic. One study prospectively evaluated the treatment plans of 275 patients with lung cancer who were seen at the thoracic oncology clinic at McGill University’s Health Center during March 2020. Most (62.5%) patients with NSCLC had advanced disease. Among the 211 patients undergoing active treatment, 57% experienced at least 1 change in their treatment plan due to the pandemic.9 Most changes represented a delay (39.7%) or cessation (14.9%) of palliative chemotherapy; 3% of patients stopped receiving palliative treatment permanently. Alterations in treatment dosing and scheduling represented 26.4% of changes. Most changes involved immunotherapy, cytotoxic chemotherapy, or a combination thereof; only a minority involved orally administered targeted agents.
Many of the changes in lung cancer treatment since the beginning of the COVID-19 pandemic arose from informed decisions that patients were making with their oncologists amidst uncertainty regarding whether systemic therapies could continue to be administered safely, noted Dr Elkrief, a co-author of the study. Certain changes, such as immunotherapy dosing and scheduling changes, reflect guidance from Canadian provincial health authorities authorizing physicians to use less frequent dosing regimens.
Indeed, several lung cancer treatment guidelines, including those from the European Society for Medical Oncology (ESMO), have cited approved modifications of treatment regimens that can help reduce patient visits, depending on the clinical context.10 Immunotherapies such as durvalumab or nivolumab, for instance, can be equally efficacious at higher doses administered every 4 weeks compared with lower doses given every 2 weeks.
Notably, efficacy of the cytotoxic chemotherapy drug paclitaxel administered every 3 weeks is comparable to that of paclitaxel administered weekly. The latter treatment regimen is somewhat easier to tolerate, said medical oncologist Taofeek Owonikoko, MD, PhD, MSCR, a professor in the department of hematology and medical oncology at Emory University School of Medicine in Atlanta, Georgia. Dr Owonikoko commented that, “with the pandemic, if you feel that the patient can tolerate the every-3-week regimen, you will go with that rather than every week. It will still end up being the same amount of drug; it’s just that you limit the opportunity for patients to get exposed [to SARS-CoV-2].”
Dr Elkrief said she and her colleagues observed a similar pattern of reduced patient visits during the second COVID-19 wave in the fall and winter of 2020, with many patients deciding in consultation with their physicians not to visit the hospital at a time of heightened risk. Now, she emphasized, there are clearer guidelines on minimizing risk within hospitals, adding that “hopefully patients with cancer will be prioritized as a vaccination group. That will greatly increase everyone’s comfort level with continuing cancer treatment and evidence-based cancer care.”
It remains unclear whether active cancer treatment increases the risk of severe COVID-19, Dr Elkrief said. But clinicians have remained cognizant of the risk of immunosuppression with treatments such as chemotherapy, Dr Owonikoko noted. For instance, he said, certain patients with advanced NSCLC have the option to be treated with immunotherapy alone or in combination with chemotherapy, which provides additional clinical benefit. Nevertheless, he noted, some clinicians might favor treating patients with immunotherapy alone given that it poses a smaller risk of immunosuppression than chemotherapy. “Those are judgment calls that oncologists would always make with or without the pandemic, but especially during the pandemic, they will be more cognizant of that call, depending on the patient sitting in front of them,” he said.