Surgery is considered the preferred treatment in patients with lung cancer who are fit to undergo the procedure. Stereotactic radiotherapy (SBRT) is guideline recommended for patients who are unfit for surgery or who decline to undergo the procedure. The ongoing debate about the role of SBRT in fit patients reflects the absence of data from completed prospective randomized clinical trials, and available comparative effectiveness data from nonrandomized comparisons are subject to confounding.1 The use of SBRT is growing worldwide, although rates vary between countries. Data from the Netherlands Cancer Registry for clinical stage I NSCLC diagnosed between 2012 and 2016 revealed that SBRT use in octogenarians increased from 75% to 84%, and in younger patients, from 31% to 43%, respectively.2 A similar U.S. National Cancer Database analysis revealed that the number of patients with early-stage NSCLC treated using radiotherapy (mainly SBRT) increased from 26% in 2010 to 29% in 2014.3
The COVID-19 pandemic has resulted in unprecedented pressure on healthcare services worldwide. Patients with lung cancer tend to have comorbid conditions such as a smoking history or pre-existing lung disease, which increases their vulnerability to COVID‐19 complications. Elective surgical operations have been suspended at some locations, and with first wave infections yet to peak in some countries, a restricted access to surgery may persist for some time.
What Has Changed in SBRT?
A need to limit patient visits and hospital contacts has led to joint recommendations by the European Society for Radiotherapy and Oncology (ESTRO) and the American Society for Radiation Oncology (ASTRO) to perform single-fraction lung SABR for selected patients.4 This recommendation was based on outcomes of two recent randomized clinical trials. The ESTRO-ASTRO expert consensus specifically addressed the role of SBRT in operable patients when timely access to surgery was unavailable, and there was a 100% consensus to offer SBRT in this situation. A majority of oncology departments in Europe have adopted the use of telemedicine to limit patient contacts.5
Patient preferences will become even more important in the pandemic era, as the treatment of stage I disease falls into the category of “preference-sensitive decisions,” which are treatments that involve significant tradeoffs affecting the patient’s quality of life (QoL) and/or length of life. Informed patient choice should be the preferred practice for preference-sensitive care.6 Among patients with early-stage lung cancer, a prospective study revealed that maintaining independence and QoL were more highly valued than survival or cancer recurrence.7 Another multisite, prospective, observational cohort study in the United States reported that approximately 30% of patients with stage I NSCLC have a clinically significant decrease in QoL 1 year after SBRT or surgical resection.8 Although surgical resection was associated with steeper declines in QOL immediately after treatment compared to SBRT, these declines were not lasting and resolved within a year for most patients.
The Impact of COVID-19
Patients who acquired perioperative COVID-19 infection had an overall 30-day mortality of 23.8%, with pulmonary complications occurring in 51% of patients, who in turn accounted for 83% of all deaths.9 It has been argued that patients who undergo elective surgery should be told that, despite measures to limit the risk of infection, there remains a risk of contracting COVID-19 in the hospital, whether before, during, or after the operation.10 It is noteworthy that a key barrier to recruitment in trials comparing surgery and SBRT in stage I NSCLC has been the pre-existing treatment preferences of patients, as illustrated by a significant proportion of patients randomly selected to the surgical group in the SABRTooth trial who declined and chose SBRT instead.11
A point of concern in some COVID-19 guidelines is the suggestion that treatment (surgery) for smaller stage I lung tumors could be deferred, whereas the 8th Edition of the TNM Classification for Lung Cancer specifies that from 1 to 5 cm, each centimeter separates tumors of significantly different prognosis. The American College of Surgeons recommends that surgery could be deferred when a solid nodule or lung cancer is less than 2 cm.12 The European Society for Medical Oncology recommends that surgery is “low priority” for solid nodules greater than 500 mm3 and with known volume doubling times of more than 600 days, but it added that SBRT is an alternative if surgery is indicated and no surgical capacity is available.13 There is a need for further study on the risk of delaying treatment, especially for small lung tumors. A National Cancer Database study evaluated the effect estimates for each 1-week delay in definitive surgery from diagnosis, with the earliest interval when the effect estimate was significantly worse from baseline, defined as the inflection point.14 Time to inflection point beyond median current wait time was considered the safe postponement period (SPP), and for 48% of cancer types, the SPP was at least 4 weeks.14 Patient delays in the pandemic era will have also to be factored in when considering the SPP. Some patients requiring analyses may have obeyed stay-at-home orders or were concerned about going to a hospital where they might contract the virus. For example, the pandemic accounted for a 25% decrease in cancer diagnosis (excluding skin cancers) in the Netherlands in the month following outbreak of COVID-19 in the country.15
In summary, clinicians and patients face unprecedented challenges in the COVID-19 era. Updated guidelines and recommendations from professional societies on early-stage lung cancer are helpful in this context, and must be well documented in decision-making by tumor boards, which can refer to the local situation (for example, R0 index) during the pandemic. In addition, the importance of shared decision-making with our patients cannot be emphasized enough.
- Chen H, Laba JM, Boldt RG, et al. Stereotactic Ablative Radiation Therapy Versus Surgery in Early Lung Cancer: A Meta-analysis of Propensity Score Studies. Int J Radiat Oncol Biol Phys. 2018;101(1):186-194.
- de Ruiter JC, Heineman DJ, Daniels JM, van Diessen JN, Damhuis RA, Hartemink KJ. The role of surgery for stage I non-small cell lung cancer in octogenarians in the era of stereotactic body radiotherapy in the Netherlands. Lung Cancer. 2020;144:64-70.
- Blom EF, Haaf KT, Arenberg DA, de Koning HJ. Uptake of minimally invasive surgery and stereotactic body radiation therapy for early stage non-small cell lung cancer in the USA: an ecological study of secular trends using the National Cancer Database. BMJ Open Resp Res. 2020;7(1):e000603.
- Guckenberger M, Belka C, Bezjak A, et al. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radioth Oncol. 2020;146:223-229.
- Slotman B, Lievens Y, Poortmans P, et al. Effect of COVID-19 pandemic on practice in European radiation oncology centers. Radioth Oncol. 2020;13;150:40-42.
- Wennberg JE, O’Connor AM, Collins ED, Weinstein JN. Extending the P4P agenda, part 1: how Medicare can improve patient decision making and reduce unnecessary care. Health Affairs. 2007(26):1564-1574.
- Sullivan DR, Eden KB, Dieckmann NF, et al. Understanding patients’ values and preferences regarding early stage lung cancer treatment decision making. Lung Cancer. 2019:131:47-57.
- Nugent SM, Golden SE, Hooker ER, et al. Longitudinal Health-Related Quality of Life among Individuals Considering Treatment for Stage I Non-Small Cell Lung Cancer. Ann Am Thorac Soc. 2020 May 20. [Epub ahead of print].
- COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27-38.
- Sokol D, Dattani R. How should surgeons obtain consent during the covid-19 pandemic? BMJ. 2020;369:m2539.
- Franks KN, McParland L, Webster J, et al. SABRTOOTH: A randomised controlled feasibility study of Stereotactic Ablative Radiotherapy (SABR) with surgery in paTients with peripheral stage I nOn-small cell lung cancer (NSCLC) cOnsidered To be at Higher risk of complications from surgical resection. Eur Respir J. 2020 Jul 2:2000118. [Epub ahead of print].
- American College of Surgeons. COVID-19 Guidelines for Triage of Thoracic Patients. https://www.facs.org/covid-19/clinical-guidance/elective-case/thoracic-…. Published March 24, 2020. Accessed July 14, 2020.
- Passaro A, Addeo A, Von Garnier C, et al. ESMO Management and treatment adapted recommendations in the COVID-19 era: Lung cancer. ESMO Open. 2020;5(Suppl 3):e000820.
- Turaga KK, Girotra S. Are We Harming Cancer Patients by Delaying Their Cancer Surgery During the COVID-19 Pandemic? Ann Surg. 2020 Jun 2;10.1097/SLA.0000000000003967.
- Dinmohamed AV, Visser O, Verhoeven RHA, et al. Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands. Lancet Oncol. 2020;21(6):750-751.