COVID-19 crisis changed treatment for most lung cancer patients

BY TED BOSWORTH

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At a cancer treatment center that tracked data prospectively, the COVID-19 epidemic led directly to treatment delays and reduced surveillance in the majority of patients being treated for lung cancer, according to recently published data.

Between March 2 and May 30, 2020, 57% of lung cancer patients had a change in their lung treatment plan attributed to the COVID-19 pandemic in their medical record, according to data from a study led by Arielle Elkrief, MD, at the Cedars Cancer Center, McGill University Health Centre, Montreal.

In the study, a substantial proportion of the treatment changes took place between April 26, 2020 and May 19, 2020, which was a peak period of infection in Canada.

“Although changes were observed in the adjuvant and surveillance settings, most changes affected patients who were receiving palliative-intent care,” the authors reported in JAMA Oncology.

“Among patients on active therapy who experienced a treatment change, 2.4% of these changes represented oral targeted agents, 17% represented cytotoxic chemotherapy, 30% represented immunotherapy, and 8% represented combination chemotherapy and immunotherapy,” the investigators reported.

Of the 275 patients enrolled for treatment in the thoracic oncology clinic for lung cancer during the period of observation, 62.5% had stage IV non–small cell lung cancer (NSCLC). Stage III NSCLC (16.7%), SCLC (13.5%), and earlier stages of NSCLC represented the remaining cases.

Dr. Arielle Elkrief

The focus of this report was on the 211 patients who received active treatment without another histology during the observation period. Of this group, 121 (57%) had at least one change in treatment justified in the medical record by the ongoing COVID-19 pandemic. Nineteen (9%) had more than one treatment change for this reason.

Palliative therapy was the most commonly altered with delays in 39.7% of patients. Palliative care was stopped in 14.9% with an average time to resumption of 36 days. It was stopped permanently in 3%.

Changes in dosing and schedule, a category different from delays, were made in 26.4% of patients. Many of these involved lengthening the interval between doses of checkpoint inhibitors, such as pembrolizumab or durvalumab. Adjuvant therapy was delayed in 2.5% of patients. The mean delay was 42 days.

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The impact of these changes in regard to lung cancer outcomes or risk of COVID-19 infection is unknown, but the authors cited a study in the Lancet that found a high rate of COVID-19–related mortality among cancer patients.

Based on their experience, the authors concluded that “clinicians should proceed with evidence-based care provision in lung cancer.” They also called for efforts at other cancer care centers to track the impact of modifications in treatment in order to understand how they affect clinical outcomes.

Asked what motivated clinicians at his center to alter lung cancer treatment schedules during the COVID-19 pandemic, Nathaniel Bouganim, MD, who is an assistant professor of oncology at McGill University Health Center, Quebec, explained that spread of infection in the cancer clinics was not the chief concern.

“I believe the fear was more community spread of the virus and less about infection control practices,” said Dr. Bouganim, who was senior author of this study. He added in an interview: “In fact, the McGill Cancer Center has recorded zero COVID cases.”

At Yale University’s Smilow Cancer Hospital, the experience appears to have been similar, particularly early in the course of the pandemic when infection rates were peaking.

“We had to move around our patients and clinic to make room for the COVID patients and bring our cancer patients to settings where the could be more protected from the virus,” reported Roy S. Herbst, MD, PhD, chief of medical oncology at Yale University, New Haven, Conn.

“We did work when possible to minimize inpatient visits using telehealth to great effectiveness. Treatment was provided as appropriate though we did, when possible, increase the intervals between therapies and avoided cytotoxic therapy when possible,” he added in an interview. “It is critical to use the most effective, cytotoxic treatments, targeted therapies, and immunotherapies at the full doses on time in fit patients to best treat lung cancer,” he said.

Over the course of the COVID-19 pandemic so far, changes in lung cancer treatment have been avoided at the H. Lee Moffitt Cancer Center and Research Institute, Tampa, according to Jacques-Pierre Fontaine, MD, FCCP, a thoracic surgeon there. Infection control practices have been adjusted but not lung cancer treatment.

“Cancer treatments are not elective, and treatment should not be delayed,” he said.

From his perspective as a surgeon, “we performed the same if not a higher number of procedures” for lung cancer when the pandemic hit.

The reason is that “we are a cancer center without an emergency room bringing in patients potentially infected with COVID-19, so we were shielded,” Dr. Fontaine explained. As a result, “we ended up taking in patients from other hospitals where cancer treatment could not be administered on a normal schedule.”

The risk of COVID-19 has changed routines, but not cancer care.

“We screen staff for COVID-19 every day. We test patients before any procedure. No visitors are allowed in our facility, and of course we are well stocked in [personal protective equipment],” Dr. Fontaine said.

In the event that a lung cancer patient does test positive for COVID-19, care is delayed but delivered promptly once the infection has resolved, according to Dr. Fontaine. The goal is to keep patients on schedule when possible.

“In lung cancer, prompt treatment is important,” Dr. Fontaine said.

Dr. Jacques-Pierre Fontaine

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