Treating Lung Cancer in COVID-19 Times: Update From Experts

Pam Harrison

April 07, 2020

Lung cancer experts in Europe issued highly considered recommendations for the management of lung cancer during the COVID-19 crisis, the main intention of which is to minimize the risk of patients getting infected by SARS-CoV-2 while in hospital receiving treatment.

The recommendations were published online April 3 in ESMO Open.

"We know that having cancer increases the risk of dying of COVID-19, although not necessarily the risk of getting the virus and we also know that having lung cancer could increase the risk of pulmonary complications from SARS-CoV-2," lead author Alfredo Addeo, MD, University Hospital of Geneva, Switzerland, told Medscape Medical News.

"But patients who are often in the hospital have a higher risk of catching the virus. So this paper is not about not giving necessary treatment, it's about treating patients the best you can based on the area where you live and the resources you have and keeping patients away from the hospital as much as possible," he added.

"The main message is, try to personalize the care you deliver," Addeo said.

"Rather than remain rigid about how you've been treating patients thus far, try to think outside the box and find a way to minimize the risk of infection and if you have to limit treatment, discuss the pros and cons of your treatment plan with the patient and make sure the message is given clearly," he emphasized.

How Much Benefit?

The first general concept to keep in mind is: How likely is a patient is to benefit from treatment?

"All regimens with a survival benefit should be maintained and prioritised whenever possible," Addeo and colleagues observe. The other co-authors of the paper are Giuseppe Banna, MD, Ospedale Cannizzaro, Catania, Italy; Alessandra Curioni-Fontecedro, MD, University Hospital Zurich, Switzerland; and Alex Friedlaender, MD, University Hospital of Geneva.

For non-small cell lung cancer (NSCLC), neoadjuvant chemotherapy for locally advanced resectable disease and sequential/concurrent chemotherapy/radiation therapy for patients with stage III lung cancer — provided they have adequate respiratory function — should be started when possible and should not be stopped without justification, the authors point out.

This is also true for first-line therapy in patients with metastatic disease. Treatment should also not be stopped without good reason among patients already receiving maintenance immune checkpoint inhibitor therapy.

For small cell lung cancer (SCLC), both first-line treatment for extensive-stage disease as well as concurrent chemotherapy/radiotherapy for patients with limited-stage disease should be started when possible, again provided they have adequate respiratory function.

Palliative or stereotactic body radiotherapy (SBRT) delivered outside the lung should also be initiated when possible in SCLC patients.

The authors caution, however, that if palliative or SBRT outside the lung requires multiple visits to the hospital, treatment to the lung should be limited to cases with compression of airways or bleeding.

Oncologists should also try to start radiotherapy on day 1 of chemotherapy because then only 2 cycles will be needed; if radiotherapy is started with cycle 2 or is given sequentially, 3 cycles of treatment will be required.

"Fractions of SBRT could be reduced, depending on organ at risk (8 fractions to 5 or 3) while palliative RT [given] as a single fraction or two (8-10 Gy or 17 Gy, respectively) should be used where possible," the authors observe.

Concurrent chemotherapy with radiotherapy for limited-stage disease should not be stopped without justification and nor should first-line treatment for metastatic SCLC, the authors continue.

Again, however, patients must have adequate respiratory function to receive or continue with concurrent chemotherapy and radiotherapy, they add.

For patients with stage III NSCLC, concurrent chemotherapy plus radiotherapy may be considered and given preferentially or not.

Similarly, oral rather than intravenous chemotherapy may be preferred for elderly NSCLC patients or for those with an ECOG performance status of 2 as well as for SCLC patients.

Delaying Surgery

As a general principle, the use of neoadjuvant chemotherapy instead of adjuvant therapy following surgery can delay the need for immediate surgery. If surgery can be delayed, "the risk of a patient catching the virus several months from now might be less," Addeo noted. Thus, treating patients upfront with chemotherapy is one tactic to consider in appropriate patients.

For NSCLC patients at high-risk for COVID-19, adjuvant chemotherapy should be discussed and potentially withheld, the authors observe.

NSCLC patients at high-risk risk for COVID-19 include those with either comorbidities such as cardiovascular or pulmonary disease as well as patients who are 70 years of age and older.

Immunotherapy should also be discussed and possibly delayed for stage III NSCLC patients following concurrent chemotherapy and radiation, they add.

Maintenance pemetrexed also may be withheld for NSCLC patients, and intervals of immunotherapy may be prolonged (eg, nivolumab every 4 weeks and pembrolizumab every 6 weeks).

Intervals of immunotherapy should be similarly prolonged for SCLC patients, they continue.

"Shorter duration of chemotherapy (eg, four cycles of chemotherapy instead of six) should be discussed with patients and maintenance chemotherapy can be withheld," the authors note.

Furthermore, "given the pandemic, it is highly likely that metastatic cancer patients will be less likely to be intubated or to be heavily ventilated compared to patients without any comorbidity," Addeo explained.

"So we have to acknowledge that metastatic lung cancer patients will be at higher risk of dying due to severe pulmonary COVID-19 complications," he added.

Therefore, third and further lines of chemotherapy in both NSCLC and SCLC patients at significant COVID-19 risk should not be initiated without having a good reason to do so.

"Prophylactic cranial irradiation (PCI) is still a matter of debate [in SCLC patients]," Addeo noted.

"So the reasonable alternative is to do surveillance MRI and in 6 or 8 months, we can probably offer PCI more safely at that point," he suggested, adding that radiation therapy to the brain should only be considered if a patient develops brain metastases.

The authors also suggest that thoracic consolidation radiotherapy for extensive stage SCLC should not be initiated unless there is good reason to do so.

Patients with family members or caregivers who have tested positive for COVID-19 should themselves be tested before or during any cancer treatment.

If patients themselves then test positive and are asymptomatic, "28 days of delay should be considered before (re)starting the treatment," the authors advise.

However, two negative tests done 1 week apart should be carried out before starting or restarting treatment, they note.

The authors have disclosed no relevant financial relationships.

ESMO Open. Published online April 3, 2020. Abstract

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