Expert Guidance: During COVID-19, Lung Cancer CT Screenings Can Be Postponed

Much attention has been given during the COVID-19 pandemic to postponing screening services, largely focusing on breast imaging. However, lung cancer screenings also fall into this category and should be delayed in an effort to protect patients and conserve valuable medical sources, according to new guidance from an international expert panel.

Published in the Journal of the American College of Radiology, a group of 21 pulmonologists, thoracic radiologists, and thoracic surgeons drafted a consensus statement on the management of lung nodules and lung cancer screenings during the pandemic.

“There was a consensus that during the COVID-19 pandemic it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource allocation,” wrote the panel, led by Peter Mazzone, M.D., MPH, director of the Cleveland Clinic Lung Cancer Program and Lung Cancer Screening Program for the Respiratory Institute. “There are multiple local, regional, and patient related factors that should be considered when applying these statements to individual patient care.”

The consensus statement was created in accordance with current COVID-19 guidance from the Centers for Disease Control & Prevention, and it touches on how providers should handle CT lung cancer screenings, as well as the management of patients who have lung nodules during this outbreak. The guidance also appeared concurrently on April 24 in CHEST and Radiology: Imaging Cancer.

Based on two video conferences, the panel compiled 12 recommendations that fall under four areas. Each recommendation achieved at least 70-percent agreement among the panelists.

Baseline and Annual Lung Cancer Screening

• Defer initiation of lung cancer screenings for referred patients.

• Delay annual screening for patients due for repeat annual chest CT screening exam (Lung-RADS 1 or 2).

Surveillance of a Previously Detected Lung Nodule

• Delay CT scan for surveillance of nodules of average <8 mm diameter for 3-to-6 months.

• Postpone surveillance CT scan of screening-detected lung nodule (Lung-RADS 3) for 3-6 months.

• Delay surveillance chest CT scan for a patient with an incidentally detected pure ground glass nodule of any size for 3-6 months.

• Delay surveillance chest CT scan for incidentally- (or screening-) detected part-solid lung nodule with the solid component 6-8 mm in diameter for 3-6 months.

• Postpone 3-month surveillance chest CT for a patient with an incidentally detected solid nodule ≥ 8 mm in average diameter or a Lung-RADS 4 screening-detected nodule with < 10 percent probability for malignancy for 3-6 months.

Evaluation of Intermediate and High-Risk Lung Nodules

• Delay, for 3-6 months, a chest CT to evaluate a patient with an incidentally detected solid nodule ≥ 8 mm in diameter (or a Lung-RADS 4 screening-detected lung nodule) with a probability of malignancy between 10-25 percent.

• Conduct a chest CT scan within 3-6 months to evaluate on incidentally- or screening-detected part-solid lung nodule with the solid component ≥ 8 mm in diameter.

• Evaluate with a PET/CT scan and/or non-surgical biopsy a patient in need of evaluation for an incidentally detected solid nodule ≥ 8mm in diameter (or Lung-RADS 4 screening-detected lung nodule) with an estimated malignancy between 65-85 percent malignancy.

• Proceed to a treatment decision, including surgical resection or stereotactic radiotherapy, for a patient with an incidentally detected solid nodule ≥ 8 mm in diameter (or Lung-RADS 4 screening-detected lung nodule) where the probability of malignancy is > 85 percent.

Management of Clinical Stage I Non-Small Cell Lung Cancer

• After assessing cancer size, growth rate, FDG/PET avidity of the primary tumor, patient values, and general patient health and fitness, treatment, including surgery, can be delayed when reasonable.

Although these recommendations fall in line with guidance from the CDC, the panel also encouraged providers to discuss the course of treatment with patients.

“Patient preferences should be taken into account in all of the scenarios, because individual patients are likely to differ in how they perceive the potential benefits and harms associated with delayed or modified evaluation and management,” they wrote. “This highlights the importance of communication about the rationale for decisions with our patients.”

Decisions should also be based, they said, upon the prevalence of COVID-19 in the community, availability of rapid testing, levels of resources, local policies, and the presence of other care environments less impacted by the virus.