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Diagnosis and Containment of Patients With Suspected Lung Cancer in the COVID-19 Pandemic


This CHEST series highlights specific studies in the COVID-19 literature that may warrant discourse or reading for members of the chest medicine community. Articles are written by members of CHEST Networks. You can read additional articles in this series.

NOTE: The perspectives shared in this article are those of the author(s) and not those of CHEST.

Diagnosis and Containment of Patients With Suspected Lung Cancer in the COVID-19 Pandemic—What Does the Literature Say?

By: Jasleen Pannu, MD
Thoracic Oncology Network

Published: June 2, 2021

The COVID-19 pandemic has had a detrimental impact on the already complex care of patients with cancer.1 In a retrospective review of 73.4 million patients undergoing cancer care in the United States, patients with cancer and COVID-19 had significantly worse outcomes (hospitalization 47.46%; death 14.93%) than patients with either alone (COVID-19 alone: hospitalization 24.26%; death 5.26%; cancer alone: hospitalization 12.39%; death 4.03%), including those with lung cancer.2,3 Some racial groups experienced disproportionate burdens of both lung cancer and COVID-19, and the intersection of these risks stand to widen existing health disparities.3 Health care systems worldwide were overwhelmed, sometimes beyond their breaking points, with the need to reallocate resources to the critically ill while containing the spread of infection.

Delaying Appointments, Shifting to Telemedicine

De Marinis et al, in Milan, Italy, reported structured, daily application of containment measures and proactive management, later adopted in several cancer centers worldwide. Social media, telemedicine, and telephone triage were used to screen patients, delay appointments where possible, and deliver home care to limit admissions to cancer centers while continuing necessary cancer treatment.4 During the 1-month study, 325 patients (43.5%) were asked to delay scheduled appointments, and 47 patients received home therapy for cancer. Over the next 5 weeks, only 1.8% of these patients tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and no deaths due to COVID-19 occurred.4

Lung Cancer Screening and Lung Nodule Management

Delays in elective testing and procedures were also necessary, but these delays were a concern in the setting of lung nodule management, where there was the possibility that an early-stage lung cancer could progress.5 The expert panel report by Mazzone et al in July 2020 addressed the management of lung nodules and lung cancer screening in the COVID-19 pandemic.6

The report recommended considering not only the risk of lung cancer but also of COVID-19 when making decisions about evaluating lung nodules, due to the threat of infection and resource limitations. This consensus statement by 24 experts in the field described 12 different clinical scenarios and the respective strategies that would be acceptable to manage lung nodules and screening while keeping into account guidance from the US Centers for Disease Control and Prevention.6 The experts agreed that delaying follow-up of lung nodules with an estimated probability of malignancy (pCA) of less than 25% by 3-6 months was acceptable.6 Only lung nodules with a very high risk of being malignant (pCA >85%) were recommended for prompt surgical resection (compared with a pre-pandemic threshold of pCA >65%).

PET scan use was proposed as a first step in patients with pCA 65% to 85% in order to minimize inadvertent benign resections. Initial lung cancer screening and annual screening for those who previously had Lung-RADS 1 and 2 could be delayed. Input from a multidisciplinary tumor board, risk-benefit discussions with patients, and periodic reevaluation of the situation depending on community penetration of COVID-19 were suggested.6

As we continue facing the challenges of this pandemic, efforts to eliminate disparities in lung cancer and COVID-19 are at times in conflict. Novel strategies are imperative to address both simultaneously while adapting to shifting circumstances and ensuring safe care within acceptable standards and guidelines.


  1. Guan W-j, Ni Z-y, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708-1720.
  2. Wang Q, Berger NA, Xu R. Analyses of risk, racial disparity, and outcomes among US patients with cancer and COVID-19 infection. JAMA Oncol. 2021;7:220-227.
  3. Karaca-Mandic P, Georgiou A, Sen S. Assessment of COVID-19 hospitalizations by race/ethnicity in 12 states. JAMA Intern Med. 2021;181:131-134.
  4. de Marinis F, Attili I, Morganti S, et al. Results of multilevel containment measures to better protect lung cancer patients from COVID-19: the IEO model. Front Oncol. 2020;10:665.
  5. Kramer BS, Berg CD, Aberle DR, et al. Lung cancer screening with low-dose helical CT: results from the National Lung Screening Trial (NLST). J Med Screen. 2011;18(3):109-111.
  6. Mazzone PJ, Gould MK, Arenberg DA, et al. Management of lung nodules and lung cancer screening during the COVID-19 pandemic: CHEST expert panel report. Chest. 2020;158:406-415.

Jasleen Pannu, MD

Jasleen Pannu, MD

Dr. Pannu is an Assistant Professor of Medicine and Director of Interventional Pulmonology Translational Research in the Division of Pulmonary, Critical Care and Sleep Medicine at The Ohio State University Medical Center, Columbus.

As an interventional pulmonologist, I am closely involved in diagnosing primary lung cancer and metastatic disease. I am passionate about early diagnosis of lung cancer and overcoming disparities in lung cancer care. My current area of focus is developing a comprehensive lung nodule program at my institution.

Read more COVID in Focus: Perspectives on the Literature:

Safety of Bronchoscopy During the COVID-19 Pandemic: An Update

Proning in COVID-19 Patients

Pulmonary Vasculopathy and Thrombosis in Patients With COVID-19