The COVID-19 pandemic prompted ESMO to come up with a structured set of recommendations for lung cancer management. As per the recommendations, though hospital admission should be reduced, all the new cases with suspicion of clinical stage III or metastatic, both for NSCLC or SCLC, or the appearance of disease-related symptoms should keep the standard work-up as per standard guidelines, without undue delay.

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COVID-19 has caused tremendous pressure on the global healthcare system; especially, the cancer community has been under pressure to safeguard cancer patients and ensure continual treatment. The dilemma associated with whether to continue or postpone cancer treatment has become a crucial aspect.

Keeping in view the hardships associated with delayed treatment, the ESMO came out with a set of recommendations for diagnosis, treatment, and follow-up for lung cancer patients. These recommendations can be used by lung cancer oncologists to prioritise the various aspects of cancer care and to mitigate the potential harm due to the COVID-19 epidemic on patients with lung cancer.

The recommendations comprises three levels of priorities, defined as per the criteria of the Cancer Care Ontario, Huntsman Cancer Institute and Magnitude of Clinical Benefit Scale

• Tier 1 (high priority)
• Tier 2 (medium priority)
• Tier 3 (low priority)

Definition of high priority as per ESMO- Patient’s condition is immediately life-threatening, clinically unstable and/or the magnitude of benefit qualifies the intervention as high priority (eg, significant overall survival gain and/or substantial improvement of the quality of life (QoL)). Below we cover the high-priority recommendations from the ESMO update.

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Priorities for lung cancer patients- Outpatient visit priorities

The ESMO recommends that standard work-up, as per guidelines, should be followed for all the new cases with suspicion of clinical stage III or metastatic.

Outpatient visit high priority includes:

1. New diagnosis or suspicion of invasive lung cancer with either:
   1. Disease-related symptoms (dyspnoea, pain, haemoptysis, etc.)
   2. Suspicion of clinical stage II/IIIA/IIIB or metastatic NSCLC or SCLC
2. Visits for treatment administration

Telemedicine platform is recommended for all non-priority outpatient appointments, with the priority evaluated based on the clinical need.

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Priorities for lung disease: Imaging

Imaging techniques in lung cancer are critical for diagnosis and disease management, however, the pandemic warrants prioritising and safeguarding the healthcare resources.

Imaging high priority includes:

• Patients with significant respiratory symptoms and/or other clinically relevant chest, cancer- or treatment-related symptoms. In patients with new respiratory symptoms such as dyspnoea, cough with or without fever, a CT-scan is recommended
• Standard staging work-up for suspected lung cancer of unknown stage or stage II/III/IV
• Biopsies for suspicious nodules or mass for suspected lung cancer of stage or stage III/IV
• Evaluation of active treatment response in the first 6 months of treatment or if suspicion of progression at any timepoint
• Pre-planned imaging evaluation per clinical trial protocol

ESMO recommends postponing and rescheduling outpatient appointments and imaging for non-critical patients, such as non-urgent diagnostic or image-guided procedure.

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Priorities for lung disease: Surgical Oncology

Establishing a priority-framework for lung cancer surgery is necessary. Risk/benefit ratio for disease aspects and alternative treatment modalities should be carefully explored.

High priority for lung cancer surgery includes:

• Drainage +/- pleurodesis of pleural effusion, pericardial effusion, tamponade risk
• Evacuation of empyema-abscess
• T2N0 tumours naïve from treatment or after induction chemotherapy
• Resectable T3/T4 tumours naïve from treatment or after induction chemotherapy
• Resectable N-1/N2 disease naïve from treatment or after induction chemotherapy
• Diagnostic procedure such as mediastinoscopy/thoracoscopy/pleural biopsy/endoscopy/transthoracic investigations for diagnostic/staging work-up

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Priorities for lung cancer: Medical Oncology – Early stage lung cancer

Improving lung cancer outcomes in the curative stage of early stage is a significant challenge. The selection and prioritisation of treatment strategy at early stages warrants proper judgement and long-term vision.

For early stage lung cancer, high priority includes:

• Concomitant chemoradiotherapy for SCLC limited disease stage I/II
• Neoadjuvant chemotherapy (enabling deferral of surgery by 3 months) in clinical stage II
• Delivery of adjuvant chemotherapy in T3/4 or N2 disease for young (<65 years old) and fit patients
• G-CSF use if febrile neutropaenia risk evaluated to be >10-15%

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Priorities for lung cancer: Medical Oncology – Locally advanced lung cancer

With the COVID-19 pandemic, managing stage III of NSCLC is a major challenge; this is due to the need to optimise and prioritise the appropriate combination, time and sequence of multiple treatment modalities, which ultimately lead to an increased risk of exposure to the novel coronavirus. However, as stage III NSCLC has significant curative potential, the treatment for this group of patients should be prioritised.

For locally advanced lung cancer, high priority includes:

• Concomitant chemoradiotherapy for SCLC limited disease stage III
• Concomitant or sequential chemoradiotherapy for inoperable NSCLC Stage III
• Starting consolidation durvalumab (within 42 days)
• Neoadjuvant chemotherapy in clinical stage III
• G-CSF use if febrile neutropaenia risk evaluated to be >10-15%

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Priorities for lung cancer: Medical Oncology – Metastatic lung cancer

To decrease the rate of mortality in patients with a new diagnosis of metastatic NSCLC, all standard options for first-line systemic therapy should be followed unaltered. With regards to second-line treatments, standard work-up should be followed in patients with symptomatic, progressive disease, where delaying the treatment could impair patient's survival.

For metastatic lung cancer, high priority includes:

• 1st-line treatment including chemotherapy, chemotherapy plus IO, IO alone or TKIs to improve prognosis, cancer-related symptoms and QoL
• Start 2nd-line chemotherapy or IO in symptomatic and progressive disease patients
• Start 2nd-line TKI in progressive disease patients
• G-CSF use has to be considered if despite optimal dose modification, risk of febrile neutropaenia is >10%
• Anti-PD-(L)1 scheduled cycles may be modified/delayed to reduce clinical visits (for instance, using 4-weekly or 6-weekly dosing instead of 2- or 3-weekly for selected agents when appropriate (where allowed from National Regulatory Agency)

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Priorities for lung cancer: Radiation Oncology

As per the ESMO, the main goal during the pandemic should be to minimise hospital visits and exposure to SARS-CoV-2; hence, the radiotherapy unit capacity should be increased for operable patients with lung cancer who may not be able to have surgery during this pandemic.

For radiation oncology, high priority includes:

• Radiotherapy for inoperable stage II-III cancers, with contra-indications for chemotherapy
• Concomitant (preferred) or sequential chemoradiotherapy for inoperable NSCLC Stage II/III
• Concomitant (preferred) or sequential chemoradiotherapy for SCLC limited disease
• Superior vena cava obstruction, significant haemoptysis, spinal cord compression, significant bone pain or any life-threatening condition amenable to palliative radiotherapy