"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."
Antonio Passaro, MD
Patients with lung cancer present with a specific scenario of cumulative risk factors that may put them at greater risk of developing the coronavirus disease 2019 (COVID-19) infection, according to Antonio Passaro, MD, and a group of experts in lung cancer from Switzerland, China, Italy, and Japan. Their paper, which was published in the Annals of Oncology, describes the need to prioritize testing for COVID-19 in patients with lung cancer.
While there is not enough data to determine the association between lung cancer and COVID-19, certain comorbidities put this patient population at a higher risk, including older age, significant cardiovascular disease and respiratory issues, smoking-related damage, and treatment-related immune suppression.
Having an international consensus on testing patients with lung cancer for COVID-19 could improve early detection among these patients and potentially reduce the severity of the infection as well as mortality.
“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.
In Italy, physicians initially tested all their patients with lung cancer for the infection, despite whether or not the patient showed symptoms. However, less than a week later the Italian Ministry of Health announced that only symptomatic patients should be tested if they were potential candidates for hospitalization. While the case fatality rate was significantly higher in patients with these comorbidities, authors also speculate that this change in policies regarding testing patients may have led to biased selection, as well as delayed treatment.
Data have demonstrated that history of smoking has been correlated with a higher incidence, as well as severity, of SARS-CoV-2, where the risk of severe symptoms is 1.4 times higher in smokers versus non-smokers (95% CI, 0.98-2.00). The risk of ICU admission, mechanical ventilation, or death is also 2.4 times higher in this patient population (95% CI, 1.42-4.04).
“It has been postulated that prior tobacco-related lung damage, including chronic obstructive pulmonary disease (COPD) and lung cancer, additionally predispose to more severe COVID-19 complications,” the authors wrote.
The defective architecture of the lung due to mechanical tumor obstruction or prior lung surgery predisposes patients to COVID-19. Additionally, the authors noted that massive cytokine release appears to be associated with the development of acute respiratory distress syndrome, a COVID-19-related event, and the presence of macrophage infiltration in tissue of the lung increases the risk for cytokine release.
The use of corticosteroids is common among patients with lung cancer, but steroids are known to reduce inflammation and immune cellular activity. However, corticosteroids may be deleterious in the management of ARDS in COVID-19, which can mask early symptoms of the infection. Routine testing among these patients would be a useful tool in this setting.
Physicians should also be considered with the use of certain therapies that may predispose patients to risks of immunosuppression. Chemotherapy, immunotherapy, and targeted therapy can cause immunosuppression in patients with lung cancer as well. Risk of COVID-19 in relation to treatment with immune checkpoint inhibitors and tyrosine kinase inhibitors remains unknown. However, radiological features of lung cancer or these types of therapy mimic COVID-19 characteristics.
“Recently, data about higher sensitivity of radiologic imaging compared to nasopharyngeal/oropharyngeal swab are emerging and, considering that lung cancer patients
periodically undergo CT scans, an emerging amount of COVID-19-suspicious imaging, even in the absence of new symptoms, is likely to increase in the next upcoming weeks,” the authors wrote.
Authors are also concerned with certain modifications that may be made to treatment of patients with lung cancer at this time due to the concerns of COVID-19. While the suspension or delay of treatment for patients with cancer may appear logical, the risks and benefits, as well as final outcomes of these modifications to treatment, are unknown, underlying the importance of collecting further data from a global registry to develop a tailored risk assessment strategy for patients with lung cancer.
The novel global registry, TERAVOLT, has been developed to collect data on this specific patient population of thoracic cancers. The objective of TERAVOLT is to develop a tailored risk assessment strategy appropriate for patients with lung cancer specifically.
The European Society for Medical Oncology will share further information on its recommendations for treatment of patients with lung cancer.
“In this scenario, baseline SARS-CoV-2 testing for all patients affected by lung cancer should be recommended,” the authors concluded. “In addition, for those patients with a negative swab test and new ground-glass opacities detected on CT scan, with or without new respiratory symptoms, bronchoscopy should be considered to increase testing sensitivity.”
Passaro A, Peters S, Mok TSK, et al. Testing for COVID-19 in lung cancer patients [Published Online 9 April 2020]. Annals of Oncology. DOI: https://doi.org/10.1016/j.annonc.2020.04.002.