Coronavirus Disease 2019 Infection in a Patient Population with Lung Cancer: Incidence, Presentation, and Alternative Diagnostic Considerations

Abstract

Introduction: Lung cancer is associated with severe coronavirus disease 2019 (COVID-19) infections. Symptom overlap between COVID-19 and lung cancer may complicate diagnostic evaluation. We aimed to investigate the incidence, symptoms, differential diagnosis, and outcomes of COVID-19 in patients with lung cancer.

Methods: To determine an at-risk population for COVID-19, we retrospectively identified patients with lung cancer receiving longitudinal care within a single institution in the 12 months (April 1, 2019 to March 31, 2020) immediately preceding the COVID-19 pandemic, including an "active therapy population" treated within the last 60 days of this period. Among patients subsequently referred for COVID-19 testing, we compared symptoms, laboratory values, radiographic findings, and outcomes of positive versus negative patients.

Results: Between April 1, 2019 and March 31, 2020, a total of 696 patients received longitudinal care, including 406 (58%) in the active therapy population. Among 55 patients referred for COVID-19 testing, 24 (44%) were positive for COVID-19, representing a cumulative incidence of 3.4% (longitudinal population) and 1.5% (active therapy population). Compared with patients who were COVID-19 negative, those who were COVID-19 positive were more likely to have a supplemental oxygen requirement (11% versus 54%, p = 0.005) and to have typical COVID-19 pneumonia imaging findings (5 versus 56%, p = 0.001). Otherwise, there were no marked differences in presenting symptoms. Among patients who were COVID-19 negative, alternative etiologies included treatment-related toxicity (26%), atypical pneumonia (22%), and disease progression (22%). A total of 16 patients positive for COVID-19 (67%) required hospitalization, and seven (29%) died from COVID-related complications.

Conclusions: COVID-19 was infrequent in this lung cancer population, but these patients experienced high rates of morbidity and mortality. Oncologists should maintain a low threshold for COVID-19 testing in patients with lung cancer presenting with acute symptoms.

Keywords: COVID-19; Lung cancer; NSCLC; SARS-CoV-2; SCLC; Thoracic oncology.

Figure 1

Consort diagram of the study cohort. “Longitudinal therapy population” are defined as those receiving systemic therapy or radiation or undergoing surgery for thoracic cancer between April 1, 2019, and March 31, 2020. “Active therapy population” are those who received systemic therapy (chemotherapy, immune checkpoint inhibitor, tyrosine kinase inhibitor, antibody-drug conjugates, allosteric inhibitors, or combinations of these therapies) in the 60 days before March 31, 2020. Patients “not on active therapy” are those who received primary thoracic oncology care at our center in the previous 12 months but had not been treated with systemic therapy 60 days before March 31, 2020. AE, adverse event; COVID-19, coronavirus disease 2019; RT-PCR, real-time polymerase chain reaction.

Figure 2

Alternative diagnoses in patients negative for COVID-19 infection. Of the 27 patients negative for COVID-19, alternative diagnoses were identified in 25. In two cases, the clinical and radiographic symptoms were attributed to the following two possible causes: case 1: grade I immune checkpoint inhibition-induced pneumonitis and an atypical pneumonia; case 2: grade II immune checkpoint inhibition-induced pneumonitis and an atypical pneumonia. COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; COP, cryptogenic organizing pneumonia; COVID-19, coronavirus disease 2019.

Figure 3

Clinical summary of patients referred for COVID-19 testing on the basis of results of routine imaging studies. Five patients with advanced lung cancer were referred for COVID-19 testing on the basis of routine restaging imaging studies. Top panel: representative CT chest images for each patient. Bottom panel: table summarizing cancer histopathology, systemic anticancer therapy, symptoms on day of imaging, imaging findings, COVID-19 RT-PCR results, additional workup, and alternative diagnoses. ∗At the time of imaging, patient was on active treatment with ATRA and arsenic trioxide for concurrent diagnosis of APML. No active lung cancer-directed systemic therapy. COVID-19, coronavirus disease 2019; CT, computed tomography; N/A, not applicable; RT-PCR, real-time polymerase chain reaction.