The effect of the COVID-19 pandemic on lung cancer care, and learning lessons from across Europe
The impact of COVID-19 in 2020 has had significant ramifications as healthcare professionals have had to switch focus to managing and controlling the virus, which has left a huge hole for patients with long-term conditions, such as cancer.
Lung cancer has long been an area of huge unmet need. It is the leading cause of cancer death globally and despite significant advancements in treatment and care of the condition, even before the pandemic, prognosis was poor.
The challenges in early diagnosis and treatment of lung cancer are now exacerbated by the overlap between symptoms of COVID-19 and lung cancer, and the need for respiratory physicians in the care of patients with either condition. It is important to learn lessons from the impact of the pandemic on health systems and care delivery now, so we may work to rapidly resolve disrupted care pathways and secure improvements to lung cancer services and patients’ outcomes in the long term.
To that end, the World Economic Forum (WEF) joined forces with the Lung Ambition Alliance, a collaboration of the International Association for the Study of Lung Cancer (IASLC), the Global Lung Cancer Coalition (GLCC), AstraZeneca and Guardant Health.
Together in partnership they established a task force to learn from the impact of COVID-19 on lung cancer services. A series of meetings brought together clinicians, patient representatives, policymakers and industry partners from five European countries (France, Germany, Italy, Spain and the UK) to identify lessons that could support the short- and long-term resilience of lung cancer services. Captured below are several of the task force’s findings and recommendations for diagnosis, lung cancer care and clinical trial participation.
Lung cancer prognosis
The main reason why the five-year survival rate in lung cancer is still poor is because the vast majority of clinically detected lung cancer cases are diagnosed at an advanced stage, when treatment options are limited.
Prognosis for lung cancer is highly dependent on the stage at which it is diagnosed: a person diagnosed with stage IV lung cancer has a 15% chance of surviving one year, compared to 80% if detected at stage I. Spotting lung cancer early relies on several things – patients noticing symptoms or understanding their own risk and presenting to health services accordingly, primary care physicians recognising patients at risk of lung cancer and referring them quickly, and easy access to diagnostic services. All of these have been affected by the pandemic – for example information from the UK shows up to a 75% drop in referrals to a lung cancer specialist in some areas during the first wave of COVID-19. In England, it is estimated that delays in diagnosis due to system pressures caused by COVID-19 could result in an additional 1,372 lung cancer deaths five years following diagnosis.
One task force member David Baldwin, chair of the UK Clinical Expert Group for Lung Cancer and Mesothelioma, gave a damning assessment: “We clinicians are seeing similar late presentations of lung cancer to those that were the norm 20 years ago. With disruptions at an unprecedented level, lung cancer patients simply can’t afford to have the clock wound back to where things were.
“We must redouble our efforts to diagnose patients early, by urgently restoring awareness and early diagnosis campaigns, rapid diagnostic and treatment pathways and approval of national lung cancer screening programmes. Patients deserve fresh investment and services to make up for lost time and accelerate innovation in lung cancer treatment options.”
With this in mind and looking at the response to the early stages of the pandemic, it is possible to identify key lessons and bring actions forward to address delays in diagnosing lung cancer.
In the short term
* Better information is needed for the public and healthcare professionals about how to spot the differences between COVID-19 and lung cancer so that people know which services to access and feel confident to seek help
* Patients need reassurance that services are safe, which requires investment in COVID-19-free clinical spaces and appropriate communication about how services are being kept safe
* There should be public health information campaigns about lung cancer to raise the public’s awareness of the signs and symptoms of lung cancer and to encourage them to seek help if they are concerned about their health
In the longer term
* There needs to be investment in strategies to identify lung cancer patients more proactively, such as targeted screening programmes for people at risk
* Real-time data collection and analysis at a national and local level can be used to identify and address the impact of COVID-19 on lung cancer patients
* Primary care settings require investment to ensure all patients with suspected lung cancer can be swiftly referred to specialist care.
Sustaining care beyond diagnosis
Even after lung cancer patients have been diagnosed, the COVID-19 pandemic has an impact on the services that they have been able to access. An IQVIA survey of 528 oncology specialists from across the five largest countries in Europe identified lung cancer as the third most impacted area of oncology, due to delays to diagnosis from the pandemic. Patient transfer delays, reduction in access to diagnostic equipment and other system pressures are resulting in a decrease in achieving a diagnosis within critical time.
The COVID-19 pandemic has had a considerable impact on lung cancer services. In an effort to sustain patients’ access to services, innovative approaches to service organisation and delivery have been employed – particularly during the early stages of the pandemic. This included widespread use of telemedicine, greater use of virtual meetings and remote monitoring of patients. In Russia, for example, AI is being used to retrospectively review CT scans conducted for COVID-19 diagnosis. This analysis has led to the detection of incidental lung nodules indicative of lung cancer that had not previously been diagnosed.
Through the use of data and technology, there have been examples of countries uniting to champion information in the fight to overcome COVID-19. The global TERAVOLT consortium was established in 2020 as a physician-led syndicate that examines the impact COVID-19 has on patients with thoracic malignancies.
As we continue to live with COVID-19, we need to see investment in technology to support patients throughout their lung cancer journey.
The impact on clinical trials
All medicines must undergo rigorous testing prior to being licensed, including through clinical trials. This is especially important for conditions such as lung cancer, where patients’ outcomes remain poor and access to innovative medicines can be critical to improving survival and quality of life.
The COVID-19 pandemic has had an impact on clinical trials for lung cancer, with only 14% of sites in Europe continuing to enrol patients at the same level as prior to the pandemic. On the other hand, we have also seen innovations in the way trials are conducted and reviewed, such as greater use of real-world evidence, remote monitoring and rolling reviews, which should be evaluated for continued use as we enter a post-COVID-19 world.
We need to act now
The impact of the pandemic has been wide-reaching – and will continue to be so – and it is critical that we do not lose sight of the people who are at risk of becoming hidden victims of COVID-19. The past few years have seen considerable advances in treatment options for lung cancer, yet prognosis remains poor. We now have the opportunity to learn lessons to change this.
The findings from the task force should assist governments, health systems, healthcare professionals and others to come together to understand the effect of the pandemic on lung cancer care, to address the immediate impact on lung cancer services, and to ensure the resilience of the system in the longer term for the benefit of lung cancer patients.
Dr Giorgio Scagliotti is the former president of IASLC (International Association for the Study of Lung Cancer), which as part of the Lung Ambition Alliance (LAA) co-created the Learning lessons from across Europe report alongside WEF. He is an expert in lung cancer and has decades of experience in lung cancer care across Europe