Experts Address Difficulties in Lung Cancer Management During COVID-19 Pandemic

In an article published in The Lancet, researchers detailed the challenges presented for lung cancer therapy during the coronavirus disease 2019 (COVID-19) pandemic. 

As a result of the pandemic, physicians have been increasingly forced to select which patients should receive anticancer therapy on the basis of who is most likely to have a positive outcome. This scenario appears to be even more severe for patients with lung cancer due to the high risk of interference of COVID-19 with their treatment.

In the early phase of COVID-19-induced pneumonia, the main CT findings include multifocal peripheral and basal ground-glass opacities, crazy paving patterns, traction bronchiectasis, and air bronchogram signs. Characterizing the more advanced phase of the disease is a progressive transition to consolidation, togetherwith pleural effusion, extensive small lung nodules, irregular interlobular or septal thickening, and adenopathies.

“These radiological manifestations can overlap with CT findings that are often found in patients with lung cancer upon disease progression or onset of concomitant pneumonia due to over- lapping opportunistic infections,” the authors wrote. “Together, these similarities can pose a major challenge to clinicians in distinguishing lung cancer evolution from a potential COVID-19 super-infection on the basis of radiological and clinical evidence, and, importantly, these specific conditions require very different therapeutic approaches.”

Further, pneumonitis can also be induced by immune checkpoint inhibitor therapy, which is widely used as a standard-of-care treatment for lung cancer in various settings. Similar to that of COVID-19 infection, the clinical symptoms of immune checkpoint inhibitor-induced pneumonitis consist mainly of cough, chest pain, dyspnea, and fever. Additionally, CT assessment of immune checkpoint inhibitor-induced pneumonitis demonstrates similar radiological findings to those seen in COVID-19 induced pneumonia, further hindering distinction between the clinical entities.

“Similarly, tyrosine kinase inhibitors can induce radiological patterns of interstitial-like pneumonitis, which develops in 4% of patients with epidermal growth factor receptor-mutant lung cancer treated with osimertinib (Tagrisso),” the authors wrote. 

“In this scenario, standard chemotherapy does not seem to represent a suitable or potentially safer alternative to immune checkpoint inhibitor therapy- neither for treating physicians who want to avoid the overlapping immune checkpoint inhibitor-related and COVID-19-related radiological and clinical changes, or for patients who are unsuitable for immune checkpoint inhibitor therapy,” the authors added. “Notably, administration of chemotherapy within the month preceding COVID-19 diagnosis has been shown to be associated with a higher risk of severe infection-related complications.”

Moreover, the aggressiveness of lung cancer malignancies does not allow for oncologists to withhold or postpone anticancer therapies. Therefore, the researchers suggest that, awaiting specific evidence-based guidelines, the management of patients with lung cancer during the COVID-19 pandemic should include specific and careful attention to their clinical radiological pulmonary signs, more so than for patients with other tumor types. Additionally, the researchers indicated that it seems reasonable to suggest that patients with lung cancer undergo systematic testing for SARS-CoV-2 at the beginning of treatment and whenever it is deemed necessary by the treating physician in the course of therapy.

“This strategy might become more feasible with the increasing availability and progressive use of real-time PCR assays that can provide COVID-19 status results within an hour,” the authors wrote. “Furthermore, the availability of laboratory IgM or IgG testing to evaluate the exposure and immunity to SARS-CoV-2 infection will be helpful when the COVID-19 pandemic begins to decline.”

According to the researchers, this allocation of resources for these methodical approaches to patients with lung cancer should aid in facilitating the most appropriate clinical management during the COVID-19 pandemic.

Reference:

Calabró L, Peters S, Soria J, et al. Challenges in lung cancer therapy during the COVID-19 pandemic. The Lancet. doi:10.1016/S2213-2600(20)30170-3.