What are best practices for taking care of lung cancer patients during the COVID-19 pandemic?

Topics: Radiation Oncology • Thoracic Malignancies • Medical Oncology • COVID-19

Shadia Jalal, Indiana University

Added March 17, 2020

2 people found this helpful

6 people agreed with this answer

This is a great question, and as always there is no one size fits all. For patients on active treatment for lung cancer such as chemoimmunotherapy, I continue to stress the importance of hand washing, social distancing, and to work on reducing wait times in the waiting room to limit exposure, etc. If I have a patient on maintenance immunotherapy who is doing well and has had a great response and is 3-6 months into treatment, I am considering skipping an immunotherapy dose, if the patient is comfortable with that, to reduce hospital visits and decrease chance of exposure.

In patients who are on surveillance with no concerning symptoms for disease recurrence, we are offering telehealth visits or delaying visits. I continue to follow ASCO, NCCN guidelines when it comes to GCSF support in patients on myelosuppressive treatments. Unfortunately many patients in our lung cancer population are elderly with lung disease and are considered high risk for COVID-19. I think just like always, clear communication with these patients and working with them to reschedule visits when appropriate, or use teleheath is very important.

Comments

Medical Oncologist, Professor, Community Practice (South)

March 18, 2020

I keep wondering if physicians can be given the option to perform those tele-health visits from a home based office to reduce the burden of their exposure, especially that they will continue to be in busy clinics and cover inpatient services.

Medical Oncologist, Assistant Professor, Academic Institution (South)

April 11, 2020

Work with your hospital leadership to develop telework agreement. It can be done.

Nagla Abdel Karim, Inova-University of Virginia

Added March 17, 2020

2 people found this helpful

3 people agreed with this answer

In light of COVID-19 risks to lung cancer patients and in light of discussion with colleagues who are oncologists in Milan-Italy, I appreciate your comments on the following proposed recommendations:

1. Newly diagnosed patients especially of small cell lung cancer; neoadjuvant, adjuvant and metastatic disease with appropriate performance status remain a priority to treat and receive growth factors support with myelosuppresive therapies.

2. Clinical trials patients remain of priority too, however follow up or lab based visits; consider tele-oncology (will be discussed)

3. Maintenance patients can be off treatment for 2 months (break of therapy; in Italy they held maintenance Rituximab)

4. Patients admitted with severe neutropenia should not be discharged with the severe neutropenia, but remain until their counts recover.

5. Follow up patients should either follow through tele-oncology or postpone clinic visit for 3 months (in Italy they were postponed for 3 months, but here, I would like to propose a tele-oncology format).

Jeffrey Bradley, University of Pennsylvania Health System

Added April 9, 2020

3 people found this helpful

There are some international guidelines being published for consideration in this COVID-19 pandemic scenario. Here is a link to the ESTRO-ASTRO guidelines. We hope you find these helpful.

https://www.sciencedirect.com/science/article/pii/S0167814020301821

Gregory Otterson, Wexner Medical Center at The Ohio State University

Added April 10, 2020

NCCN will soon have lung cancer specific documents/recommendations. Hope these will be helpful.

Comments

Radiation Oncologist, Assistant Professor, Academic Institution (South)

April 10, 2020

See the link below for an ESTRO-ASTRO consensus statement on management of lung cancer during the current pandemic.

https://www.thegreenjournal.com/article/S0167-8140(20)30182-1/fulltext

Radiation Oncologist, Associate Professor, Community Practice (Northeast)

April 22, 2020

Very helpful, thanks.

theMednet is a knowledge-sharing community of 30,276 physicians

Related Questions

What is the role for molecular agents alone for medically inoperable NSCLC who is not a good candidate for chemoRT?

Ryan Whitaker

Vanderbilt-Ingram Cancer Center

If medically inoperable and deemed not a chemo candidate, my preference would be definitive RT alone using a hypofractionated approach to account for the absence of radiosensitizing chemotherapy even for patients with targetable driver mutations. The best data we currently have would then say to consider consolidation immunotherapy. We do not yet have data to support adjuvant targeted therapies after definitive radiation but given the success after definitive resection in ADAURA, I would anticip... (more)

How would you manage a left sided triple negative breast cancer with a concurrent left sided locally advanced non-small cell lung cancer?

Hatem Soliman

H Lee Moffitt Cancer Center, University of South Florida

This is a tough one to juggle as prolonging therapy for the TNBC could adversely affect the NSCLC or vice versa. If the patient is appropriate for it, I would attempt a platinum/taxane/aPD-1 for 4 cycles and assess response in the breast with MRI along with repeat imaging of chest. The most straightforward scenario is a pCR in the breast that can be addressed with a mastectomy and no radiation or adjuvant therapy that would significantly delay a lobectomy for the NSCLC. If there is residual dise... (more)

How would you approach a patient with limited stage SCLC who progressed immediately after completing chemoradiation with brain metastasis?

Henry Park

Yale School of Medicine

For 1-10 brain metastases from SCLC, consider the NRG CC009 clinical trial randomizing between SRS and hippocampal-avoidance WBRT! (more)

How do the results of TROPION-Lung01 Phase III trial change your practice in the management of locally advanced or metastatic NSCLC?

Balazs Halmos

Albert Einstein College of Medicine at Montefiore Medical Center

Well, short-term the answer to this excellent question is simple- not at all as datopotomab deruxtecan is not approved in any context, therefore, we will need to await an FDA decision as to when/how dato (for short) can be integrated into our practices. However, why not daydream a little bit in the wake of the TROPION-Lung01 data having been presented at ESMO as to how we might implement dato into our practices if/when it becomes available. Before digging into the data, let’s step back fo... (more)

What systemic therapy would you offer to a patient with metastatic EGFR exon 19 deleted NSCLC to the brain with isolated CNS progression while on osimertinib 80 mg and progressed through WBRT?

Tejas Patil

University of Colorado

If this is isolated CNS progression, the answer will depend on the number of metastatic sites. This is worth a conversation with your radiation oncologist. If there are 1-5 sites progressing within the CNS, it may be reasonable to consider treating these with SRS (even if patients have had prior whole brain radiotherapy) using an oligoprogression paradigm and staying on osimertinib. If the CNS progression is more widespread, then you can attempt a dose escalation to 160 mg PO daily. A retrospect... (more)

When do you offer SBRT for a small, slowly growing lung lesion?

Drew Moghanaki

UCLA | VA Greater Los Angeles Healthcare System

I caution ALL radiation oncologists from pulling the trigger on a case like this in a vacuum. Why did I use the word "caution"? It's because we recently studied how often a radiation oncology program is comfortable delivering SBRT w/o histopathological confirmation, and the range was between 0 - 61%. Ref: Wilkie et al., PMID 34409207We are not diagnostic experts, and the depth of knowledge that our pulmonology and radiology colleagues have is too valuable not to solicit whenever there isn't a hi... (more)

How are you approaching patients with early-stage NSCLC who progress on neoadjuvant chemo-immunotherapy and are no longer surgical candidates?

Jeffrey Bradley

University of Pennsylvania Health System

This is a good question, and we are seeing it too often these days. This question cites progression as the reason for not proceeding to surgery after neoadjuvant chemo-IO. We are also seeing patient refusal and ineligibility (i.e. N3 disease that didn't respond) as reasons. I think it's very important that these neoadjuvant chemo-IO patients see a surgeon and that both patient and surgeon agree to this treatment pathway. It's also important to recall the eligibility for these trials, specificall... (more)

Will you consider definitive concurrent chemoradiation for stage IV lung adenocarcinoma with metastasis limited to an internal mammary lymph node?

Ryan Whitaker

Vanderbilt-Ingram Cancer Center

I'd certainly consider it upfront if lung and cardiac constraints can be reasonably met. There have been a few small series now demonstrating good outcomes in patients who received definitive chemoradiation to thoracic disease in the setting of limited metastatic disease. Generally, I would favor an approach of upfront systemic therapy (IO +/- chemo based on PD-L1 and driver mutation status) and restage after a few cycles. If disease response/stability, then would offer definitive consolidative ... (more)

Would you ever consider repeating chemoradiation for patients with locally recurrent small cell lung cancer after prior chemoradiation for LS-SCLC?

Gregory Otterson

Wexner Medical Center at The Ohio State University

As with any good question, the answer is, it depends. Several factors would impact this decision - specifically the time frame - has it been a very short interval or long? I would at least ask the question if the relapse is SOLELY local-regional (i.e., no evidence of recurrence outside of the chest after a good faith effort including MRI brain, PET, etc), that it is biopsy-proven, and if the time since completion of last treatment (four cycles of platinum/etoposide) has been a year or more. Then... (more)

In patients with EGFR mutant L858R stage III NSCLC who are unresectable due to multistation N2 disease, would you consider upfront osimertinib over definitive intent CCRT?

Tejas Patil

University of Colorado

This is a very complex question that is common among our thoracic tumor board discussions. I'll answer the latter question first. In this case, I would not offer consolidative durvalumab.There are data that immune checkpoint inhibitors (ICIs) have minimal to no benefit in the metastatic setting based on translational data [Jia et al., PMID 30784054, Gavralidis and Gainor, PMID 33298723], large retrospective series [e.g. Mazieres et al., PMID 31125062, Negrao et al., PMID 34376553] and several ne... (more)

Why do I have to sign in?

Related Questions