Researchers Outline Recommendations for Testing Patients with Lung Cancer for COVID-19

In an article that will appear in Annals of Oncology, researchers outlined recommendations for testing patients with lung cancer for the coronavirus disease 2019 (COVID-19), a respiratory tract infection caused by the severe acute respiratory syndrome (SARS) coronavirus (COV), also named SARS-CoV-2.

Though all types of malignancies appear to be associated with high COVID-19 prevalence, morbidity, and mortality, patients with lung cancer represent specific cumulative risk factors for COVID-19 complications, including older age, significant cardiovascular and respiratory co-morbidities, smoking-related lung damage, as well as treatment-related immune impairment or suppression. 

“Defective pulmonary architecture from mechanical tumor obstruction or previous lung surgery may also predispose to infection,” the authors wrote. “Changes in the anatomy of airway and pulmonary tissue lead to intra- and peri-tumoral microenvironment alteration, which may secondarily affect immune cell infiltration characterized by an increase in macrophages and inflammation.”

Additionally, the presence of macrophage infiltration in lung tissue presents a higher risk for cytokine release. During SARS-CoV-2 infection, massive cytokine release has been deemed to be the major step leading to the development of acute respiratory distress syndrome (ARDS). Given that patients with lung cancer demonstrate similar clinical symptoms to the SARS-CoV-2 infections, the researchers suggested the need for an accurate COVID-19 screening model that would allow for early detection and potentially reduce the risk of severe complication and mortality. 

“A significant proportion of lung cancer patients need corticosteroids for prophylaxis, treatment and symptom control related to cancer or chronic obstructive pulmonary disease. It is well established that steroids may reduce inflammation and immune cellular activity, including lymphopenia and impaired T-cell function,” the authors added. “Corticosteroids are possibly deleterious in the management of COVID-19 ARDS and they may mask some of the early symptoms of SARS-CoV-2 infection, arguing for routine SARS-CoV-2 testing in patients receiving steroids.”

Moreover, the thoracic oncology community has also expressed concerns on the predisposing risks of immunosuppression by cancer therapy, including chemotherapy, immunotherapy, and molecularly targeted therapy. The researchers suggested that this may impose specific consideration on the schedule and dose of cytotoxic chemotherapy for lung cancer patients in epidemic regions. 

Further, while the impact of immune checkpoint inhibitors on COVID-19 remains unknown, radiological features of lung cancer or those related to these treatments may be characterized by ground-glass opacities, mimicking COVID-19 radiological characteristics. However, the researchers indicated that data about higher sensitivity of radiologic imaging compared to nasopharyngeal or oropharyngeal swab are materializing and an emerging amount of COVID-19-suspicious imaging is likely to increase.

“In the era of COVID-19, the optimal management of patients with lung cancer remains unknown and the oncology community should have increased awareness to prevent the emergence of an increase in cancer-related and infectious mortality,” the authors wrote. “Despite the current lack of robust data, it is essential to establish an international consensus on testing for SARS-CoV-2 in lung cancer patients, where the early identification of SARS-CoV-2 may result in tailored management.”

The researchers went on to recommend baseline SARS-CoV-2 testing for all patients with lung cancer. Additionally, for those with a negative swab test and new ground-glass opacities detected on CT scan, with or without new respiratory symptoms, the researchers suggested that bronchoscopy should be considered to increase testing sensitivity.

Reference:

Passaro A, Peters S, Mok T, Attili I, Mitsudomi T, Marinis F. Testing for COVID-19 in Lung Cancer Patients. Annals of Oncology. doi:10.1016/j.annonc.2020.04.002.