Researchers Release Alternative Treatment Strategies During COVID-19 for NSCLC

A nationwide team of clinical investigators, including oncologists from Fox Chase Cancer Center, MD Anderson Cancer Center, Johns Hopkins University, and other institutions teamed up to explore options on how to manage patients with locally advanced non-small cell lung cancer (NSCLC) in a multidisciplinary setting during the ongoing pandemic of coronavirus disease 2019 (COVID-19). The clinical recommendations were published in the Journal of Thoracic Oncology.¹

“These are strategies that you can use if your resources are limited and you feel your patients are at risk.” Sameera Kumar, MD, one of the authors on the paper and an assistant professor in the Department of Radiation Oncology at Fox Chase Cancer Center, said in a statement. “It’s a guide for what to do if, for example, another situation like New York happens; if it gets really bad and the rates of infection significantly increase. Otherwise, the standard of care is appropriate as well,”²

For these patients, there is a likeliness for comorbidities that increase their risk of severe morbidity and mortality if they get COVID-19, making them vulnerable during this pandemic. The paper suggests options for pathologic diagnosis and nodal staging, surgical management, nonoperative management, what do for patients who are infected, communication, and other multidisciplinary approaches. The standard-of-care procedures and therapies may not be the best options for patients with NSCLC in the current situation.

“We’re dealing with lung cancer and our [patients with] lung cancer may be more at risk for severe disease due to COVID-19. A lot of the management we do puts them at greater risk after that,” Kumar said in a press release. “This paper addresses some strategies for how to manage those patients.”

For instance, it is suggested for physicians to consider staging the mediastinum with 18F-FDG-PET-CT to avoid endobronchial ultrasound or mediastinoscopy, which is more invasive. Another consideration to keep in mind treatment-wise is for patients receiving chemotherapy, which causes them to have decreased immunity; patients who receive radiation therapy need to come in daily for treatment, according to Kumar.

“Every single day is another exposure,” Kumar explained. “In some cases with stage III [disease], we’ll do chemoradiation and immunotherapy or chemoradiation and surgery. With surgery, that’s a lot of risk to both the patient and the providers. Recent data shows that surgical outcomes in patients who have COVID, even if they’re asymptomatic, are much worse.”

Physicians with patients who are infected with COVID-19 should consider withholding therapy until the patient has recovered, but there should be no delay for treatment of patients without infection, the authors wrote in the conclusion of the article. They also suggest that alternative management approaches that can reduce the risk of contracting or transmitting COVID-19.

“This paper includes strategies like giving sequential chemotherapy and then radiation. We would do hypofractionated radiation, so instead of coming in for 6 weeks, you’re only coming in for 3 weeks. By doing it sequentially with chemotherapy and then radiation, we’re not combining the immune-suppressive effects of chemotherapy and the frequent visits of radiation at the same time,” Kumar said in the press release.

For the caretakers of patients with NSCLC, the main goal of this paper is to describe how to reduce the amount of times they have to come into the healthcare facility, as well as reduce the risk of exposure to COVID-19 and other infections. It also explains how to reduce the immunocompromising effects of the therapies used to treat patient’s disease.

_References:

_{1. Kumar S, Chmura S, Robinson C, et al. Alternative multidisciplinary management options for locally advanced NSCLC during the coronavirus disease 2019 global pandemic. J Thor Oncol. 2020;15(7):P1137-1146. doi:10.1016/j.jtho2020.04.016}

_{2. Fox Chase researchers help identify best practices for cancer patient care during COVID-19 [press release]. Fox Chase. Published July 1, 2020. Accessed July 16, 2020. https://bit.ly/2WsTA0n}

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