The clinical impact of COVID-19 and concurrent lung cancer

By Naveed Saleh, MD, MS, for MDLinx
Published April 28, 2020

Key Takeaways

The recent COVID-19 pandemic has impacted world health in tangible—as well as yet unforeseen—ways. One particularly worrisome population for infection with viral pneumonia is patients with lung cancer. 

“[W]ithout sufficient clinical awareness, a missed diagnosis of viral pneumonia may occur due to the fever and respiratory symptoms caused by lung cancer and its secondary diseases...Scientific protection and individualized management of lung cancer patients are particularly important during virus epidemic prevention and control,” wrote the authors of a recent article on the impact of viral pneumonia among patients with lung cancer. 

Focusing on COVID-19, let’s look at the comorbidities of viral pneumonia and lung cancer.

Lung cancer and COVID-19 risk

In a retrospective study published in The Lancet Oncology, which spanned 575 hospitals across China, researchers collected and analyzed data from 1,590 patients with confirmed COVID-19, among which 18 had a history of cancer. Of these patients, 5 (28%) had lung cancer, which was the most common type of cancer. Those with cancer and COVID-19 were older, with a mean age of 63.1 years vs 48.7 years among patients without cancer. 

Interestingly, researchers noted that patients with cancer were at higher risk of severe events (ie, admission to the ICU requiring intensive ventilation and/or death) than those without cancer. Specifically, patients who received chemotherapy or surgery in the past month were at greater risk of clinically severe events compared with those who did not receive such treatment. The researchers also noted that the incidence of cancer in the sample population was higher than that of the overall Chinese population. In all, patients with cancer were found to be at greater risk of COVID-19 than those without cancer, and patients with cancer had poorer outcomes from COVID-19.

The researchers thus proposed three major treatment strategies for patients with cancer during the COVID-19 pandemic as well as other potential novel viral onslaughts: 

“First, an intentional postponing of adjuvant chemotherapy or elective surgery for stable cancer should be considered in endemic areas. Second, stronger personal protection provisions should be made for patients with cancer or cancer survivors. Third, more intensive surveillance or treatment should be considered when patients with cancer are infected with SARS-CoV-2, especially in older patients or those with other comorbidities.”

Although findings from this retrospective study were “excellent,” according to the authors of a related commentary published in The Lancet Oncology, some limitations were noted.

“First, the data in the Comment by Liang and colleagues showed a higher percentage of patients with cancer in the COVID-19 cohort than in the overall population. However, this observation is not sufficient to conclude that patients with cancer had a higher risk of COVID-19. The incidence of COVID-19 in patients with cancer would be more informative in assessing whether or not patients with cancer have an increased risk of COVID-19,” wrote the authors of the commentary.

They continued: “Second, we reviewed the cancer history of the 18 individuals discussed in Liang and colleagues' Comment. We are concerned that such a small sample size with a large amount of heterogeneity, presenting as various cancer types with different biological behaviours, highly variable disease courses (from 0–16 years), and diverse treatment strategies, might be filled with contingency and thus not ideally representative of the whole population with cancer. Notably, half of the patients with cancer had a disease course of more than 4 years, indicating that a substantial proportion of these patients might be clinically cured. Therefore, any conclusions that generalise to all patients with cancer should be interpreted with caution.”

They concluded: “Third, 13 (72%) of 18 patients with cancer had a history of surgical resection; the prolonged effects induced by surgery including immunosuppression should not be neglected. Comparison of patients with COVID-19 and surgical history with and without cancer would be of interest.”

Nevertheless, authors of a Chinese-language review article, published in the Chinese Journal of Lung Cancer, seemed to support the idea of targeted, prioritized treatment strategies for patients with cancer—particularly lung cancer—amid the COVID-19 pandemic:

“The protection provisions and control measures aiming to protect lung cancer patients from COVID-19 have been increasingly concerned. During the COVID-19 outbreak period, it should be carefully differentiated for fever and respiratory symptoms for lung cancer patients receiving anti-tumor treatment, in order to evaluate the risk of COVID-19. Moreover, it is necessary to carry out meticulous and individualized clinical management for lung cancer patients to effectively protect the patients from COVID-19.”

Honing in: Pathology

Although clinical data regarding the specific health effects of COVID-19 on patients with lung cancer are limited, case studies are proving to be valuable in understanding the pulmonary pathology of the viral disease. Most recently, researchers from Wuhan University, China, performed histopathological studies in two patients with lung cancer receiving lobectomies for adenocarcinoma, who were retrospectively found to have COVID-19 at the time of surgery. In addition to the tumors, the lungs of both patients demonstrated proteinaceous exudates, edema, focal reactive hyperplasia of pneumocytes with patchy inflammation, and multinucleated giant cells. The presence of hyaline membranes was minimal. Moreover, likely due to early presentation, the patients did not demonstrate signs of viral pneumonia.

The first patient, an 84-year-old woman, received antibiotics, assisted oxygenation, and robust supportive care, all to no avail. She decompensated—eventually desatting to 62.6% and her heart rate dropping to 40 beats per minute—before dying. The patient was autopsied.

The second patient, a 73-year-old man, received elective lobectomy and developed fever on postoperative day 9, replete with chest tightness, muscle pain, and dry cough. In addition to testing positive for COVID-19  (but negative for influenza and other viral agents), labs came back demonstrating lymphocytopenia. Repeat CT demonstrated expanded ground-glass opacity of the bilateral upper lobes, which is consistent with viral pneumonia. The man was admitted to the infectious disease ward and received treatment for COVID-19, gradually recovering by day 20. Resected lobes were taken for pathological examination.

The researchers go on to note that although the female patient was afebrile, she did exhibit early-onset neutrophilia and lymphocytopenia, which are both characteristic of COVID-19 and could aid with diagnosis. On the other hand, the male patient developed a fever a few days post-CT findings, suggesting delay of onset of symptoms in these patients, per the authors.

“It seems that the time for early lung lesions or COVID-19 to become severe enough cause clinical symptoms is rather long,” wrote the authors. 

“Even among patients with fever, the typically used polymerase chain reaction test may be negative, owing to the absence of viruses in the upper respiratory tract despite the presence of pneumonia. However, radiographic changes can occur early (chest CT scan is mostly employed in the People’s Republic of China during the outbreak). Therefore, during an epidemic season, it is prudent to carefully evaluate any lung infiltration for GGO, and an appropriate serology test must be performed to rule out potential infection,” they concluded.

Panning out: Diagnosis and management 

For more general suggestions on the oncologic management of community-acquired viruses—including influenza, respiratory syncytial virus, adenovirus, parainfluenza virus, influenza, and human metapneumovirus—the Infectious Diseases Working Party of the German Society for Haematology and Medical Oncology has published guidelines on diagnosis on management.

With community-acquired viruses in patients with cancer resulting in pneumonia in about 30% of those affected—with an associated mortality of about 25%—the 18-member panel recommended practicing good hand hygiene, contact isolation, and face masks as part of general management. For CRV infection diagnosis, combined nasal/throat swabs or washes/aspirates were found to offer the best results, and they suggested the use of nucleic acid amplification based-techniques for the detection of pathogens.

For respiratory syncytial virus, the panel recommended treatment with ribavirin plus intravenous immunoglobulins. They also noted that ribavirin may be effective for parainfluenza virus and human metapneumovirus, although the data on efficacy have been mixed. Cidofovir, they suggested, may be used to treat adenovirus pneumonitis.

Challenges and unanswered questions

One overriding difficulty when assessing the impact of COVID-19 and other novel respiratory viruses on the precarious state of lung cancers is a lack of research. 

In commentary published in the Annals of Oncology, sole author, William K. Oh, MD, Tisch Cancer Institute and Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, offered the following take:

“We expect that in the months to come, more detailed studies will be forthcoming on the impact of  COVID-19 infection in cancer patients, including the risk of infection, the clinical impact of COVID-19 and concurrent cancer, the effect on different types of cancer, and the ability to deliver appropriate and  even curative cancer treatments in the setting of infection. 

“For now, many questions remain unanswered: Should cancer treatments such as chemotherapy or  radiotherapy be delayed or modified?  Should cancer patients undergo a differential screening process for COVID-19 infection, compared with the general population?  How can we reduce the rate of nosocomial  infections?

“[We] will need to understand the heterogeneity in effectiveness of what we hope are soon-to-be  approved COVID-19 vaccines and antiviral agents in cancer patients, and that COVID-19 infection will  become just one additional factor to take into consideration in the comprehensive management of oncology patient.”

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