Delaying surgery
As a general principle, the use of neoadjuvant chemotherapy instead of adjuvant therapy following surgery can delay the need for immediate surgery. If surgery can be delayed, “the risk of a patient catching the virus several months from now might be less,” Addeo noted. Thus, treating patients upfront with chemotherapy is one tactic to consider in appropriate patients.
For NSCLC patients at high risk for COVID-19, adjuvant chemotherapy should be discussed and potentially withheld, the authors observe.
NSCLC patients at high risk for COVID-19 include those with comorbidities, such as cardiovascular or pulmonary disease, as well as patients who are 70 years of age and older.
Immunotherapy should also be discussed and possibly delayed for stage III NSCLC patients following concurrent chemotherapy and radiation, they add.
Maintenance pemetrexed also may be withheld for NSCLC patients, and intervals of immunotherapy may be prolonged (e.g., nivolumab every 4 weeks and pembrolizumab every 6 weeks).
Intervals of immunotherapy should be similarly prolonged for SCLC patients, they continue.
“Shorter duration of chemotherapy (e.g., four cycles of chemotherapy instead of six) should be discussed with patients and maintenance chemotherapy can be withheld,” the authors note.
Furthermore, “given the pandemic, it is highly likely that metastatic cancer patients will be less likely to be intubated or to be heavily ventilated compared to patients without any comorbidity,” Addeo explained.
“So we have to acknowledge that metastatic lung cancer patients will be at higher risk of dying due to severe pulmonary COVID-19 complications,” he added.
Therefore, third and further lines of chemotherapy in both NSCLC and SCLC patients at significant COVID-19 risk should not be initiated without having a good reason to do so.
“Prophylactic cranial irradiation (PCI) is still a matter of debate [in SCLC patients],” Addeo noted. “So the reasonable alternative is to do surveillance MRI, and, in 6 or 8 months, we can probably offer PCI more safely at that point,” he suggested, adding that radiation therapy to the brain should only be considered if a patient develops brain metastases.
The authors also suggest that thoracic consolidation radiotherapy for extensive stage SCLC should not be initiated unless there is good reason to do so.
Patients with family members or caregivers who have tested positive for COVID-19 should themselves be tested before or during any cancer treatment.
If patients themselves then test positive and are asymptomatic, “28 days of delay should be considered before (re)starting the treatment,” the authors advise.
However, two negative tests done 1 week apart should be carried out before starting or restarting treatment, they note.
The authors have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
