To the Editor:
The outbreak of 2019 novel coronavirus (coronavirus disease 2019 [COVID-19]) has been declared a pandemic spread by the WHO on March 11, 2020. Some countries have been hit earlier and with lightning violence, leading to the collapse of health facilities and putting public health to test. This epidemiologic and social emergency puts at risk of undertreatment not only patients with acute infections but also health care pathways for other diseases. Diagnostic tests and hospital facilities are largely used for patients with COVID-19, and most resources are invested in this field. Nevertheless, it is our duty, as surgical specialists, not to forget our patients, especially patients with cancer. What is happening to the lung cancer pathways of referral and treatment? For how long do we have to face this emergency? What will be the cost in terms of lung cancer-related death in this scenario?
It is a management and ethics dilemma, and the answer is not easy to find in the absence of evidences.
1
We established in our Lung Cancer Unit a new risk stratification for lung cancer progression and COVID-19 infection (Table 1). We matched both and elaborated a new integrated stratification risk to prevent adverse outcomes from COVID-19 after oncologic treatment (Table 2).
Table 1New Risk Stratification or Lung Cancer Progression and COVID-19 Infection
| Low | High | |
|---|---|---|
| Risk of progression | T1 (a–c) N (0–1) T2 (a–b) N (0–1) T3 (N0–1) | Surgical T4 (any N) Surgical N2 (any T) Surgical oligometastasis |
| Risk of COVID-19 | <70 y <2 associated disease | >70 y >2 associated disease; immunosuppression |
COVID-19, coronavirus disease 2019.
Table 2New Integrated Risk Classification
| Stage I | Low risk of progression and low risk of COVID-19 infection |
| Stage IIa | High risk of progression and low risk of COVID-19 infection |
| Stage IIb | Low risk of progression and high risk of COVID-19 infection |
| Stage III | High risk of progression and high risk of COVID-19 infection |
COVID-19, coronavirus disease 2019.
We promote new therapeutic options on the basis of the integrated classification as follows:
Stage I: Anatomical lung resection, the early stages allow definitive oncologic treatment without the need for further hospital admission or adjuvant treatments (low risk of infection).
Stage IIa: Anatomical lung resection (low risk of infection).
Stage IIb: Discuss with the patient the possibility of a follow-up (up to 3 mo) before a definitive therapeutic decision after the epidemiologic peak has been overcome. Personalized treatments are evaluated.
Stage III: Consider exclusive nonsurgical treatments.
This algorithm of care tries to balance the risk of dying from cancer with the risk of incurring a potentially fatal infection after major surgery or any oncologic treatment. It is partially evidence-based and mostly on the basis of common sense and on the need for supporting the current emergency without forgetting our patients.
Reference
Kutikov A, Weinberg DS, Edelman MJ, Horwitz EM, Uzzo RG, Fisher RI. A war on two fronts: cancer care in the time of COVID-19 [e-pub ahead of print]. Ann Intern Med. https://doi.org/10.7326/M20-1133, accessed March 27, 2020.
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Published online: April 11, 2020
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© 2020 International Association for the Study of Lung Cancer. Published by Elsevier Inc.
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