Patients with lung cancer should take all recommended precautions against COVID-19, but they must also keep up with their cancer care, doctors advise.
Alisa Brenes, 63, is a 20-year survivor of lung cancer, and she spends a lot of time worrying about COVID-19. “I first became aware of COVID-19 through my lung cancer community, which was discussing this new disease and how it affects the lungs,” Brenes recalls. “At first, I didn’t feel any panic, (as) most of the local cases were in Westchester, (New York), but shortly after that my office told us we were going home and New York City was going on pause.”
Brenes, a legal assistant living in Manhattan, is just one of the many hundreds of thousands of people in the United States who have survived lung cancer or are facing a new diagnosis and are trying to understand their risks in what has become the COVID-19 era.
According to the Centers for Disease Control and Prevention (CDC), COVID-19 is a respiratory illness caused by a virus that can spread from person to person, and its symptoms can range from mild or none to severe illness. The virus cells first infect the respiratory and nasal lining, causing inflammation, explains Dr. David M. Jablons, chief of general thoracic surgery at the University of California, San Francisco and a professor of thoracic oncology at its Helen Diller Family Comprehensive Cancer Center.
“That is why some patients can get a cough or shortness of breath, and in severe cases, people can develop pneumonia or interstitial lung disease,” a group of disorders that can cause progressive lung scarring, Jablons says.
Everyone is at risk for getting COVID-19, but certain groups, including older adults and those of any age with serious underlying medical conditions, might be at a higher risk for severe illness if they contract the virus, according to the CDC.
Lung cancer itself likely does not put people at increased risk of contracting COVID-19, but some of the other illnesses or treatments associated with the malignancy may increase the severity of the virus, according to Dr. Joshua K. Sabari, a medical oncologist at NYU Langone Health’s Perlmutter Cancer Center and an assistant professor at its NYU Grossman School of Medicine in New York City. One of those conditions is simply age, as the average patient who receives a diagnosis of lung cancer is 70 years old.
“Other pulmonary comorbidities (coexisting illnesses) associated with lung cancer, such as chronic obstructive pulmonary disease and the use of certain cytotoxic chemotherapies to treat lung cancer, may also increase risk compared with targeted therapies or immunotherapy and chemotherapy combined,” Sabari says.
Although chemotherapy leaves patients with lung cancer immunocompromised, meaning that their bodies are more prone to infection, study results have been mixed about whether the treatment contributes to the risk of contracting COVID-19 or having a severe case.
Some of the best data available on the relationship between lung cancer and COVID-19 are from the TERAVOLT global registry study. Recently published data from TERAVOLT showed that patients with stage 4 non-small cell lung cancer face a higher risk of complications and death if they get COVID-19. When various factors were looked at independently, the study showed that older age, treatment with chemotherapy and the presence of comorbidities were associated with an increased risk of death among these patients. However, in an analysis of multiple factors looked at together — typically considered a more accurate measure — only smoking history was associated with an increased risk of death.
Another study, this one conducted by researchers at Memorial Sloan Kettering Cancer Center in New York City, analyzed the cases of 102 patients who had both lung cancer and confirmed COVID-19; they found that the virus was severe in 62% of the patients but accounted for only 11% of the deaths among the group studied. Chronic obstructive pulmonary disease and smoking status were associated with increased severity of COVID- 19, but recent chemotherapy was not.
Most patients with early-stage lung cancer found incidentally through screening or on a chest X-ray prior to another surgery are likely not at any increased risk from COVID-19 compared with the general population, Jablons says, adding that he is not aware of any patients with lung cancer at his cancer center who contracted COVID-19 since the pandemic started.
Although her evaluation is anecdotal rather than scientific, Brenes has seen a similar trend: None of her close friends from the lung cancer community have told her they had the virus, and Brenes has heard through the grapevine of only a handful of people within that community who have been sick with the illness.
One important thing to remember is that cancer will not “shelter in place” when people do, Jablons says.
“In the past few months, there have not been as many incidental early-stage cancers found through screening because people are avoiding going to the hospital or for routine health care,” he says. “That may be a bigger risk to someone’s long-term survival than COVID-19.”
Brenes admits that she delayed some of her regularly scheduled follow-up appointments.
“I was a few months late for my routine low-dose CT (scan),” she says, referring to a screening test for individuals with a history of smoking that checks the lungs for lesions. “I was afraid to go to my cancer center — Mount Sinai in New York — which was a COVID-19 hospital. I was afraid to take mass transportation or to take a cab.”
To lower her risk for exposure, Brenes eventually called to have her scans scheduled at a private radiology center within walking distance and asked to have the first appointment of the week after the CT scanner had been out of use for 48 hours over the weekend.
Sabari, who practices in New York City, says he knows of a lot of patients who are fearful of in-person health care visits.
“We definitely missed opportunities to diagnose patients early and cure their disease,” Sabari says. “We have also seen a lot of mortality in lung cancer patients from not accessing care or getting the correct care during the pandemic.”
Right now, in any area with lower COVID-19 rates, patients should not delay treatment, he says. Even during the peak of the pandemic, he continued to treat patients with stage 2 or 3 disease, for whom the goal of chemotherapy is to cure the cancer.
Even in those areas with higher rates of COVID-19, patients should actively communicate with their health care teams on the best way to approach treatment, according to Dr. Konstantinos Leventakos, a medical oncologist and an assistant professor of medicine and oncology at Mayo Clinic in Rochester, Minnesota.
For some patients with advanced disease, the recommended treatment approach may include enrolling in a clinical trial. Fortunately, most centers have these studies up and running again. “Some trials halted enrollment at the start of the pandemic, but we are now able to reopen them safely,” Leventakos says.
The requirements of each clinical trial are different, and some may mandate that patients undergo COVID-19 testing before they receive treatment. Other changes made to the design of some trials during the pandemic aim to make participation more accessible, for instance, by requiring fewer cancer center visits than would otherwise be expected or using televisits or local providers when possible. “We have to constantly balance the risk of potentially life-threatening infection in patients with lung cancer with the short- and long-term consequences of delaying cancer care,” Leventakos says. “That is why good communication with your oncology team is the only way to make the best decision.”
According to Jablons, if required to come onsite, patients are safe at most treatment centers, especially at high-volume centers of excellence where thorough precautions have been put into place to prevent transmission of the virus. If concerns exist, patients should inquire about the safety precautions that are being taken for both employees and patients at the facility.
Tiffany Fagnani, 39, said she has experienced some cancellations or rescheduling of treatment and follow-up appointments at Fox Chase Cancer Center in Philadelphia since the pandemic began, but that she feels safe going in when necessary because the center has been able to maintain a COVID-19-free status.
Fagnani, a nurse case manager living in Pennsylvania, received a diagnosis of stage 4 lung cancer with brain metastases in July 2017. Today, even though the disease is stable, she understands the importance of not delaying care.
“I know that I still have to go in for certain appointments, and for others I am able to talk with my team using telehealth,” Fagnani says. She sees this compromise as the best way to prioritize her care while still being cautious.
When Fagnani goes out, she wears a mask and checks to make sure everyone around her is doing the same. If they are not, she avoids going near them. She also avoids crowded spaces where social distancing is not possible.
One challenge for Fagnani was that she was in the process of having a new home built when the pandemic hit.
“When we did walkthroughs, I asked that it only be me, my realtor and the builder,” she says. “We were all masked, and we were all socially distanced.”
In the more crowded setting of New York City, Brenes also takes precautions. “I always wear a mask if I have to leave my apartment or even for the laundry room, to get mail from the lobby or to get a home delivery,” Brenes says.
“I wear a disposable mask with a reusable lung cancer awareness mask over it.”
As many public service announcements have emphasized throughout the pandemic, frequent hand washing and keeping fingers away from the face are also important. Another way to protect health is to keep the lungs and body as healthy as possible, Leventakos says.
“At home, a healthy lifestyle can help overall health: Make healthy choices in order to keep your body strong,” Leventakos recommends. “Get enough sleep so that you wake feeling rested. Choose a healthy, balanced diet. Aim to get exercise most days of the week.”
Importantly, he says, find healthy ways to reduce stress.
“I do have high anxiety, and it has affected my mental health,” Brenes notes. To help manage her anxiety, Brenes has signed up for meditation and chanting classes on Zoom, which help her relax. When she feels anxious, she tries to focus on her breathing. Brenes also turns to the lung cancer community and its Zoom chats to talk about her fears and concerns.
Patients in need of support can turn to online communities like LUNGevity, which offers weekly virtual meetups for patients, survivors and caregivers across the country. Similarly, the GO2 Foundation for Lung Cancer has moved its Lung Cancer Living Room, a monthly patient education and support series, to a virtual plat- form. Fagnani says that she still sees some friends in person, at least the ones she knows are following all appropriate COVID-19-related precautions. She has also found a renewed joy in cooking.
“I have been doing grocery delivery, and sometimes there are certain things that you
can’t get,” Fagnani says. “I have learned to open the cupboard and see what I have to create a new meal or new recipes. I have really enjoyed that.”
As winter months approach, Sabari says that patients with lung cancer should be cautious but not fearful.
“I recommend that all patients get a flu shot, and if you are 65 or older, get the high-dose flu shot,” Sabari says. “We can’t become complacent. We have to continue to wear masks, wash hands routinely (and) socially isolate and distance when possible.”
He also emphasizes that, with all that health care experts have learned about COVID-19 since earlier this year, the benefits of treating lung cancer far outweigh the risks of the virus.
“Take every possible precaution that you can, but until we have a vaccine or until a greater proportion of the population has antibodies, COVID-19 is something that is going to remain with us, and dealing with it has to become a new normal,” Sabari says.
Leventakos agrees. He recommends that all patients and their families or caregivers get familiar with the COVID-19 precautions at their clinic or hospital and closely monitor the levels of the virus in their local area.
Finally, he says, it is important to remember that each patient’s experience is unique.
“Even though, statistically, COVID-19 might cause more complications in patients with cancer, and lung cancer, specifically, every patient has a different course,” Leventakos says. “This is why it is important for patients to communicate any change in their health with their oncology team.”
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