COVID Disrupts Lung Cancer Screens: One Center's Account

Pam Harrison

December 23, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The COVID-19 pandemic has again compromised the delivery of cancer care, this time disrupting a lung cancer screening program and potentially adversely affecting patient outcomes, a study from a single center in Ohio shows.

"COVID-19 caused a significant disruption in lung cancer screening, leading to a decrease in new patients screened and an increased proportion of suspicious nodules once screening resumed," said Robert Van Haren, MD, University of Cincinnati College of Medicine, Cincinnati, Ohio, in a statement.

"By using lung cancer and our screening program as a model, this early analysis shows the consequences related to the pandemic for both screening programs and cancer care," he added.

The study was published online December 17 in the Journal of the American College of Surgeons.

Monthly Drops in New Patients, Screens, and More

The low-dose CT (LDCT) screening database was initiated at the institution in 2012. At the time of the current analysis, 2153 patients (average age, 63.8 years) had participated in the program. "A majority of patients screened were current smokers, with an average pack-years of 53," the investigators note. Chronic obstructive pulmonary disease (31.9%) and occupational exposures (23.4%) were common.

Monthly average screening visits were compared for the period January 2017 – February 2020 and the period March 2020 – July 2020, when COVID-19 was prevalent. The investigators explain that the screening program was suspended starting March 13, 2020, because of the risk for COVID-19, and 818 screening visits were canceled.

Phased reopening of the screening program began on May 5, and full opening occurred on June 1. During the COVID-19 interval, total monthly screening visits dropped to 39 visits. By comparison, the pre–COVID-19 participation level was 146 visits per month (P < .01), the investigators report.

The monthly caseload of new patients dropped to 15 during the COVID-19 interval, compared to 56 new patients per month prior to the pandemic. When the screening center reopened, 3- and 6-month follow-ups were prioritized; these increased from a baseline level of 11 follow-up visits to 30 visits after the screening center reopened (P < .01).

"However, despite complete reopening of LDCT operations, new patient monthly LDCTs have remained low (P = .04)," the authors note. The "no-show" rate also increased significantly from a baseline level of 15% to 40% during the COVID-19 months (P < .04).

The majority of the no-shows, approximately 80%, were for annual exams; approximately 9% were for baseline scans; and about 11% were for follow-up appointments. "Most concerning, the percentage of patients with lung nodules suspicious for malignancy (Lung RADS 4) was significantly increased after screening operations returned," Van Haren and colleagues observe — to 29%, compared to 8% prior to the suspension of operations (P < .01).

During the COVID-19 months, there was a significant increase in the number of referrals for intervention from thoracic surgery and interventional pulmonology, at 44% following the reopening, compared with roughly 21% in the pre-COVID period (P = .04).

"COVID 19 has dramatically impacted many aspects of medicine, including the field of oncology," Van Haren and colleagues observe.

Bigger Picture

Nationally, during March and April 2020, there was a 46% decrease in new cancer diagnoses for six common malignancies in the United States. The Netherlands Cancer Registry reported an almost 30% decrease in new cancer diagnoses in all primary cancer sites between February 24, 2020, and April 12, 2020, across the country.

The study authors also observe that national utilization of LDCT screening for lung cancer had already been suboptimal, "so any further decrease has potential negative consequences both in terms of cancer-related mortality and future utilization of lung cancer screening."

On the other hand, mitigation of the risk for COVID-19 is especially important for cancer patients, inasmuch as mortality rates are high among cancer patients who do contract the disease.

"Lung cancer patients are particularly at risk, due to underlying comorbidities such as smoking and pulmonary disease," the authors emphasize.

For the management of lung cancer during the pandemic, the Thoracic Surgery Outcomes Research Network has recommended deferring surgery for 3 months if hospital resources are limited because of COVID-19. If resources are not limited, it recommends surgery only for node-positive lung cancer and for tumors 2 cm in diameter or larger or for patients who have received neoadjuvant therapy.

"Lung cancer screening operations should be prioritized and continued to prevent negative consequences such as delay in diagnosis which could lead to increased cancer-specific mortality," Van Haren and colleagues advise. They acknowledge that at their institution, there is still a backlog of new patients awaiting initial screening, and canceled appointments are still being rescheduled.

Van Haren is a consultant to Intuitive Surgical, Inc.

J Am Coll Surg. Published online December 17, 2020. Full text

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