In 2020, lung cancer was the second most common cancer diagnosis across the globe, with 2.2 million new cases (equivalent to 12.2% of all cancers worldwide) and accounting for 1.8 million deaths. In Ireland, there are approximately 2,700 people diagnosed with lung cancer each year and the disease represents an enormous national health and socioeconomic burden.
On the 11th of March 2020, COVID-19 was declared a global pandemic by the World Health Organisation. COVID-19 has enforced many changes to lung cancer care, affecting the numbers of patients attending for clinic appointments, resulting in delayed access to diagnostics and negatively impacting treatment timelines. Because of the pandemic and the resultant societal lockdowns, clinicians have been forced to adapt how rapid access clinics are run, leading to the development of hybrid models of care, with establishment of virtual clinics, modification of diagnostic pathways and scaling up of surgical and medical and radiation oncology activity at private hospitals in an effort to expedite patient treatments.
COVID-19 Effects on Diagnostic and Therapeutic Pathways
Clinic Referrals and Patient Attendance
Under the auspices of the National Cancer Control Programme (NCCP), specific referral pathways were established over a decade ago from primary care to urgent hospital outpatient clinic evaluation for patients with symptoms suggestive of lung cancer. These individuals can expect an appointment for evaluation at a specialized cancer centre within 10 working days. Since the program’s establishment up to and including 2019, there was a year-on-year increase in the numbers of new patients assessed across the 8 Rapid Access Clinics in Ireland overall through this pathway. A report published by the NCCP in Ireland however found that new clinic attendances dropped by 33% with the onset of the pandemic, though did recover thereafter (fig 1). In March and April 2020 there was a 29% and 49% reduction, respectively, in electronic-referrals to expert centres, the preferred method of referral. Cancer Research UK similarly found that referral rates were 40% lower than before the pandemic-enforced lockdown across Britain.
There are a number of factors which accounted for the decrease in patient clinic attendances during the initial phase of the pandemic. Patients with symptoms concerning for lung cancer frequently postponed outpatient appointments through concerns about acquiring the infection in the hospital setting. The overlap in symptomology between COVID-19 and lung cancer led to some patients self-isolating further due to concern about being infectious, particularly at periods when access to testing for the virus was delayed, such as was the case in early waves of the pandemic.
For those patients who contracted COVID-19, the initial mandatory period of self-isolation in the context of infection (or as a result of being a close contact with another infected person) also resulted in delays in initial clinic reviews. Furthermore, patients who developed more severe disease frequently experienced a clinical deterioration in pulmonary status that negatively impacted these individuals’ suitability to undergo invasive testing and/or treatment.
A recent publication by Flores et al in the Journal of Thoracic Oncology reported on evidence of a stage migration among patients attending the Mount Sinai Cancer Centre in New York City. These investigators reported that the proportion of those with stage III/IV disease at presentation in the early phase of the pandemic was nearly double that of the pre-pandemic annual average, whereas there was a 50% decrease in the numbers presenting with stage 0, I and II disease. This is reflected in other centres in the U.S. including Cornell Health, also in New York City, and Washington State. In a centre in Turkey, Can Guven et al. reported that new referrals of localised non-small cell lung cancer (NSCLC) were greater in 2019 than in 2020, whereas there was an increase in the numbers presenting with advanced stage disease. In Australia, Degeling et al. developed an inverse stage-shift model to estimate the impact of COVID-19 on mortality and health economics. They estimated that the proportion of stage I lung cancers in 2020 that would progress during a 3- and 6-month delay were 2.1% and 8% respectively. This is of particular importance, given the strong inverse relationship between increasing stage and survival.
Figure 1. New attendances at the lung rapid access clinics in 2019 vs 2020, NCCP
Access to Diagnostics
Bronchoscopy is a critically important component and diagnostic tool in the assessment of lung cancer. However, access to this diagnostic tool early in the COVID-19 pandemic was significantly reduced, in order to protect both healthcare workers and patients, due to its aerosolgenerating nature and high risk of virus transmission. While it was later demonstrated that bronchoscopy can be safely undertaken with protective measures in place, it had a significant impact on access to diagnostics in Ireland initially. This was reflected in other reported international experiences also. For example, a study involving 37 units across Portugal published by Guedes et al noted a 31% decrease in the number of bronchoscopies performed, with the mean of 345 (±249) procedures carried out in each centre in 2020 compared to 500 (±346) the year prior. Indeed, in some jurisdictions, aerosol-generating bronchoscopic procedures (including endobronchial ultrasound (EBUS)) were completely suspended. A study across 58 cancer centres in the U.K. by Bartlett-Pestell and co-authors reported that bronchoscopy and EBUS services were completely suspended in 16 (27.6%) and 10 (17.2%) sites, respectively, in the early phase of the pandemic.
Because of this significant risk of virus transmission, alterations in bronchoscopy unit operating procedure have become necessary. Protective measures, including routine pre-procedural swab/safety questionnaire and careful adherence to full personal protective equipment use (PPE), including use of FFP2/3 masks as standard, were rolled out. In Ireland, a protocol on guidance for safe bronchoscopy unit operations was published in 2020 by the Health Service Executive (HSE) in conjunction with the Irish Thoracic Society (ITS). Similar guidelines were published by the British Thoracic Society and other international respiratory groups.
The implementation of new infection control and procedure room disinfection protocols however has led to an ubiquitous lengthening of interprocedural time delays, resulting in reduced capacity throughout the country, particularly for single procedure room units. The requirement for pre-procedural COVID-19 nasopharyngeal swab to help identify patients with potentially asymptomatic infection also posed logistic challenges to both patients and endoscopy units and procedure cancellations.
While there is as yet no screening program for early detection of lung cancer in Ireland, the COVID-19 pandemic saw a significant reduction, and, in certain regions, suspension of annual low-dose computed tomography (LDCT) screening in territories where it has been established. Pre-pandemic, the U.S. Centre for Disease Control and Prevention (CDC) reported that only approximately one in eight adults who met the eligibility criteria for LDCT screening attended for screening and most centres reported a significant reduction in patients undergoing this assessment as a result of COVID-enforced restrictions and patient preferences.
There have been arguments for and against pausing screening during the pandemic. Proponents in favour of temporarily suspending these programs point to the potential exposure of patients to the virus through hospital attendances leading to speculation that this risk competes with the mortality benefit conferred by early cancer detection, particularly given the pressures on acute health care systems in flux. Advocates for continuing LDCT screening in spite of the ongoing widespread virus spread highlight that risk of transmission can be minimised in an outpatient setting where mask wearing is mandatory, particularly with the widespread rollout of COVID-19 vaccination programs, in conjunction with readily available PCR and/or antigen virus testing, and highlight the potential of this program to detect early stage (i.e. curable) cancers. This benefit is particularly evident among marginalised populations that have particularly high risk of the disease. The National Cancer Institute (NCI) have acknowledged that the pandemic-associated reduction in the numbers screened will inevitably lead to an increase of patients diagnosed with later stage disease.
COVID-19 has caused significant disruption in the delivery of systemic treatment for oncology patients. A study from McGill University in Montreal noted that of 211 patients who were receiving active treatment at the onset of the pandemic, 121 (57%) experienced at least one change in the lung cancer treatment plan. In Ireland, although potentially overestimated due to movement of treatments off-site, day case attendance for chemotherapy reached its lowest point in April 2020, with an approximate 30% reduction from expected levels (across all cancer types) compared to previous years.
Among patients who progressed to cancer-directed therapy but contracted COVID-19 during their treatment, infection-enforced unscheduled breaks in therapy posed a risk of worse outcomes. A study by authors based at Memorial Sloan Kettering Cancer Centre in the U.S. reported that 62% of those with lung cancer who contracted COVID-19 were hospitalised and 25% of patients died.
The pandemic caused a similar major disruption to surgical services. An Annals of Oncology study found that a delay in surgery beyond 6 months is associated with a 5-35% decline in 5-year survival depending on age and tumour stage. In Ireland, between March to June 2020 inclusive, there were 740 less cancer resections performed (among all fields of surgical oncology), corresponding to a reduction of 14% overall.
Changing approach to Lung Cancer Care
Virtual consults and Telehealth
During the COVID-19 pandemic, there was a marked increase in virtual consulting and telehealth. This has allowed the timely review and management planning for lung cancer patients in both the immediate and remote setting. There has been also greater emphasis placed on virtual multidisciplinary meetings which has also allowed specialist input outside of tertiary centres. A telehealth study published earlier this year by West et al in the AccessHope Cancer Centre in California reported on the benefit of a remote subspecialist second opinion availability to assist on management decisions of lung cancer cases. This study identified evidence-based management changes affecting initiallyrecommended treatments in 28% of study subjects and confirmed the potential role of integrated subspecialist care for patients, irrespective of location. This was of particular relevance during periods of travel restrictions and/ or for patients otherwise having to ordinarily travel long distances to attend expert centres in person.
Changes in Treatment Paradigms
In Ireland, there was an early focus on migrating much of the complex, time-sensitive surgical workload (thoracic oncology activity included) to private hospitals with equivalent facilities and expertise, including post-operative critical care, in order to allow an outlet for public hospitals that were regularly operating at surge capacity. This move was supported by the Private Hospital Agreement and was in place until June 2020, with private hospital utilisation enabling urgent treatments to be undertaken in a timely fashion for public patients.
Over the subsequent course of the pandemic, further bespoke local arrangements between the HSE and various private hospitals have been established across the county in order to ensure timely access to predominantly curative-intent surgical intervention, but also to other cancer therapeutic modalities. Indeed, The HSE is establishing a framework through which public hospitals will be able to routinely access private hospitals’ services in order to expedite treatments for patients where this is deemed optimal with respect to adherence to nationally agreed key performance indicators.
Systemic anti-cancer therapy services were similarly routinely moved offsite from some NCCP specialised centres as the number of COVID-19 admissions began to rise in HSE hospitals. Protocols were regularly updated throughout the pandemic by cancer centres to limit risk of COVID-19 spread among day-case patients receiving systemic anticancer treatments, with arrangements similar to those for surgical caseload.
The COVID-19 pandemic brought previously unimaginable challenges to cancer care around the world, and healthcare teams and systems have had to adapt to a dynamic situation accordingly. Delays in patients being assessed and diagnosed with lung cancer will inevitably result in delays in initiation of their treatments. Moreover, the backlog of patients with delayed initial presentation as a result of lockdowns will have knock on effects on access to diagnostic services at hospitals dealing with a significantly increased burden of unscheduled care overall. As a result, their tumour management risks moving potentially from one of curative intent to disease control, with resultant reduced survival prospects. This is especially worrisome when one considers the comparatively poor outcomes for lung cancer patients overall. In contradistinction to those diseases that typically present with acute symptoms through emergency pathways (e.g. cardiovascular disease), the true excess mortality due to COVID-19 wrought disruption to cancer pathways will likely not be fully evident for several years. Indeed, the NCCP acknowledge that the full impact of the pandemic on survival rates for lung cancer patients in Ireland will not be known until long term outcome data are available through the National Cancer Registry.
However, despite this, it is clear from our experience of the COVID-19 pandemic to date that we must continue to improve provision of cancer services as we hopefully move towards the post-COVID 19 era. While there were initial concerns regarding the potential for missed cancers during virtual reviews, overall, this modality of patient assessment has been a success and has now become embedded as a core element in the model of cancer care.
In the United States, the Presidents Cancer Panel (PCP) under the Biden Administration hopes to increase uptake in cancer screenings to counteract the poor uptake prior to the pandemic and the subsequent reduction since the emergence of COVID-19. In Ireland, the Department of Health (DoH) and the NCCP worked closely with key stakeholders, including the ITS and the clinical leads from the national expert centres throughout the pandemic in order to prioritize continued provision of cancer services, in spite of extraordinarily challenging circumstances. There was a restoration of services funding in 2019, followed by further funding for the implementation of the National Cancer Strategy in 2021 which will have lasting benefit though 2022 and beyond. The DoH and NCCP, like all healthcare staff, hope that the ‘spirit of innovation’ demonstrated throughout the pandemic will continue into the future, to better serve patients with lung cancer.
References available on request
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