LUNGevity and four other lung cancer organizations are issuing regular joint statements on coronavirus to help people understand what is known about COVID-19, find reliable sources of information, and be aware of its potential impact on vulnerable populations, including those with lung cancer.
Also see our "Special Edition: COVID-19 and Lung Cancer" newsletters: June 12 | May 29 | May 15 | May 1 | April 17 | April 10 | April 3
As of August 9, 2020, we are approaching 20 million cases of COVID-19 worldwide, with almost 5 million cases and 160,000 deaths in the US alone. In this week’s update, we want to shift our attention to another looming healthcare crisis resulting from the pandemic, namely a significant decline in new cancer diagnoses. Given the importance of maintaining appointment schedules, we will also present questions that you may want to ask your healthcare provider in advance of visits to the doctor. Finally, we will highlight ongoing advances in lung cancer research, because cancer doesn’t stop and neither do we.
What is the impact of COVID-19 on new cancer diagnoses?
In the early days of the pandemic here in the US, many stakeholders conducted various modeling simulations to look at the short-term and long-term impacts of the pandemic, particularly related to people continuing to get their recommended cancer screenings (mammograms, colonoscopies). These studies highlighted a looming crisis, predicting a rapid decline in the number of new cancer diagnoses. Dr. Ned Sharpless, Director of the National Cancer Institute, highlighted some of this data in a recent presentation at the AACR COVID-19 and Cancer Conference and in an editorial for Science.
This past week, a new study showed an alarming overall drop (46%) in new cancer diagnoses across six different tumor types, including lung cancer, for the period from March 1 to April 18, 2020:
Additional reports from across the country indicate an even higher drop in new cancer diagnoses. The COVID and Cancer Research Network reported a decline of 74% across 20 sites in the US for April 2020 compared to April 2019.
While people were encouraged to delay these essential screenings during the spring, we know that early detection of cancer is critical for achieving the best outcome and so we want to stress the importance of keeping up with your medical appointments and recommended screenings. To that end, we want to empower you with a set of questions to ask your doctor in advance of any visits so that you feel they are taking appropriate precautions to ensure your safety.
What Should I Ask My Doctor About What They’re Doing to Keep Me Safe?
It’s not unusual to be concerned about the risk of exposure to coronavirus when you go to a clinic or hospital during a pandemic. A facility that is currently experiencing a large volume of COVID-19 patients, or limiting certain procedures or services, may have limitations on which patients it can accommodate. However, most facilities are ready to welcome patients.
Hospital and clinic facilities are taking extra precautions to keep their patients safe. Many facilities are posting videos and information on their websites explaining which precautions they’ve implemented (here is an example video).
If you can’t find information online about the facility you want to visit, call the facility and ask about their precautions. Here are some questions you can ask your care provider or facility before an in-person appointment:
Additional steps YOU can take to help keep yourself safe before, during, and after a visit inside a hospital or clinic:
And lung cancer research continues in full swing!
This year’s World Conference on Lung Cancer (WCLC 2020), hosted by the International Association for the Study of Lung Cancer, went virtual due to the COVID-19 pandemic. Originally scheduled to be held in Singapore from August 8-12, 2020, the scientific sessions will be available from January 28-31, 2021.
WCLC 2020 was officially kicked off on August 8, 2020 with the Presidential Symposium live telecast at 7 PM Singapore time. The Presidential Symposium is a platform to present practice-changing research in the early detection or treatment of lung cancer. This year’s Symposium had three fantastic Phase III trial presentations on immunotherapy for non-small cell lung cancer (NSCLC), a new targeted therapy for ALK-positive lung cancer, and immunotherapy for mesothelioma.
These three presentations will likely set the foundation for new drug approvals and remind us that lung cancer research will continue, no matter what COVID-19 brings!
Resources and websites
These updates began on March 3, 2020—a week before the World Health Organization declared COVID-19 a pandemic—when concerns arose in the lung cancer community regarding news out of China about a novel respiratory virus especially deadly to patients with lung cancer. Dr. Upal Basu Roy (who holds a Masters in Public Health), Dr. Amy Moore (whose PhD research was in virology), and Janet Freeman-Daily (a lung cancer research advocate) led lung cancer patient advocacy groups’ efforts to provide vetted, scientific information with a unified voice. Our goal is to provide a trusted source of information that each member of the community can use to assess their risk and make healthy choices for themselves and their families.
As of July 26, 2020, there have been over 16 million cases of COVID-19 worldwide. This week, the US surpassed 4 million cases—while our nation accounts for just over 4% of the world’s population, we make up 25% of virus cases. Another alarming statistic is the rapid pace with which we keep hitting stark new milestones—it took a mere 15 days for our cases to jump from 3 million to 4 million. These numbers reflect the exponential growth of viruses when appropriate public health measures are not heeded by enough members of the population.
The American Association of Cancer Research held a special virtual conference titled “COVID-19 and Cancer” on July 20-22, 2020. It is increasingly apparent that cancer and COVID-19 present a unique and unfortunate convergence, with lung cancer patients being among the most at risk for severe symptoms from the disease. This conference grew out of the research community’s need to understand the intersection of these two diseases and reflects the rapid mobilization of cancer scientists to apply their talents to finding solutions to this unprecedented global crisis. As one scientist stated, it is our “moral obligation” to help.
The lung cancer advocacy groups had two “poster” presentations at this conference. The first one summarized the origins of our joint COVID-19 statements and their impact on the lung cancer community. The second one discussed patient concerns that have emerged through these updates and how the advocacy groups can develop programs to address them.
Several real-world studies were presented at the conference that addressed overall risk for cancer patients as well as lung cancer in particular. Real-world studies rely on data collected from patients receiving treatment at their regular cancer centers or hospitals (ie, patients not receiving treatment through a clinical trial). Currently, real-world data seems to be the richest source of data for learning about how SARS-CoV-2 (as a virus) and COVID-19 (as a disease) impact cancer patients.
Registry data is entered by the patient’s treating physician after the patient has a confirmed diagnosis of COVID-19. Data from two big registries were presented at this conference.
Single-institution data provide convenient samples to understand the natural history of a specific disease. At the conference, data from Memorial Sloan Kettering Cancer Center in New York City showed that prior immunotherapy for lung cancer did not impact outcomes of SARS-CoV-2–positive lung cancer patients. This data seems to contradict other registry-based efforts which have suggested that immunotherapy may predict worse outcomes. At the height of the pandemic in NYC, 20% of MSKCC’s lung cancer patients with COVID-19 died but many, including those with late-stage cancer, recovered. This study suggests patient-specific factors (such as type of treatment and patient characteristics) may determine overall risk and susceptibility to worse outcomes. It is important to keep in mind that standard of care and patient characteristics may be unique in a specific institution and therefore the results may not be generalizable.
One study presented at the conference that looked at electronic health records of patients in the US showed that an active cancer diagnosis coupled with co-morbidities such as diabetes and hypertension predicted worse outcomes for COVID-19.
Some common themes emerged for lung cancer patients:
We are still learning about how patient-specific factors and treatment-specific factors related to lung cancer can influence the severity of COVID-19. It is best to discuss how an individual patient’s situation will be impacted with the treating physician.
What is abundantly clear at this point is that multiple studies point to increased risk and worse outcomes in lung cancer patients with COVID-19. As the pandemic continues to spread throughout the US, it is imperative that lung cancer patients continue to take the threat seriously and take appropriate steps to protect themselves and those around them:
The impact of the COVID-19 pandemic on the mental health of oncologists cannot be underestimated. Several studies suggest that oncologists will likely suffer from “burn-out ” syndrome and post-traumatic stress disorder (PTSD). Two studies documenting the effect of the pandemic on mental health of oncology professionals were presented at the conference.
Both these studies highlight the importance of developing adequate mental health support services for healthcare professionals as the effects of the pandemic emerge.
As patients and advocates who work regularly and intimately with oncology healthcare professionals, we must not forget to express our gratitude to all members of the patient care team.
As of July 1, 2020, more than 10 million people worldwide have been infected with SARS-CoV-2, the virus that causes COVID-19. In the United States alone, more than 3 million people have tested positive, as of July 10, 2020. Our knowledge about how the virus affects our immune systems and other organs is continuously evolving. Along with this knowledge, doctors are becoming better at managing patients with a confirmed diagnosis of COVID-19. However, it is important to keep in mind that the virus is still infectious.
In this update, we answer some key questions about the current need for public health measures, testing in light of the recent rise in COVID-19 cases, what the test results means, some recent press on “new strains” of SARS-CoV-2, and finally what this means for herd (community) immunity.
Current data still suggest the virus is most commonly spread person-to-person, via droplets expelled by talking, coughing, or sneezing while in close face-to-face contact. The virus may also spread via aerosols (smaller droplets that remain suspended in air) but at this point, this has not been clearly established. People can have an active case of the virus and show no symptoms (asymptomatic spread). Until a vaccine is available, we need to take action to prevent transmission of SARS-CoV-2 through these strategies:
If you or your loved one suspects that they have been exposed to SARS-CoV-2, and/or have developed the three most common COVID-19 symptoms (fever, cough, and shortness of breath), we recommend you get tested.
Currently, three tests are available for COVID-19. The choice of test depends on whether you suspect that you have an active (existing) infection, or you were infected in the past and want to confirm infection.
| Stage of infection | Current infection | Past Infection | |
| Type of Test | PCR test | Antigen test | Antibody test |
| How is a sample collected? | A nasal or throat swab | A nasal or throat swab | A blood sample |
| What does a positive test result mean? | You have an active SARS-CoV-2 infection. Even if you do not have symptoms, a positive result may suggest you can infect others. | You have an active SARS-CoV-2 infection. Even if you do not have symptoms, a positive result may suggest you can infect others. | You were possibly exposed to SARS-CoV-2 in the past, even if you did not have major symptoms.
HOWEVER, this does NOT necessarily mean you have immunity to the virus (we are still learning how long immunity might last). |
| What does a negative test result mean? | You might not be currently infected with SARS-CoV-2.
HOWEVER, this does NOT necessarily mean you don’t have a current infection -- especially if you display symptoms. Your doctor will take into account the entire clinical picture and not just test results. |
You might not be currently infected with SARS-CoV-2.
HOWEVER, this does NOT necessarily mean you don’t have a current infection --- especially if you display symptoms. Your doctor will take into account the entire clinical picture and not just test results. |
You might not have been exposed to SARS-CoV-2.
HOWEVER, this does NOT necessarily mean you were not exposed in the past. It is becoming increasingly clear that antibodies against SARS-CoV-2 do not last for a very long time. Therefore, timing of test matters. |
More testing will help us to identify more people who have an active case of COVID-19 and may be able to spread the disease, whether or not they have active symptoms. An accurate count of active cases tells us where the virus is currently spreading and hopefully helps us to implement prevention measures in time to limit spread of the disease in that area.
A preliminary manuscript (which has not yet undergone peer review) describes the emergence of a new mutation seen in a specific gene of the SARS-CoV-2 virus. This mutation, which was first discovered in Europe, is called D614G. It causes an increase in the number of spike proteins in the virus. Since the spike protein is how the virus attaches to human cells, the authors concluded that this mutation makes the virus more infectious. However, it does not appear to make the resulting disease more severe or deadly. Currently, the real-world implications of this mutation and its impact on the development of vaccines and treatments are still unclear.
Many countries are using blood tests to look for SARS-CoV-2 antibodies in their populations. Testing of blood serum is called serology. The percentage of individuals in a population that have these antibodies in their blood serum is called seroprevalence. As COVID-19 spreads across the globe, different areas will have different levels of seroprevalence.
The CDC is now conducting large-scale geographic seroprevalence surveys at a number of sites across the country. Initial results from the first six sites showed rates of people who tested positive for SARS-CoV-2 antibodies varied from about 1% (in WA state) to about 7% (in greater NYC area).
Several global seroprevalence studies have been published recently. In Spain, which was hit hard by COVID-19 in the spring of 2020, approximately 5% of people in the 36,000 households tested had antibodies against SARS-CoV-2 (they are “seropositive”—their serum tested positive for antibodies). The seropositive rate is closer to 10% near Madrid but only 3% along the coast. Given that 95% of Spaniards do not have antibodies (seronegative), the authors conclude that it is important to maintain the public health measures described above.
A second study from Brazil also found regional variability in seroprevalence, with an overall seropositive rate of 1.4%. However, surprisingly, some cities along the Amazon had some of the highest rates reported so far, approaching 25%. This finding further counters the argument that SARS-CoV-2 is susceptible to heat, since Brazil maintains a hot, tropical climate.
Herd immunity (or community immunity) occurs when a high percentage of the community is immune to a disease through vaccination and/or prior illness. We currently face several challenges to achieving herd immunity. First, seropositivity rates remain significantly below the ~70% required to achieve herd immunity, even in hotspot areas such as NYC. Second, a growing number of reports suggest that antibody levels fall off significantly as early as 8 weeks after infection (though other features of the immune system may provide some protection).
Some have suggested that public health efforts to reduce transmission are only delaying the acquisition of herd immunity. Sweden has been held up as a model for keeping a country open to develop herd immunity. However, Sweden serves more as a cautionary tale -- it experienced much higher death rates than its Scandinavian neighbors yet was not spared the economic impact of the pandemic. Various models have suggested that efforts to achieve herd immunity by natural infection (ie, letting the virus run its course without vaccines) would result in over 30 million deaths globally.
Letting the virus run its course comes at extraordinary cost in terms of human lives. Further, given the low rates of seropositivity among areas hard-hit by the virus and the rapidly declining antibody levels in individuals, it seems unlikely that we will achieve herd immunity WITHOUT a vaccine.
These updates are intended to give you the latest evidence on what we know and to provide a framework for you to make your own decisions as we all learn how to navigate this new “normal.” In that spirit, we share this recent graphic that helps assess the relative risk of various daily activities:
American Medical Association resources for healthcare providers.
As of June 28, 2020, the United States has reported more than 2.5 million cases of COVID-19 and 125,484 deaths. We are now seeing a rapid escalation in cases in states across the US. Some would argue that these increases simply reflect more testing, but that only tells part of the story. Perhaps a more meaningful metric is the rate of new hospitalizations and ICU bed capacity. Seven states (AZ, AR, CA, NC, SC, TN, TX) are now reporting their highest hospitalization rates since the pandemic started. In hard-hit Houston, TX, ICU bed occupancy stands at 97% at Texas Medical Center. Though only a quarter of that number is currently due to COVID-19 cases, there is once again growing concern about the ability of our hospitals to handle the rapidly increasing number of patients, especially once a second wave of infections strikes.
There are also some changing demographics with this most recent uptick in cases, including growing numbers among young adults ages 20-30. While that may seem to be good news at first, since younger people for the most part have a less severe form of the disease than the elderly or those with underlying comorbidities, this also creates a potential reservoir of the virus that could rapidly extend to more vulnerable populations in the surrounding community.
In the absence of a vaccine or an effective treatment, our best modes of protection remain continued social distancing, frequent handwashing, and wearing masks or facial coverings. A paper from The Lancet supports the use of face masks in reducing transmission in both the healthcare and community setting. The lack of a spike in cases related to recent national protests also suggests that masks played a large role in preventing transmission of the virus. As cases continue to rise across the country, more and more states are beginning to mandate the use of masks or facial coverings, as shown below:
In our June 15, 2020 update, we presented findings from the TERAVOLT study, which has reported an increased mortality rate (33%) in lung cancer patients with COVID-19. Some have questioned this study’s findings and how translatable they are to the situation here in the US. New data from Memorial Sloan Kettering Cancer Center (MSKCC) in NYC were reported for a cohort of 102 patients with both lung cancer and COVID-19. Of these patients, 62% were hospitalized and 25% died. Of the patients who required ICU-level care (21%), 72% died. However, COVID-19 severity appeared to correlate more with patient-specific factors than with tumor-specific characteristics or treatments. Thus, while this is a small study, it does reinforce the vulnerability of lung cancer patients to COVID-19. Another study from Memorial Sloan Kettering Cancer Center looked at a cohort of 423 cancer patients with COVID-19 (8% of whom were lung cancer patients) and found that 20% developed severe respiratory illness (including 9% who required mechanical ventilation) and 12% died within 30 days. In addition, the authors found that administration of immunotherapy was associated with a higher risk of complications. Despite small sample size of patients from single institutions and from different countries, all these studies reinforce two points: cancer patients may be at a higher risk of developing complications from COVID-19 and various patient-specific (such as lung damage from radiation therapy) and treatment-specific (immunosuppressive treatments such as chemotherapy) factors determine the extent of severity.
New research out of China suggests that the antibody response (a measure of immunity) to SARS-CoV-2 infection may not last as long as for other respiratory viruses, particularly among asymptomatic patients. The study, published in Nature Medicine, suggests that antibody levels fall off by more than 70% in both asymptomatic and symptomatic patients by 8 weeks following infection. Though the sample size is small, if true, these results have important implications for establishing “herd immunity” (also sometimes referred to as community immunity) through natural infection as well as vaccination efforts.
Additionally, the paper above described radiological imaging findings in the lungs of asymptomatic patients, including ground-glass opacities as shown below. Coupled with prior reports of extreme lung damage in some patients (including a healthy 20-year-old woman who required a double-lung transplant), these data, though from a small cohort of patients, affirm that there is still much we do not know yet about COVID-19’s impacts and whether infection has a lasting impact on lung function in patients who recover. In the case of lung cancer, the overlap between radiological findings in COVID-19 and lung cancer complicates diagnosis, treatment, and management of patients.
In light of these studies and others that suggest an increased risk for patients with lung cancer, researchers from the fields of lung cancer, virology, immunology, and epidemiology are rapidly mobilizing to create large-scale programs to address questions such as:
In summary, we continue to advise our community to maintain public health precautions as they go about their daily activities such as household chores and groceries. In a recent New York Times article, former director of the CDC (under the Obama administration) Dr. Tom Frieden says, “Start with the three Ws: wear a mask, wash your hands, and watch your distance.” Now more than three months into the pandemic, hospitals and clinics have excellent procedures in place to ensure that patients are kept safe during clinic appointments. We strongly advise lung cancer patients to check with their doctors on what these precautions are, in case they are concerned about getting exposed to SARS-CoV-2 while seeking healthcare. It is not advisable to miss clinic appointments without consulting your healthcare team.
Lung cancer patient advocates attended AACR’s Virtual Annual Meeting II on June 22-24. As expected, many presentations focused on the intersection of COVID-19 and cancer as well as our current national dialog on racial issues. Dr. Lisa Newman presented work on the double hit minority cancer patients are facing as a result of the ongoing pandemic. Dr. Ned Sharpless, Director of the National Cancer Institute (NCI), reported data predicting an additional 10K cancer deaths over the next decade as a result of missed screenings, delays in diagnosis, and reductions in cancer care. Though these models were for breast and colorectal cancer, there is equal concern about the potential impacts on lung cancer. The lung cancer advocacy groups must continue to push forward policies that protect minority communities and ensure access to continued screening and care during the current crisis.
Thank you to everyone who participated in our recent survey to collect data on the value of these updates and patient concerns that have emerged as a result. We are pleased to report that we have had two abstracts accepted for presentation at the upcoming AACR Virtual Meeting: COVID-19 and Cancer being held July 22-24. Our community will be well represented as we learn even more about the intersection of these two diseases and the implications for lung cancer in particular.
As of June 12, 2020, the United States has reported more than 2 million cases of COVID-19, and 113,914 have died from this disease. States are in different phases of reopening and shelter-in-place restrictions, and lockdown have been eased in almost every state in the US. With restrictions being lifted despite the upsurge in new cases, a big question remains.
Is it safe to return to routine activities? The short answer to this question is NO – we are not yet ready to return to routine activities.
In this week’s update, we provide evidence on why the lung cancer community needs to be vigilant about the risk of exposure to SARS-CoV-2, the virus that causes COVID-19. We also describe the impact of easing shelter-in-place restrictions in different states in the US and conclude by providing expert guidance from epidemiologists on what to expect over the next year.
1. Lung cancer patients are at higher risk of developing complications from COVID-19: The Thoracic cancERs international coVid 19 cOLlaboraTion (TERAVOLT) registry study is specifically tracking outcomes for lung cancer patients infected with COVID-19. Recently published data from this study suggests that stage IV non-small cell lung cancer (NSCLC) patients are at higher risk of complications and mortality if they get infected with SARS-CoV-2. Of the patients included in the study, 33% succumbed to complications from COVID-19. Though the data generated for this study is primarily from European countries, it is highly probable the findings will hold true in other high-income countries such as the United States. Though the study does not provide information on the outcomes of small cell lung cancer (SCLC) patients, we anticipate that the findings will hold true for SCLC as well, given the high symptom burden of SCLC. Also, the TERAVOLT study has identified smoking history as an important predictor of developing complications from COVID-19. This suggests that SCLC patients may be at higher risk of a severe form of COVID-19, given the association of SCLC with active tobacco exposure.
It is important to keep in mind that the CDC considers patients with lung co-morbidities (such as lung cancer) to be at a higher risk of developing complications from COVID-19.
2. Easing shelter-in-place restrictions has led to an escalation in new COVID-19 cases in the United States: It is now proven that public health measures such as home isolation, business closures, and other large-scale social distancing measures have had large and measurable health benefits in containing the spread of COVID-19 and “flattening the curve”, as described by a recent research study in the journal Nature. Therefore, before lifting or removing these restrictions, there needs to be careful deliberation taking into account the local case load of COVID-19 and availability of critical hospital resources, should there be a spike in cases when restrictions are lifted. In order to assist states in reopening, the CDC has suggested a phased approach to easing shelter-in-place restrictions. However, it is becoming increasingly apparent that we will need to monitor reopening with caution and continue to maintain public health precautions.
If you are curious to see how your state is performing in light of the recent lifting of shelter-in-place restrictions, please check out this article.
3. We should continue to maintain public health measures to minimize exposure to SARS-CoV-2: Easing shelter-in-place restrictions does not mean we should stop maintaining public health precautions. We highly recommend that everyone:
As a lung cancer patient or caregiver, if you have any questions on how to maintain public health measures as you run errands and go to work, please check out the CDC resources here. We are also learning about the long-term effects of an infection. Impact of COVID-19 on the body can last for several months. In some extreme cases, damage to the lungs is severe enough to require a double-lung transplant. We therefore firmly believe that it’s better to be safe than sorry!
4. Epidemiologists suggest that the timeline for resuming different activities will be determined by the availability of a vaccine against SARS-CoV-2: In a recent article in the New York Times, 511 epidemiologists were asked to rate how soon they would resume different activities. Below are the results of this opinion survey. Though this data is not meant to serve as guidelines for the general public, it gives us a picture of where expert opinion lies with regard to when to resume normal activities.
This past week marked a grim milestone in the United States, as we officially surpassed 100,000 deaths from COVID-19. Our groups continue to recommend that the lung cancer community adhere to best practices to limit exposure, including wearing masks/face coverings when out in public, frequent handwashing, ongoing social distancing, and limiting nonessential travel.
Normally at this time, representatives from our respective organizations would be in Chicago for the annual American Society of Clinical Oncology (ASCO) meeting, for which over 40,000 oncology professionals gather to share best practices in clinical oncology research and academic and community practice. In light of the ongoing pandemic, ASCO 2020 was held as a virtual conference.
Note: There are many exciting updates and recent FDA drug approvals in the lung cancer space. These are being shared via other channels through our respective organizations and will not be covered here since our goal is to focus exclusively on relevant COVID-19 updates for the lung cancer community.
In this week’s update, we will cover three topics:
Previous reports have suggested that lung cancer patients infected with COVID-19 have worse outcomes. During ASCO 2020, we heard updates from two different registry efforts focused on tracking cancer patient outcomes:
Take-home message from these studies: COVID-19 presents a unique threat to all cancer patients, especially those with lung cancer. Various international efforts are underway to understand these risks and what it means for patients and their cancer care. As states continue to reopen, it is important not to let your guard down and to maintain all the precautions you have been taking over the past few months. This virus has not gone away and it is important that you and your loved ones take appropriate steps to minimize exposure.
Authors of these weekly updates, including Dr. Jan Baranski, Janet Freeman-Daily, Dr. Amy Moore, and Dr. Upal Basu Roy, recently participated in the International Association for the Study of Lung Cancer (IASLC) “Lung Cancer Considered” podcast. They were joined by Jill Feldman, Dr. Alice Berger, Dr. Christine Lovly, and Dr. Brendon Stiles to discuss impacts of COVID-19 on lung cancer research. Despite the obstacles created by the pandemic, lung cancer research marches on and we think you will be encouraged and inspired by the discussion. Listen to the podcast here.
In light of the COVID-19 pandemic and its impact on cancer care, AACR is convening a special conference focused on the presentation of emerging data in basic, clinical, and epidemiologic research related to COVID-19 and cancer. Lung cancer patients are especially vulnerable to developing a serious case of COVID-19. In order to provide the community accurate, up-to-date, and curated scientific information on COVID-19 and cancer, lung cancer patient advocacy groups have come together to support our community through joint advocacy updates.
We need your help and your perspective! We are inviting you to participate in this 10-minute survey to capture your concerns about COVID-19, and whether you found this collaboration and the updates useful. The survey will close at midnight Pacific Daylight Time, Friday, June 5, 2020, to allow us to prepare abstracts for submission to the AACR "COVID-19 and Cancer" virtual meeting.
If you prefer, you can copy and paste this link in your web browser to take the survey: https://www.surveymonkey.com/r/LC_JT_Updates
The data we collect from the survey will also be shared openly across all advocacy groups once the conference is completed. Thank you for your help and for providing us your perspective.
As different states are relaxing shelter-at-home orders and businesses are planning to reopen, it is important to understand the true extent of COVID-19 infections: both active infections (patients who are currently infected) and past infections (patients who were infected in the past and have now recovered).
Currently, active infections are tested using a nasal swab test. The FDA also recently approved a rapid antigen detection test to identify actively infected cases.
Past infections are identified through serological (blood) tests that detect antibodies against the SARS-CoV-2 virus.
The following infographic shows the differences between the tests used for COVID-19.
However, interpreting the results of the test may be tricky. Also, the results depend on various factors:
For example, Amy (in the San Francisco Bay Area) got sick on January 23, 2020, and her antibody test from May 15, 2020, was negative. Upal (in New York City) got sick on March 14, 2020, and his antibody test from May 4, 2020 was positive. Could this be because Amy didn’t produce enough antibodies? Because the antibodies decrease with time? Because the test was not done correctly? Or could it reflect differing test sensitivity?
To answer these types of questions will take time. In case you want to learn more about the issues with interpreting test results, here is a helpful article.
In this week’s update, we present a short video (below), and transcript of the discussion, with Nicolas Vabret, PhD, Assistant Professor of Medicine, Hematology and Medical Oncology at Icahn School of Medicine at Mount Sinai. Dr. Vabret, a virologist/immunologist, answers important questions, such as:
The authors of this weekly advocacy update are all scientists (nerds) and so before we get to this week’s update, indulge a little humor: “May the Fourth be with you!” Now back to our regularly scheduled programming:
As of May 2, 2020, the Centers for Disease Control and Prevention (CDC) reported 1,062,446 cases of COVID-19 and 62,406 COVID-19-associated deaths. Many states are beginning to loosen restrictions and reopen certain businesses. It is worth noting that in Georgia, the first state to reopen, the shelter-in-place policy has been extended through June 12, 2020, for the most at-risk populations, including those over age 65; those in nursing homes or long-term care facilities; those with chronic lung disease, moderate to severe asthma, severe heart disease, class III/severe obesity, diabetes, liver disease, chronic kidney disease and undergoing dialysis; as well as those who are immunocompromised.
On Friday, May 1, 2020, the Food and Drug Administration (FDA) granted emergency use authorization for the antiviral drug remdesivir for the most severely ill COVID-19 patients. While this is an encouraging development, we must provide a word of caution in that we still do not have effective treatments for broad use by the general public or a vaccine.
In light of the ongoing COVID-19 pandemic, the American Association of Cancer Research (AACR) shifted its annual meeting to a virtual format and broke it into two separate events. The first was held on April 27 -28, 2020. In this week’s update, we will discuss some of the information presented during this meeting and what it means for the cancer community. In particular, we will focus on answering three questions:
Since we first started providing these updates in early March 2020, there has been growing evidence that lung cancer patients infected with COVID-19 have worse outcomes. During the AACR plenary session on “COVID-19 and Cancer,” an international team led by Dr. Marina Garassino presented early data for TERAVOLT, a global registry collecting characteristics and outcomes of patients with thoracic cancers affected by COVID-19. They reported a disturbingly high mortality rate of 34.6% (66/191) among patients with thoracic cancers.
As research advocates serving the lung cancer community, we recognize that these data are alarming. The immediate implications of these results fall in line with what we have been advising those who fall in high-risk groups, including lung cancer patients: continue to practice social distancing when possible, wear protective face coverings when out in public, wash hands often, and minimize travel to essential needs only (medical appointments, procuring groceries or prescriptions).
Our April 20, 2020, update discussed the increasing role of telehealth in management of patient care, and our April 27, 2020, update focused on the guidelines issued by leading medical organizations and societies. Our March 30, 2020, update included impacts on clinical trials—as states begin to reopen, some trial sites are resuming enrollment. Thus, it remains imperative that you talk with your treatment team about your individual treatment plan.
Indeed, as a result of the COVID-19 pandemic, doctors and scientists are reevaluating treatment schedules and the “usual way of doing business.” One example is the recent April 28, 2020, FDA approval for a new dosing regimen for the immunotherapy drug pembrolizumab. This approval is based on data presented at the 2020 AACR Virtual Meeting.
Dr. Jacob Sands, a leading lung cancer medical oncologist at Dana-Farber Cancer Institute, provides a nice discussion on the importance of individualized lung cancer management in the COVID-19 era.
We recommend that you follow information from trusted and medically vetted websites such as the CDC, the WHO, and the IASLC. Information on how to access these websites is included in the Resources and websites section below.
Our understanding of COVID-19 is evolving rapidly. This means that what was true a month ago may not be true under current circumstances, as doctors and scientists generate more evidence. You might hear contradictory information from different sources or at different times. As an example, the antimalarial and autoimmune disease drug hydroxychloroquine was shown to have positive effect in COVID-19 patients in early studies. However, further study with more patients showed hydroxychloroquine was not as effective as it was initially thought to be, and highlighted the fact that hydroxychloroquine comes with a range of side effects that make it unsuitable for use in patients with heart issues. This is a great example of the scientific method whereby a finding or a hypothesis changes as new information is gathered.
We also caution on how one should interpret information shared across media and press during these times. COVID-19 is a global pandemic and is affecting the oncology community everywhere in the world. Given the urgent global need for information on effective COVID-19 management, healthcare providers are sharing preliminary information as quickly as possible with the goal of learning from each other’s experiences. This means that not all information shared publicly will have the same level of evidence as formal clinical trials. The information is important and valuable, but it is not yet validated in large groups of patients.
When judging what you read from publicly available sources, we suggest you use the Evidence-Based Medicine (EBM) Pyramid as a guiding framework
EBM Pyramid and EBM Page Generator, copyright 2006, Trustees of Dartmouth College and Yale University. All Rights Reserved. Produced by Jan Glover, David Izzo, Karen Odato and Lei Wang.
Higher quality of evidence takes longer to get published to allow for collecting larger amounts of data, statistical analysis, and scientific peer review. Most of the literature currently available on COVID-19 and lung cancer are case reports and studies of a small number of patients in a few institutions. COVID-19 has not been around long enough to enable large, formal clinical trials about its impact on lung cancer treatment. If you have questions about whether published COVID-19 findings might affect your lung cancer treatment, please discuss your individual situation with your treating physician.
Most academic research institutions, including universities and hospitals, have shut down most research labs and closed enrollment in some clinical trials to accommodate government-imposed shelter in place mandates and protect researchers’ lives. Only critical research, such as maintaining cell lines or animal models for preclinical research and some clinical trials with strong evidence of effectiveness, is being allowed to continue. These are institutionally mandated restrictions that have been put into place to protect university staff. Some researchers who are also clinicians have been deployed to assist with COVID-19-related clinical duties. Bench scientists who are not involved with clinical duties have been advised to work from home in activities such as grant and manuscript writing, and data analysis.
Funders of academic lung cancer research in the US such as the National Cancer Institute, the Department of Defense, and private non-profits (e.g., LUNGevity Foundation, GO2 Foundation, Lung Cancer Research Foundation, Lung Cancer Foundation of America) have all made concessions to accommodate the needs of the scientific community and best support investigators during this critical time, while trying to minimize any delays in lung cancer research. Concessions include:
As of April 24, 2020, the Centers for Disease Control and Prevention (CDC) reports 895,766 cases of COVID-19 and 50,439 COVID-19-associated deaths. As the number of cases continue to rise, the importance of maintaining social distancing and following shelter in place/quarantine orders is central to flattening the COVID-19 curve.
In this week’s update, we address how different professional societies/organizations are addressing lung cancer screening and treatment during the COVID-19 pandemic. As described in the National Academy Press, the mission of the professional societies is primarily educational and informational. Their influence flows from their continuing and highly visible functions: to publish professional journals, to develop professional excellence, to raise public awareness, and to make awards. Through their work, they help to define and set standards for their professional fields and to promote high standards of quality through awards and other forms of recognition.
In this week’s update, we provide you with a brief summary of what different professional societies are saying about COVID-19 and lung cancer treatment. These consensus statements are a testament to the way the global oncology community is working together to ensure that lung cancer patients continue to get the best care possible. The following have been included in today’s update based on availability of information.
CHEST - American College of Chest Physicians
ASCO - American Society of Clinical Oncology
ESMO - European Society for Medical Oncology
ATS - American Thoracic Society
NCCN -National Comprehensive Cancer Network
ASTRO - American Society for Radiation Oncology
ESTRO - European Society for Radiotherapy & Oncology
The recent consensus statement from CHEST states that it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure to SARS-CoV-2 and the need for resource reallocation.
This means that for individuals who have not yet initiated screening, they should wait to be screened.
In those individuals where nodules are detected through a low-dose CT (LDCT) scan, the consensus statement suggests follow-up and nodule management should depend on the size of the nodule, availability of local facilities, prevalence of COVID-19 in the region, and patient-specific factors (presence of other serious health issues such as diabetes and heart disease.
According to Schrag and colleagues,
oncology care generally falls into four categories.
It is important to note that recommendations should be adapted to reflect the status of the patient and available facilities.
ATS has proposed the use of a three-phase framework to decide how to proceed with lung surgery. It defines three phases of hospital status based on:
Each phase has a compass statement that is meant to give additional direction on how to manage number of lung surgeries, based on perceived risk to patients and hospital staff.
|
Phase 1 |
Phase 2 |
Phase 3 |
|
|
|
|
Compass statement: Surgery restricted to patients whose survivorship likely to be compromised by surgical delay of 3 months |
Compass statement: Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next few days |
Compass statement: Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next few hours |
Specific treatment decisions should be made by the patient and their treating physician, keeping in mind the framework discussed in question 2.
The ASTRO-ESTRO consensus statement follows a similar approach to the ATS statement and takes into account the local and regional scenario of the COVID-19 pandemic.
In a risk-mitigation pandemic scenario where radiotherapy resources remain available, efforts should be made not to compromise the prognosis of lung cancer patients and guideline-recommended radiation therapy should be practiced. Postponement or interruption of radiation therapy of COVID-19 positive patients should be considered to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection.
In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors included potential for cure, relative benefit of radiation, life expectancy, and performance status.
Specific treatment decisions should be made by the patient and their treating physician, keeping in mind the framework discussed in question 2.
The three professional societies/organizations (ASCO, ESMO, and NCCN) are aligned in their recommendations for lung cancer patients. All societies note that the risk of COVID-19 must be balanced against the risk to the patient of lung cancer progression, which in most cases still represents the highest risk of mortality in lung cancer patients. Individual clinical judgment is necessary. The recommendations provided by these societies cannot provide absolutes for alternate strategies during the COVID-19 outbreak. Specific treatment decisions should be made by the patient and their treating physician, keeping in mind the framework discussed in question 2. It is important to note that most of these recommendations would not normally be considered standard of care or optimal but are reasonable under these unusual circumstances in which minimizing visits and potential exposure has become a priority.
NCCN further suggests that entry points to the health care system should feature screening of patients and providers (i.e., questionnaire, temperature-based screening, standard and rapid COVID-19 testing). If resources are sufficient, screening of visitors who can accompany patients is reasonable, although many institutions have visitation restrictions to facilitate social distancing.
Shared decision-making is a process in which patients and doctors work together to make decisions and select tests, treatments, and care plans based on clinical evidence that balances risks and expected outcomes with what individual patient value. The consensus statements from all the professional societies urge doctors to have candid discussions with their patients and to take into account patient preferences and values when making decisions for screening and treatment.
Physicians don’t have much data to help guide treatment decisions for lung cancer patients who also have COVID-19. To gather this data, the global lung cancer community has come together to develop the TERAVOLT registry. The registry is collecting information on patients with thoracic cancer infected with COVID-19 regardless of therapies administered. More than 100 physicians worldwide are participating, and the number is growing. Currently, patients cannot deposit their data into the registry themselves. If you have or had a confirmed case of COVID-19 and would like your data included in the registry, talk to your doctor about joining the TERAVOLT registry.
As of April 18, 2020, the Centers for Disease Control and Prevention (CDC) reports 661,712 cases of COVID-19 and 33,049 COVID-19-associated deaths. A recent study conducted by researchers at Stanford University suggests that this number is an underrepresentation of the total number of infected individuals. We must urge caution with interpretation of this study, which is still undergoing peer review. Some are interpreting the findings to mean we should accelerate loosening of social distancing policies across the country. However, researchers still do not know if the presence of antibodies confers protection or how long such immunity might last. Further, in the absence of any effective therapeutics or a vaccine, local flareups are still a risk, as has been witnessed in other countries. Social distancing is working and should be maintained for now.
In this week’s update, we address the following important topics:
Role of telehealth in the era of COVID-19
Impact of COVID-19 on lung cancer clinical trials
The terms “telehealth” and “telemedicine” are used interchangeably to describe using telecommunications technologies to deliver health care. It includes a variety of services that deliver health care, public health, and health education, and ranges from methods as simple as telephone calls and email to live video, mobile apps, remote patient monitoring and uploading scan images. The Center for Connected Health Policy (CCHP) provides an excellent overview of telehealth here.
In light of the COVID-19 pandemic, federal and state policies are rapidly adapting to allow for greater utilization of telehealth services. The Centers for Medicare and Medicaid Services (CMS) have created some useful fact sheets highlighting various policy changes, including this one summarizing Medicare telemedicine services and this one addressing sweeping regulatory changes to meet patients’ needs during this time. Private health insurance companies are also modifying their policies to enable greater use of telehealth. CCHP is maintaining an updated list of COVID-19 telehealth coverage policies.
The challenge with adapting telehealth policies in real-time to address an unfolding and unprecedented public health crisis is that, in a pre-COVID-19 world, federal and state policies varied widely in how telehealth services were provided and covered. Most of the current challenges relate to regulatory and reimbursement issues, including licensure requirements. Even as the popularity of telehealth among patients grows, private healthcare payers have been slow to embrace the technology. The Federation of State Medical Boards is maintaining an updated list of states currently waiving telehealth licensure requirements.
The “digital divide” is also a barrier to accessing telehealth. Patients who are elderly, in areas with poor Internet or cellular coverage, or economically disadvantaged may not be able to access the technology necessary to telehealth.
Again, laws vary by state regarding how telehealth is being implemented and what health insurance companies and providers can do. Review your health insurance plan benefits and policies frequently to learn how they may be changing. This CCHP list of COVID-19 state actions may also be helpful.
CCHP also monitors state and federal telehealth legislation to provide a clear overview of policy across the nation. As a citizen, you can monitor legislation that has been introduced in your state and testify to show your support or opposition. You can call your legislators to ensure your needs are being heard.
For a great overview and more in-depth discussion on all of these points on telehealth, please check out GO2 Foundation for Lung Cancer’s Rapid Response Living Room from April 14, 2020, featuring Dr. Joelle Fathi.
The United States Food and Drug Administration (FDA) has issued guidance to clinical trial sponsors (pharmaceutical companies and government agencies), institutional review boards (IRBs), and researchers on how to adapt lung cancer clinical trials in the era of COVID-19. The FDA emphasizes that patients’ safety should be at the forefront of considerations at all times. Below, we answer three important questions for patients (and their caregivers).
1. How is the FDA allowing the use of telehealth for lung cancer clinical trials?
The FDA allows for changes to be made to the clinical trial protocol without prior FDA review or approval if the change is intended to protect the life and well-being of the patient. Therefore, changes in protocol conduct necessary to immediately assure patient safety, such as use of telehealth for safety monitoring instead of on-site visits, can be immediately implemented once the new protocol has been approved by an IRB. The FDA can then be subsequently notified. It is important to note that the consult is just one part of patient safety monitoring. The patient’s clinical trial team and the clinical trial sponsor will also need to have a clear plan in place to ensure that patient safety is prioritized in case routine monitoring such as blood tests and heart function exams are unable to be conducted.
2. If a patient is receiving their drug through a pharmacy at the clinical trial site, can they now receive the drug through home delivery?
The FDA understands that there may be a risk of exposure to SARS-CoV-2 when a patient visits a clinical trial site. In case a patient is receiving their drug (such as a targeted therapy pill) through their clinical trial site pharmacy, the clinical trial sponsor now has the option of directly mailing the drug to the patient’s home as long as the following conditions are met:
3. If a patient is receiving a drug given through infusion, can they now receive the clinical trial treatment through home infusion?
This is an extremely important question for the lung cancer community—where clinical trials often require an infusion of a chemotherapy, an immunotherapy, an angiogenesis inhibitor, or a combination of the above.
The FDA understands and appreciates that a patient may be exposed to SARS-CoV-2 when they travel to their routine clinical trial infusion center. Therefore, the FDA is open to alternative sites for administration (eg, home nursing or alternative sites closer to a patient’s home where the infusion is given by trained medical personnel who are not part of the study team). The ultimate decision to allow this switch to home infusion or local infusion is based on the following criteria:
Another option is delaying or discontinuing infusion for a period of time while the patient continues to be on the study. This decision needs to be made jointly by the clinical trial team and the patient.
Note: The ultimate decision on whether to allow a home infusion or local infusion is highly dependent on the drug being tested. Some infusions cannot be given at a local infusion center or through home infusion. Examples include drugs that require ability to manage potential infusion reactions with specific medication, or treatments such as gene therapy or cell therapy that require exacting handling procedures and patient monitoring.
LUNGevity Foundation recently conducted an Oncology Center of Excellence (OCE) listening session with FDA leadership and lung cancer patients. Stay tuned for the recorded webinar that can be accessed here.
As of April 11, 2020, the Centers for Disease Control and Prevention (CDC) reports 492,416 cases of COVID-19 and 18,559 COVID-19-associated deaths. The United States now has the highest number of confirmed COVID-19 cases in the world. These numbers may be an underestimation of the true burden of the disease due to lack of testing and a high proportion of asymptomatic yet infectious individuals.
We urge everyone to continue to social distance: it is working!
Washington and California quickly imposed statewide social distancing through stringent shelter-in-place or stay-at-home policies once deaths occurred within their borders. The graph below shows that COVID-19 deaths are still increasing in these two states, but not as fast as in other states. Deaths in New York State are now doubling every 3 days (when last week it was every 2 days), and in Washington State and some California counties, deaths are doubling only every week.
The most up-to-date version of the graph below can be accessed from the New York Times website here.
In this week’s update, we answer the following important questions:
If you or your loved one (caregiver) has a confirmed diagnosis of COVID-19, your/their healthcare provider will be the right person to decide what type of treatment is useful. Please do not treat COVID-19-related symptoms without consulting your healthcare provider. Do not try to procure or hoard medications such as hydroxychloroquine that are approved for use in other conditions, as this is creating a shortage of these medications for patients with conditions for which the drugs are already approved.
Currently, no specific treatment or vaccine is available for COVID-19. This continues to be an area of intense investigation. Some of the drugs described below may be available to COVID-19 through compassionate access. This does not mean a drug is approved for the treatment of COVID-19. It is important to keep in mind that properly controlled clinical trials take a long time to conduct.
Various compounds such as remdesivir and hydroxychloroquine are being studied for the treatment of COVID-19.
Historically, vaccines against viruses have been very effective in eradication of common viral diseases such as smallpox and polio. From an individual perspective, vaccination prevents or modifies the severity of a disease. From a public health perspective, a vaccine eliminates or eradicates a disease from the population (for example, smallpox). Since the SARS epidemic in 2003, several companies and institutions have already developed platforms for vaccine development against coronaviruses, which is a family of viruses that includes SARS-CoV-2, the causative agent of COVID-19. On January 23, 2020, the Coalition for Epidemic Preparedness Innovations (CEPI) was the first to announce funding of $12.5 million to develop vaccines against SARS-CoV-2 by three companies. Since then, both philanthropic and industry efforts have been mobilized for the development of a vaccine against SARS-CoV-2. As of April 9, 2020, there are close to 80 vaccine development efforts. It is important to keep in mind that vaccine development is a lengthy process and best-case estimates suggest that it will take a minimum of 18 months to deliver an effective vaccine against SARS-CoV-2. Even once a candidate vaccine is identified, it must be manufactured at scale for a global population. To speed these efforts, the Gates Foundation has announced that it is supporting construction of factories to pursue development of seven vaccine candidates.
Recently, the Bill & Melinda Gates Foundation also announced a $125 million partnership with Wellcome and Mastercard to accelerate the development of new drugs to treat SARS-CoV-2 infection. To track treatments that are being investigated for COVID-19, please check out the Milken Institute COVID-19 treatment and vaccine tracker. Here, you will also find information on clinical trials testing potential COVID-19 drugs/vaccines.
If you (as a patient) or a loved one (a caregiver) exhibits the symptoms of COVID-19 (including but not limited to fever, dry cough, shortness of breath), immediately follow self-quarantine procedures. Immediately contact your healthcare provider (could be your primary care physician) about whether you need to get tested. Your healthcare provider will be able to guide you on next steps. The CDC and the Association of Public Health Laboratories maintain a list of laboratories that are currently conducting COVID-19 tests.
Please remember that you may not have symptoms even if you are infected with SARS-CoV-2. Social distancing is the only way to avoid getting infected with the virus. As a caregiver, please take extra precautions when you need to leave your house or apartment.
The answer is – we do not know. When an individual is infected with a pathogen, such as bacteria or a virus, typically the body mounts an immune response. This is true even in individuals who remain asymptomatic. The immediate immune response ensures that the pathogen is eliminated from the body, and immunological memory (the basis of vaccination) ensures that if the body encounters the pathogen in the future, the immune system is ready to fight it off.
In the case of SARS-CoV-2, based on experience with other coronaviruses such as SARS-CoV and MERS-CoV, we believe that development of immunity will be highly individual-specific. Some individuals may develop high amounts of antibodies against SARS-CoV-2 while others may not. Furthermore, it is not currently clear whether a one-time infection with SARS-CoV-2 confers lifetime immunity against the virus. Scientists are still evaluating what level of immunity is needed to confer protection against future infections with SARS-CoV-2.
The answer as of April 13, 2020 is - we do not know. In order to check if an individual has been infected with a pathogen, healthcare providers can conduct blood tests (also known as serological tests) to check for indicators of immunity. For example, if you received the MMR vaccine, the doctor can check if you have immunity against measles, mumps, and rubella by looking at antibody titers in your blood.
In the case of SARS-CoV-2, the goal is to develop such a blood test that will help identify:
Currently, scientists are studying which antigens of the SARS-CoV-2 will be the most effective in generating immunity. Several groups are developing blood tests, and one test has been FDA approved (but is not yet publicly available). There is hope that such tests will become available within the next few months (and probably sooner in some places), and will be useful in guiding how quickly normal activities can resume.
In the era of COVID-19 when information is evolving rapidly—with new information being available daily—it is important to depend on trusted and reputable sources of information. You will encounter several sources of information such as:
It is incredibly important to verify sources of your information to ensure that we are not spreading false information, which not only can cause unnecessary panic but can be downright harmful (such as misinformation regarding drugs). A good resource that provides guidelines to evaluate health information can be found here.
The number of confirmed cases of COVID-19 continues to grow in the US. As of April 5, 2020, there are 312,089 confirmed cases of COVID-19 in the US. These numbers may be an underestimation of the true burden of the disease due to lack of testing and a high proportion of asymptomatic yet infectious individuals.
To get a real-time understanding of the cases in the US, you can access the map through The New York Times.
In this week’s update, we answer the following important questions:
YES, IT IS! Washington and California quickly imposed statewide social distancing through stringent shelter-in-place or stay-at-home policies once deaths occurred within their borders. The graph below shows that COVID-19 deaths are still increasing in these two states, but not as fast as in other states. Deaths in New York State are doubling every 2 days, but in Washington State deaths are doubling only every 7 days.
The most up-to-date version of the graph below can be accessed from the New York Times website here.
The CDC continues to recommend social distancing to help decrease transmission of COVID-19 within the community. Social distancing measures, such as cancelling public gatherings and avoiding crowds, can slow the spread of the virus and spread cases out over a longer period of time, which can help hospitals provide care while avoiding being overwhelmed by patients. Social distancing helps “flatten the curve” in the spread of an infectious disease.
This is especially critical because hospitals and health systems are working at full capacity. Flattening the curve ensures that systems are functional and people who require care the most can get the attention they need. The CDC recommends a distance of 6 feet or 2 meters as the minimum distance between individuals as part of COVID-19 mitigation strategy.
We encourage you to check out CDC’s COVID-19 community mitigation strategies here.
YES, social distancing is currently the only known public health measure that can protect us from SARS-CoV-2. Social distancing minimizes risk of exposure to the virus. It is important to keep in mind that social distancing is NOT the same as social isolation. We encourage you to keep in touch with all your family, friends, and loved ones through phone and video conversations. Just because we are social distancing doesn’t mean we have to be socially isolated.
Social distancing is different from self-quarantine. Self-quarantine should be practiced by people who have been exposed to SARS-CoV-2 and who are at risk for coming down with COVID-19. It involves:
You do not need to have symptoms of COVID-19 to self-quarantine. Caregivers who have travelled or are leaving their homes frequently to run errands may choose to self-quarantine especially in COVID-19 hot zones.
NO! You should not be leaving your urban apartment or home and moving to a rural area for the following reasons:
Do not indulge in “disaster gentrification” for your own safety, the safety of your loved ones, and that of other community members. It is our duty to keep rural communities insulated from this disease as much as possible.
YES! The CDC reports that a significant portion of individuals with COVID-19 lack symptoms (“asymptomatic”) and that even those who will eventually develop symptoms (“pre-symptomatic”) can transmit the virus to others before showing symptoms. This means that the virus can spread between people interacting in close proximity—for example, speaking, coughing, or sneezing—even if those people are not exhibiting symptoms. In light of this new evidence, CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (eg, grocery stores and pharmacies) especially in areas of significant community-based transmission.
Masks should be worn in conjunction with maintaining adequate social distancing. It is also important to keep in mind that these face masks are not surgical masks or N95 masks (to be used primarily by healthcare workers as part of personal protective equipment).
Please watch this handy video to make your own homemade masks:
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html
Though the CDC does not typically make suggestions about domestic travel, they highly recommend avoiding all non-essential travel within the US. Several cities and states already have a shelter-in-place order. Points to keep in mind should you need to consider domestic travel (from the CDC):
This update has been written in collaboration with Dr. Brendon Stiles. He is a thoracic surgeon at New York-Presbyterian Hospital and an Associate Professor of Cardiothoracic Surgery at Weill Cornell Medicine.
That question must be on the mind of many lung cancer patients as they consider treatment during the COVID-19 pandemic. We are currently in the middle of an unprecedented crisis that has left hospitals short on resources and personnel. That has led to shutting down “elective” surgical cases (surgeries that are not considered to be of medical emergency) at many hospitals, particularly in places such as New York City that are COVID-19 hot zones.
Are cancer cases truly “elective”? And how long can patients and their surgeons actually wait?
We don’t have a lot of data making a strong case for waiting or not waiting. Some lung cancer-specific data suggests that the decision should be made based on how “quickly” the lung cancer grows. It takes on average 13.2 years for a lung adenocarcinoma to get to 1 cm in size and 14.4 years to get to 3 cm. While other subtypes of lung cancer and other cancers may move much more quickly, this would obviously suggest that there is some time allowable prior to treatment for many cancers. In that context, postponing surgery a few weeks or months may outweigh the risks of exposure to COVID-19.
It is, however, unclear what is the appropriate waiting time for each individual patient. Most studies have suggested that for early-stage lung cancer, there is some risk of tumor progression that comes with delayed treatment. That said, the risk appears to be small and not particularly predictable. At this time, for hospitals that still have resources, the American College of Surgery recommends surgical resection as soon as feasible for patients with solid or predominantly solid cancer over 2 cm in size, while it recommends deferring lung cancer resection even in these hospitals for tumors less than 2 cm or for those that are predominantly ground glass.
In the current situation, patients with early-stage lung cancer should also consider alternatives to surgical resection. This is particularly true in areas that are the most affected by COVID-19, where surgery may not be an option for an extended period. Outpatient centers likely have less exposures than inpatient where we know there are many COVID patients. Also, patients spend less time in radiation treatment facilities. Finally, radiation (at least early on) preserves lung function and doesn’t risk immediate decrease in lung capacity, which may put patients at risk for more complications should they become infected. Good data is available on the efficacy of stereotactic ablative radiotherapy (SABR or SBRT) for the treatment of early-stage lung cancer. It is also worth noting that radiation, particularly stereotactic, doesn’t preclude surgery down the road.
It is not clear how data on treatment delay can be applied to patients with later-stage disease. Certainly patients with clear-cut stage II or III lung cancer could be started on outpatient chemotherapy or chemoradiation with surgery pushed down the road several months if needed
As of March 30, 2020, cases of the virus surge in countries around the world. The United States now has the highest number of COVID-19 cases globally. The CDC has issued a travel advisory for the New York tri-state area, which has the highest number of cases in the country.
In this week’s update, we discuss lung cancer treatment and clinical trials in the era of COVID-19. The information presented in this update, though current, is a work in progress built on very little data. Implementation across institutions and trial sites will vary based on availability of resources and healthcare workers.
Also, please don’t forget to check out the Resources list.
The oncology community is currently balancing treatment decisions for lung cancer patients, in light of the COVID-19 pandemic. Two factors are being used to decide what’s best for our patients:
The CDC continues to recommend social distancing to help decrease transmission of COVID-19 within the community. Social distancing measures, such as cancelling public gatherings and avoiding crowds, can slow the spread of the virus and spread cases out over a longer period of time, which can help hospitals provide care while avoiding being overwhelmed by patients. Social distancing helps “flatten the curve” in the spread of an infectious disease. This is especially critical because hospitals and health systems are working at full capacity. Flattening the curve ensures that systems are functional and people who require care the most can get the attention they need. The CDC recommends a distance of 6 feet or 2 meters as the minimum distance between individuals as part of COVID-19 mitigation strategy.
Currently, lung cancer patients may need to engage with the oncology care system for the following reasons:
Also, family members may sometimes accompany patients when they are visiting their doctors.
Recent studies out of China suggest that hospital admissions and repeated clinic visits increase the risk of COVID-19 exposure for patients. Further, a JAMA Oncology study reported that the infection risk for cancer patients in a tertiary care institution was 2-fold higher than the cumulative incidence observed in the city of Wuhan over the same time period. In light of these data and the rapidly evolving COVID-19 pandemic, the oncology community has come up with the following suggestions for cancer treatment. Please be advised that these recommendations are subject to change.
If you have a confirmed diagnosis, you may not wish to delay treatment (such as chemotherapy and radiation). You and your doctor should discuss what’s right for you.
Several recent forums have discussed the management of lung cancer during the COVID-19 pandemic. Topics that are currently being addressed by lung cancer providers/thought leaders include:
All treatment decisions should be made jointly by you and your doctor. Do not change your treatment plan or doctor’s visit without consulting your doctor first.
Telehealth or remote consults may be an option for checking in with your doctor. Also, there may be the option to be referred to a “COVID-19-free” hospital or treatment center.
Clinical trials continue to be a source of lifesaving therapies for lung cancer patients. The COVID-19 pandemic has affected the conduct of clinical trials due to the following reasons:
The US Food and Drug Administration (FDA) has recently issued guidance to help clinical trial sponsors figure out the best approaches to ensure that trials can proceed within resource-constrained settings. A clinical trial sponsor in this case is defined as any entity (for example, a pharmaceutical company) involved in the development and testing of drugs and other interventions in clinical trials. Below we have summarized key points from the FDA guidance that are important from the patient perspective.
For clinical trials that are already ongoing:
Several sponsors already have different measures in place to allow conduct of clinical trials and avoid as much disruption as possible, such as:
If you are part of a clinical trial, we recommend you discuss your trial participation immediately with your research team. If you were considering enrolling in a clinical trial, you may want to discuss with your treating physician what options are available for you. Any decision about trial participation should be made jointly by you and your healthcare team.
As cases of the virus surge in countries around the world, with Italy being particularly hard hit, many nations are taking extreme steps to mitigate the outbreak, including whole country lockdowns. Here in the United States, the President declared a national emergency on March 13, 2020. Several states have declared shelter-in-place to minimize non-essential activities and mitigate transmission. President Trump has declared California, New York State, and Washington State to be major disaster areas.
In this week’s update, we discuss the following topics related to COVID-19:
SARS-CoV-2 is the seventh coronavirus known to infect humans. SARS-CoV, MERS-CoV, and SARS-CoV-2 can cause severe disease, whereas HKU1, NL63, OC43, and 229E are associated with mild symptoms. There has been a lot of speculation on the origin of SARS-CoV-2. Scientists have now sequenced the genetic material of the virus isolated from different patients. These sequencing results clearly establish that SARS-CoV-2 is not a genetically engineered virus, meaning it is not manmade.1
The researchers provide two scenarios for the origin of SARS-CoV-2. In one scenario, the virus evolved to its current pathogenic (disease-causing) state through natural selection in a non-human host and then jumped to humans. This is how previous coronavirus outbreaks have emerged, with humans contracting the virus after direct exposure to civets (SARS) and camels (MERS). The researchers proposed bats as the most likely reservoir for SARS-CoV-2 as it is very similar to a bat coronavirus. In the other proposed scenario, a non-pathogenic version of the virus jumped from an animal host into humans and then evolved to its current pathogenic state within the human population. For instance, some coronaviruses from pangolins, armadillo-like mammals found in Asia and Africa, have similarities to SARS-CoV-2. A coronavirus from a pangolin could possibly have been transmitted to a human, either directly or through an intermediary host such as civets or ferrets.
Initial data on COVID-19 suggested that when stratified by age, the elderly were the most likely to develop a more severe form of COVID-19. Recent data released by the CDC demonstrated that this is not the case anymore. As shown in the figure below, almost all age groups are susceptible to a serious form of COVID-19 that requires hospitalization.2
This is especially important to keep in mind given that younger people have been more resistant to social distancing.
A recent study found that the SARS-CoV-2 virus (which causes COVID-19) can survive up to four hours on copper, up to 24 hours on cardboard, and up to two to three days on plastic and stainless steel. The researchers also found that this virus can hang out as droplets in the air for up to three hours before they fall. But most often they will fall more quickly.3
The researchers were able to detect viable viral particles for at least 72 hours on the four surfaces studied. This suggests that transmission of SARS-Cov-2 is possible through aerosols and fomites (solid objects and surfaces that are able to carry pathogens and transmit infections).
We recommend that after you bring articles into your home, you do the following:
Data from initial cases of COVID-19 suggested that most transmissions were occurring through individuals who showed signs and symptoms of COVID-19. This is, however, not the case. It is now estimated that as many as 31% of new COVID-19 infections are being caused as a result of transmission through asymptomatic individuals—those who have been infected with SARS-CoV-2 but don’t shown signs and symptoms of the disease.4 This is an especially important aspect of SARS-CoV-2 transmission and reinforces why we need to practice stringent social distancing to flatten the curve.
Individuals infected with SARS-CoV-2 may present with gastrointestinal symptoms such as anorexia (83.8%), diarrhea (29.3%), vomiting (0.8%), and abdominal pain (0.4%).5 These gastrointestinal symptoms may show up even before respiratory symptoms of COVID-19. Furthermore, a small sample of patients presented with only gastrointestinal symptoms. If you have unexplained gastrointestinal issues, we suggest that you talk to your doctor promptly. Also, conjunctivitis may be present in a small subset of patients as well. 6
Given the uncertainty over availability of medical care during the COVID-19 emergency, we suggest everyone review their legal documents and ensure they have a current Durable Power of Attorney and Advance Directive. This virus can progress very rapidly and seriously interfere with breathing, which means you cannot be certain that you will be able to make your wishes known verbally if you get severely ill. Discuss your wishes with your family and ensure everyone knows where to find these important documents.
If you haven’t completed these legal documents, some estate planning attorneys may be willing to help prepare and witness them via video conferencing so that you do not have to leave your home.
If you are not sure how to get started, please review the resources available at https://theconversationproject.org/
Short answer: yes. Long answer: we’re not sure.
On March 18, the World Health Organization (WHO) posted an article suggesting that patients who have COVID-19 avoid taking ibuprofen, based on observations of patients in France.7 However, later the same day, WHO changed their stance and said patients who have COVID-19 should not avoid taking ibuprofen.8
This is a good example of how quickly information is evolving during this pandemic. It’s difficult for doctors to know whether to act on information that is based on the experience of only a few (or even one) patient.
The World Health Organization officially declared the COVID-19 outbreak a pandemic on March 11, 2020. As cases of the virus surge in countries around the world, with Italy being particularly hard hit, many nations are taking extreme steps to mitigate the outbreak, including whole country lockdowns. Here in the United States, the President declared a national emergency on March 13, 2020.
In this week’s update, we discuss four important topics related to COVID-19.
COVID-19 is caused by the virus SARS-CoV-2. Individuals infected with SARS-CoV-2 appear to shed the virus from their respiratory tract (e.g., when coughing) even when symptoms may be very minor. Individuals infected with SARS-CoV-2 appear to shed the virus from their respiratory tract during the prodromal period.1 The prodromal period is part of an infectious disease cycle. It is defined as the period during which the symptoms felt by an infected individual may not be very specific or severe. The infected person can still perform usual functions and can therefore continue to be infectious. An infected individual can shed virus with very minor signs and symptoms.2 This explains why we are seeing widespread transmission in the community (this didn’t happen with SARS).
The reproductive number (R0)– the number of secondary infections generated from one infected individual – is estimated to be between 2 and 2.5 for COVID-19 virus.3 This means that a single infected person infects 2.5 people, which is higher than for the influenza virus. Approximately 3 to 5 days after infection, a person starts shedding virus and can infect others. Therefore, within a month, a single case can lead to 244 new cases.
The CDC now recommends social distancing to help decrease transmission of COVID-19 within the community.4 Social distancing measures, such as cancelling public gatherings and avoiding crowds, can slow the spread of the virus and spread cases out over a longer period of time, which can help hospitals provide care while avoiding being overwhelmed by patients. Social distancing helps “flatten the curve” in the spread of an infectious disease. This is especially critical because hospitals and health systems are working at full capacity. Flattening the curve ensures that systems are functional and people who require care the most can get the attention they need. The CDC recommends a distance of 6 feet or 2 meters as the minimum distance between individuals. 5
In case you are interested, we invite you to take a look at the CDC’s community transmission mitigation strategy document (cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf).
It may be a good idea to consider rescheduling or switching to a virtual appointment if your treating physician or cancer center provides this option. Note that virtual appointments are not appropriate for infusions for chemotherapy or immunotherapy, or potentially critical scans. If you have an oncology visit due in the next couple of months, please contact your treating physician as soon as possible to discuss what’s the right approach for you and whether they anticipate any drug shortages due to supply chain disruption.
Several hospitals are now limiting the number of visitors and/or people accompanying patients to no more than one at a time. In Seattle, the area hardest hit with cases, some hospitals are implementing the following measures to avoid being overwhelmed6:
We are seeing transmission in the community, so it’s likely the virus is more widespread in the United States than we imagine. However, we don’t have hard data because testing was not implemented in the earlier days of the epidemic in the US.7 Right now, most people need to have symptoms before they can be tested. As more test kits are distributed, testing will hopefully expand. Drive-through testing has been made available in a few locations but is not yet widely available. As we have stated previously, the symptoms of COVID-19 infection include fever, dry cough and shortness of breath. If you suspect that you have been infected, you should call your doctor or local health department to determine next steps. The availability of tests varies on where you live.
The CDC is maintaining an updated list of where tests are currently being performed in the US.8
Additionally, state health departments are a valuable resource, providing hotlines and websites with information about what to do if you are concerned that you or a loved one might be infected (links in the references).
Please check out Janet Freeman-Daily’s article where she describes her experience as a lung cancer survivor with a cough and the difficulties she faced to get tested for COVID-19. Janet lives in the Seattle, WA area, a COVID-19 hotspot.
Fred Hutchinson Cancer Research Center in Seattle published a helpful blog post, “Coronavirus: what cancer patients need to know.”
As advocacy organizations dedicated to serving the needs of lung cancer patients, all of us are closely monitoring the latest developments related to the outbreak caused by the novel coronavirus, SARS-CoV-2, and the resulting disease, COVID-19.
In this update, we have included additional information on facts about COVID-19, symptoms, testing, information about populations at risk of serious infection, and what you should do to protect yourself from COVID-19.
We are following updates provided by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), which can be found here:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen
https://www.cdc.gov/coronavirus/2019-ncov/index.html
Symptoms may appear 2-14 days after exposure and may include:
As of today, the CDC recommends testing symptomatic individuals. Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested.4
Do not read or share information about COVID-19 from websites that are not maintained by reputable public health organizations (for example, the CDC). When in doubt, check your facts with what’s posted on the CDC or WHO website.
We understand and appreciate the severity of the new coronavirus epidemic (also known as COVID-19) that’s spreading globally. As advocacy organizations dedicated to serving the needs of lung cancer patients, all of us are closely monitoring the latest developments related to the outbreak caused by the novel coronavirus, SARS-CoV-2, and the resulting disease, COVID-19.
This is a rapidly evolving situation and we are following updates provided by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), which can be found here:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen https://www.cdc.gov/coronavirus/2019-ncov/index.html
Do not read or share information about COVID-19 from websites that are not maintained by reputed public health organizations (for example, the CDC). When in doubt, check your facts with what’s posted on the CDC or WHO website.
This website is not intended to, and does not, provide medical advice, professional diagnosis, opinion, treatment, or services. Medical information provided on this site is for informational and educational purposes only. After reading content from this website, you are encouraged to review the information carefully with your physician.
© 2020 LUNGevity Foundation. All rights reserved. 
