On April 28, 2020, a draft of a scientific manuscript was posted on social media that raised concerns in the lung cancer community. The report was from a single radiation oncology department in New York City that identified people who tested positive for COVID-19 and who had received radiotherapy for a variety of cancers. After evaluating their data, the authors concluded that “COVID-19 patients with a history of radiotherapy for cancer have a poor prognosis, and mortality risk appears to be associated with the extent of lung irradiation.”
We carefully reviewed this manuscript to see if people with lung cancer who have been treated with radiotherapy should be concerned. Our analysis of the study shows that it is impossible to determine whether lung radiotherapy was related to the poor outcomes that were seen in people with lung cancer who presented with COVID-19 at their hospital. The authors used a statistical model that didn’t account for a lot of other factors, such as whether the people with lung cancer had other health problems that would have made them more vulnerable to bad outcomes. It is also important to emphasize that the study had a small sample size of only 14 people with lung cancer. While we applaud the authors for proactively getting this information out into the public domain, we urge that caution should be exercised when relating the study to an individual patient’s treatment situation.
Key questions that have been raised are addressed below:
Question: Were the people with lung cancer sicker at the time of COVID-19 infection?
Answer: This study did not report anyone’s health status, so therefore we just don’t know. Those details were not collected or compared.
Question: Why did people with COVID-19 do better if they received radiotherapy to the breast or prostate instead of the lung?
Answer: People with breast and prostate cancer are often in better health. Without further details about anyone’s health in this study, we simply do not know that radiotherapy contributed to anyone’s bad outcomes.
Question: Do you think that the effects of lung cancer surgery or chemotherapy had any role in some of the people having worse outcomes?
Answer: It could have, but again we just don’t know. The study did not report any information on surgery or systemic therapy.
Question: Why did patients who received a higher mean dose of lung radiotherapy do worse with COVID-19?
Answer: This is a complicated question that we’ll try to simplify. It’s important to recognize that people who receive higher mean doses of lung radiotherapy typically have larger tumors. Next, larger tumors can lead to collapsed lungs. This increases the risk of pneumonia, which can certainly worsen outcomes with or without COVID-19. Also, larger tumors are usually treated with concurrent chemotherapy, which can have its own ill effects. Unfortunately, the report didn’t include any information about tumor size, lung collapse, or delivery of systemic therapies. Therefore, we are in the dark about this.
Question: The report found that even low doses of lung radiotherapy led to worse outcomes in people infected with COVID-19. How could that be?
Answer: There is no reliable rationale to explain this, especially since there is plenty of data that show that low doses of 1 Gy are very safe to the lungs. As the authors stated, we believe that more data would be needed to confirm what they reported in their statistical model.
Question: What should people with lung cancer make of such a small study that raised so much concern on social media?
Answer: As the authors state in their report, further evaluations are needed to draw any meaningful conclusions. The findings cannot be taken as conclusive, as it is entirely possible that other factors that had nothing to do with lung radiotherapy affected patient outcomes.
Question: What should people with lung cancer do if they previously received or are about to be treated with lung radiotherapy?
Answer: It’s important to emphasize that radiotherapy has a curative role in lung cancer and can save lives. Therefore, people with early-stage or locally advanced lung cancer should not delay their treatments based on this single small study. We believe the most important thing at this time for all of us to do is to take every precaution possible during the COVID-19 pandemic to minimize the risk of getting infected. Please wear a mask at all times whenever in public, do NOT touch your face, and wash your hands frequently. Many people with lung cancer are being safely treated with lung radiotherapy at this time all around the world, and we are unaware of any other studies to corroborate the findings from this small report out of New York City.
For those who want to learn more about specific radiation therapy-related management options for lung cancer in the COVID-19 era, two peer-reviewed references are listed below.
- An article co-authored by two members of the LUNGevity Scientific Advisory Board (Dr. Donington and Dr. Moghanaki):
Alternative Multidisciplinary Management Options for Locally Advanced Non-Small Cell Lung Cancer During the COVID-19 Global Pandemic. Journal of Thoracic Oncology (2020), doi: https://doi.org/10.1016/j.jtho.2020.04.016.
- A consensus statement co-authored by Dr. Higgins:
Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radiotherapy and Oncology, https://doi.org/10.1016/j.radonc.2020.04.001