Lung cancer care during the COVID-19 era: What physicians need to know
The COVID-19 pandemic presents unprecedented challenges to lung cancer care. As research has shown, patients with lung cancer have the highest rates of COVID-19 among patients with cancer, as well as a particularly high rate of poor outcomes when infected.
Healio spoke with Julie Brahmer, MD, professor of oncology at Johns Hopkins University School of Medicine and member of the Lung Cancer Research Foundation’s Scientific Advisory Board, about these challenges, how the pandemic has impacted lung cancer treatment and what further research is needed.
How does COVID-19 infection impact patients with lung cancer?
Brahmer: COVID-19 affects patients with lung cancer in various ways. We don’t know a lot right now, but we certainly know more than we did earlier in the year. Based on data that have come out of China and Europe and now New York, we do know that lung cancer patients seem to be more vulnerable to complications from COVID. Patients with lung cancer also seem to have higher rates of hospitalization compared with patients with other cancers.
The only thing that we do not know is if our lung cancer patients are more likely to develop disease. Since we don’t have universal testing and are only testing patients with symptoms in the United States, we don’t know how many lung cancer patients are asymptomatic, but are positive for COVID. In the next couple of months, we may be able to better assess whether lung cancer patients are more likely to develop any sort of symptoms when exposed to COVID.
The biggest message here is that the rate of COVID complications is quite high among lung cancer patients compared with those with other cancers. We think this may be related to other health issues that lung cancer patients are more prone to, particularly a history of smoking, a history of baseline pulmonary disease such as COPD, and other health issues like high blood pressure or diabetes, that are associated with higher complication rates with COVID infections.
How has lung cancer care changed during this pandemic?
Brahmer: The data out of Memorial Sloan Kettering have enlightened us on our concerns about whether or not patients treated with immunotherapy or chemotherapy have a higher complication rate. At least based on these limited data, there does not seem to be an association between immunotherapy and complications from COVID infections. We feel comfortable treating patients with lung cancer with immunotherapy in this era of potentially being exposed to COVID.
There are also questions about wheather patients should be on chemotherapy during this time when there’s the risk for COVID-19 infection. Based on some other data that have come out of Memorial Sloan Kettering, we are not seeing higher rates of complications just because a patient is receiving chemotherapy. However, other data from an international registry of lung cancer patients diagnosed with COVID-19 showed that patients on chemotherapy have a higher risk of complications from COVID-19. In the beginning, many physicians were concerned about starting treatment or skipping treatment. But, based on these data, if a patient needs to be treated, we should do what’s best for the patient to get the cancer under control. Now with new FDA approvals of less frequent dosing of immunotherapy and trying to decrease the risk for being exposed to COVID for patients, this makes more sense than holding off on treatment for patients with advanced disease.
If someone recently had surgery and were trying to decide when to start adjuvant therapy, making sure a patient is fully recovered after surgery before starting adjuvant chemotherapy would be wise rather than starting them right after surgery to allow the patient to not have to come in and risk exposure.
Being in the clinic, we screen patients by phone before they come in and also at the door for any symptoms that are concerning for COVID infections and test symptomatic patients for COVID. This awareness and strict screening in clinics have really decreased the risk for exposure for patients. There was a time when patients were concerned about having to come in, but they can be reassured that clinics are some of the safest places to come, compared with other places such as the grocery store or large crowds.
Lung cancer care for patients with metastatic disease has not changed that much. We have now been able to prescribe immunotherapy less frequently so patients don’t have to come in as often, which has been extremely helpful.
During this time, it is more difficult to get patients to surgery. For a period of time at my institution, surgeries were drastically decreased because of a more stringent process to get patients on schedule based on either limited ICU access post-surgery or the limits on personal protective gear that’s required at the time of surgery. There were some delays in surgery, particularly for those patients with extremely small disease, but there are no delays for surgery for patients who needed immediate care. Now, we are screening all patients for COVID before going to surgery to decrease their risk.
I am worried that during this pandemic, patients are holding off on screening and that screening programs may potentially be decreased. We don’t see evidence of that at the moment, but my concern is that people are putting off screening or don’t have access to necessary screening. I am hoping that screening will continue so that we can actively continue to diagnose patients in earlier stage disease.
How does COVID-19 infection affect the treatment of lung cancer?
Brahmer: If a patient with lung cancer becomes infected with COVID-19, we will hold therapy and restart therapy only if the patient is fully recovered from their symptoms and preferably, nasopharyngeal swab negative. There are some patients who are infected with COVID but have no symptoms. These patients must be followed long enough to the point where potential complications don’t appear to be an issue.
At my institution, we have a unit within our cancer center called “biomode” where people wear full protective gear to continue treatment or supportive care for cancer patients who are positive for COVID-19. We’ve been very lucky and have had very few lung cancer patients test positive for COVID-19.
What challenges do lung cancer specialists face during the COVID-19 era?
Brahmer: The challenge is really access and trying to evaluate patients remotely. Patients are very scared to come into the hospital because of the fear of being exposed to COVID-19, as well as the limitations on visitors able to come with them. Within our clinic, this is slowly loosening up, but we have found that on the flipside, telehealth has actually allowed us to have greater access to the patient’s family and friends who want to be involved in their care. We can have all the people that the patients want dialed in and we can discuss their situation, so that is somewhat easier.
However, we have had patients show up with more severe symptoms because they tried to wait it out at home much longer due to their fear of coming into the hospital. So, we are trying to figure out ways to assess patients remotely and encourage patients to let us know about symptoms early on, so we can get them to urgent care as early as possible rather than waiting until they are seriously sick.
What further research is needed on COVID-19 and lung cancer?
Brahmer: My questions are: are our patients with lung cancer more susceptible to developing COVID-19 when being exposed? Are lung cancer patients as likely to develop immunity when vaccines are used or when they are exposed? Are they able to develop antibodies to try to protect themselves?
Answering those questions are needed and will come over time.
Additionally, larger studies are needed to better assess the impact of therapy when our lung cancer patients are infected with COVID.
What is your message to physicians treating patients with lung cancer during this time?
Brahmer: The key thing here is that while there is a risk for developing COVID-19 severe disease, it is important for oncologists to stress to their patients with lung cancer that no matter what they are paying attention to their cancer and needs. While things are definitely not normal, we certainly want to bring care to them through telehealth and developing novel ways to assess them remotely to try to decrease their risk of exposure. In some ways, we are even more in touch with our patients.
I greatly appreciate the advocacy groups in helping to inform lung cancer patients about COVID and their risks. Over the past couple of months, we’ve had even more options for treatment for lung cancer approved by the FDA and that continues to give us great hope for improving survival and improving their quality of life when diagnosed with lung cancer.