Lung cancer management in the COVID-19 era requires an individualized approach
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Amid the COVID-19 pandemic, it is important to pay close attention to individual clinical and radiological pulmonary signs of patients with lung cancer while awaiting specific evidence-based treatment guidelines.
“There is a lot we are still learning about COVID-19,” Jacob Sands, MD, oncologist at Lowe Center for Thoracic Oncology at Dana-Farber Cancer Institute and a GO2 Foundation Scientific Leadership Board member, told Healio. “We are still unaware of the full prevalence in the U.S. general population let alone among those with lung cancer, as testing is still not widespread enough to make true estimates. What we know is that people with lung cancer often have some lung damage or limited lung capacity, which is known to increase the risk for worse outcomes with COVID-19.”
Sands spoke with Healio about the impact of COVID-19 on the management of patients with lung cancer, how to prioritize treatments during the pandemic, and recommendations for reducing risk for COVID-19 among this patient population.
Question: Does lung cancer in conjunction with COVID-19 increase the likelihood of poorer outcomes due to underlying disease?
Answer: Data out of China showed people with cancer in general had worse outcomes or ended up needing higher levels of care, and lung cancer was on the worst end of that spectrum. A young never-smoker who is on a targeted therapy with limited volume of disease is different from someone aged 85 years with chronic obstructive pulmonary disease and bulky disease throughout their lungs. These are two very different scenarios with the biggest difference in lung capacity between the two. We are not sure if lung cancer itself changes outcomes or if patients with lung cancer have limited lung capacity and/or other comorbidities that increase the likelihood of poorer outcomes with COVID-19.
Q: Does evidence suggest there is a specific treatment for lung cancer that is directly associated with increased risk for COVID-19?
A: Anyone who has limited lung capacity due to surgery or radiation is at increased risk. Worse lung function or worse lung capacity increase risk for worse outcomes with COVID-19, but we do not yet know specifics on whether any lung cancer treatments affect risk, as there is not a lot of data that would suggest this. Interestingly, checkpoint inhibitors can cause pneumonitis, which can include shortness of breath and cough — similar to what we may see with COVID-19. In addition, people with COVID-19 do not always test positive for the virus. We have seen people come into our hospital who have a high suspicion for COVID-19, but their polymerase chain reaction test was negative more than once. We would consider that a rule-out for COVID-19; however, if someone still has a high suspicion for COVID-19, then I have continued to treat them for COVID-19.
We treated one patient for COVID-19 because she was highly suspicious, but the PCR test was negative twice. We continued to treat her for COVID-19 and contacted the Department of Public Health. Antibody tests showed she has high antibody levels, so she very likely did have COVID-19 and is recovering from it. She does not have lung cancer, but this tells us there are people for whom the test does not show COVID-19. So, if a patient on a checkpoint inhibitor has what we typically would think is pneumonitis, there may be some challenges to differentiating between that and COVID-19. There is a lot of benefit to giving checkpoint inhibitors during these challenging times, and this is not to suggest checkpoint inhibitors worsen outcomes. We do not have any evidence suggesting worse outcomes with checkpoint inhibitors among patients with lung cancer.
Q: Has the potential difficulty in diagnosing COVID-19 among individuals with lung cancer caused heightened anxiety among your patients?
A: Patients with lung cancer are certainly anxious about this. Those who are young with EGFR-mutated lung cancer, for example — without much disease burden and ongoing good control with targeted therapy — their risk for COVID-19 is not the same as older patients with COPD. Still, the lower-risk individuals are more worried than the general population. In some ways, this is good because it means they are isolating themselves more and doing more to prevent getting this virus.
Indeed, it is more difficult to diagnose COVID-19 in patients with lung cancer. These are people who sometimes have a cough all the time. There are other symptoms that can skew more toward COVID-19, such as fever, and these symptoms should be a red flag. Yet, not having a fever does not mean the patient does not have the virus. We do not yet have enough widespread testing throughout the country to feel confident about this virus.
Q: How have you prioritized which lung cancer treatments to keep on schedule and which treatments or appointments to delay to minimize patient exposure to the health care setting?
A: This is entirely dependent upon what is going on in local areas. Broad recommendations have been made by organizations regarding treatment of patients with lung cancer during this time, but it is important to emphasize that any patient’s care should be discussed between the patient and the treating physician. In areas where there has been a significant surge in COVID-19 cases, the decision about delaying treatment might be different than in areas where they are not yet seeing a lot of cases or strain to the hospital system.
In everything we do, we have a risk-benefit balance that we weigh. Chemotherapy may cause a patient’s white blood cell count to drop, and they may become neutropenic. They may have a fever that generally would result in hospitalization. However, it would be a terrible thing for this patient to show up at a bustling ED with neutropenia during this time.
Some decisions around treatment can be impacted by this risk, because the risk is higher if there are complications associated with treatment. For example, a patient with stage IV lung cancer who has high PD-L1 expression can be treated with pembrolizumab (Keytruda, Merck) alone and, in some cases, chemotherapy plus pembrolizumab is warranted. However, because chemotherapy has the potential for neutropenia, that may alter the decision for some patients during this time.
On the other hand, a patient with stage III lung cancer or any new small cell lung cancer really needs to be treated — the risk for delaying treatment is significant. Small cell lung cancer spreads rapidly, so if it is limited-stage disease it requires treatment with curative intent — and to not proceed with treatment is to risk losing the opportunity for cure. In extensive-stage small cell lung cancer, the cancer grows rapidly — and to not initiate treatment is to risk rapid demise.
For patients with stage IV non-small cell lung cancer, we perform a workup to assess the potential for giving them targeted therapy and eligibility. This is wonderful because in many cases, the side effect profile of those targeted therapies is more favorable than chemotherapy. During non-COVID-19 times, we may diagnose a patient with lung cancer and it could take weeks before we are able to treat them. During the COVID-19 pandemic, if a patient is clinically stable and we do the workup for targeted therapy options, we are not immediately initiating treatment anyway. Or, if a patient has a small nodule — an early stage IA diagnosis — surgeons may choose to hold off on operating in areas where there is a surge of COVID-19 cases. In some cases, focused radiation rather than going to the operating room could be a better option during these times. These are the types of individual options to weigh.
Q: How are you approaching COVID-19 testing for your patients with lung cancer?
A: The only way we will adequately control this virus in our country is through widespread testing and tracing of cases. I would love to be able to test everybody, but we do not yet have the capacity for that. People are only being tested if they are symptomatic or are in certain high-risk groups. This includes patients in certain high-risk groups, such as those undergoing bone marrow transplantation, but not all patients with lung cancer. It is encouraging to see that testing has been increasing rapidly; hopefully soon we will see more testing available.
Q: Should patients with lung cancer be instructed to do anything markedly different than the usual recommendations to reduce their risk for COVID-19?
A: This weighs into the risk-benefit ratio. Although it is important to reduce the risks associated with COVID-19, we need to ensure that we are not drastically increasing risks associated with lung cancer. We should continue to treat patients who need treatment, especially those who need it urgently. Curative intent treatments continue to be very important. However, there are instances where we can delay treatment. For example, I have a patient who has been on immunotherapy for 1.5 years, and I am not as strict about having them come in every 3 weeks for treatment. To skip one cycle makes sense for that individual, but that is very different from someone who is starting immunotherapy. This is something that clinicians have to carefully weigh depending on their area. It is important to ensure that they are reducing risk for the patient in clinic, but still treating patients. – by Jennifer Southall
For more information:
Jacob Sands, MD, can be reached at Dana-Farber Cancer Institute, 450 Brookline Ave., HIM 240, Boston, MA 02115;email: jacob_sands@dfci.harvard.edu.
Disclosures: Sands reports consultant/advisory board roles with AbbVie, AstraZeneca, Eli Lilly, Foundation Medicine, Genentech, Guardant Health, Incyte, Loxo Oncology, Medtronic, Merck and PharmaMar.
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