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Lung cancer diagnoses declined and outcomes deteriorated during the first 6 months of 2020, coinciding with the COVID-19 pandemic, according to a retrospective cohort study from Spain.

The number of new lung cancer cases decreased by 38% from January to June 2020 as compared with the same period a year earlier. The 30-day mortality almost doubled, and median overall survival (OS) decreased by more than a month.

"Lung cancer diagnosis is being affected during COVID," Roxana Reyes, MD, of Hospital Clinic de Barcelona, said during the (WCLC) virtual congress. "In non-small cell lung cancer [NSCLC], we have noticed more symptomatic and more severe cases diagnosed during COVID. We observed poor outcomes, with an elevated 30-day mortality rate."

"The COVID-19 pandemic is likely to last for a prolonged period of time, so we have to make a special effort for ensuring cancer diagnosis and treatment of our patients."

The presentation was included in a WCLC press briefing that focused on the impact of COVID-19 on lung cancer care, including patient-related outcomes.

Consistent Data

Reyes' study continued a narration that emerged early in the COVID-19 pandemic: Declining attention to cancer screening, reduced hours for non-essential care, and reallocation of strained healthcare resources to deal with the pandemic. The retrospective analysis examined the pandemic's impact on diagnoses and outcomes at two tertiary hospitals, but likely mirrored the experience at centers worldwide.

"Patients with cancer are highly vulnerable," said Reyes. "They have increased rates of severity and mortality. Patients with lung cancer are a particularly high-risk population. In Spain, the first and second wave of the pandemic caused a state of emergency and prioritization of health services, which could delay the diagnosis and treatment of cancer patients. Our objective was to study lung cancer incidence, severity, and outcomes during COVID."

Investigators compared data on thoracic malignancies for January to June in 2019 (pre-COVID) and in 2020 (during the pandemic). They investigated differences in number of new lung cancer cases, disease severity (defined by performance status, stage, or presence of significant complications at diagnosis), and 30-day mortality.

During the first 6 months of 2019, clinicians diagnosed 100 new cases of lung cancer. A year later the total number of cases declined to 62. The histology distribution did not change (68% NSCLC and 32% small-cell lung cancer [SCLC]). Patients during the two periods had a similar medical history with the exception of non-smokers, whose representation doubled during the pandemic (8% vs 16%). Age, sex distribution, and performance status at diagnosis were similar.

Focusing on patients with NSCLC, Reyes said the number of new diagnoses declined from 13 per month to nine (36%). Disease severity increased during the pandemic, including emergencies (3% vs 7%), hospitalization (18% vs 21%), death during hospitalization (17% vs 44%), advanced disease at diagnosis (46% vs 58%), more than two metastatic sites (12% vs 16%), and symptomatic disease (63% vs 74%).

The number of SCLC diagnoses decreased by 42% during the pandemic. However, disease severity actually declined for all of the parameters that defined severity.

Lung cancer-associated mortality increased during the pandemic, said Reyes. The 30-day mortality increased from 25% pre-pandemic to 49% for patients with NSCLC and from 18% to 32% for SCLC. Median overall survival was 7.9 months in 2019 and 6.7 months in 2020.

Psychological Impact

Beyond the impact of COVID-19 on cancer care, the pandemic has worsened the psychological distress of patients, as described by Domenico Galetta, MD, PhD, of the Giovanni Paolo II Cancer Institute in Bari, Italy.

Population-based studies have documented increased rates of anxiety, depression, and post-traumatic stress disorder during the pandemic. However, the psychologic impact on patients with cancer has not been studied extensively, said Galetta. He reported findings from a study of 176 patients from an oncology outpatient clinic. The cohort comprised 77 patients with lymphoma, 59 with lung cancer, and 40 with breast cancer.

Each patient completed a battery of questionnaires to assess psychological status: Hospital Anxiety and Depression Scale (HADS); Impact of Event Scale-revised (IES-r); and a brief structured questionnaire about worry.

The HADS results showed that 55% of patients reported general distress, 44.5% reported depression, and 58% reported anxiety. Rates were similar for men and women, but patients with lung cancer had higher scores for all of the parameters assessed by HADS as compared with patients who had lymphoma or breast cancer. The IES-r data showed that a fourth of the patients had high levels of stress, reported more often by women (27.3% vs 18.4%, P<0.05).

Men and women alike had high levels of worry, but women were more concerned about getting infected during a hospital visit (60% vs 40%), delayed treatment (62% vs 38%), and potential difficulties with contacting their oncologists (66% vs 34%). Men were more worried about financial issues (57% vs 43%).

"Protecting cancer patients is an important component of public health measures to address the COVID-19 epidemic," Galetta said. "Special interventions to promote mental well-being in patients in this period of the coronavirus pandemic need to be implemented as soon as possible, especially with regard to women and lung cancer patients."

A separate study of 302 patients with lung cancer interviewed after shelter-in-place restrictions showed that 96% had concerns about interrupted cancer care during the pandemic. Almost half reported interruptions in cancer care, 18% said they had trouble getting appropriate care, and 45% worried about getting care after the pandemic.

"Our study reveals that patients with lung cancer continue to feel vulnerable and ill-equipped to navigate cancer care post shelter-in-place," said Jessica Selig, of the LUNGevity Foundation in Chicago. "Indeed, patient-specific factors (treatment status) and local COVID-19 caseload are important predictors of patient worries. Access to healthcare should be taken into account both during patient-physician discussions and during lung cancer care planning at a systems level."