The post below is shared with permission. It can also be found on the websites of the lung cancer advocacy organizations listed at the end of this blog post.

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These updates began on March 3, 2020–a week before the World Health Organization declared COVID-19 a pandemic–when concerns arose in the lung cancer community regarding news out of China about a novel respiratory virus especially deadly to patients with lung cancer. Dr. Upal Basu Roy (who holds a Masters in Public Health), Dr. Amy Moore (whose PhD research was in virology), and Janet Freeman-Daily (a lung cancer research advocate) led lung cancer patient advocacy groups’ efforts to provide vetted, scientific information with a unified voice. Our goal is to provide a trusted source of information that each member of the community can use to assess their risk and make healthy choices for themselves and their families.

As of July 26, 2020, there have been over 16 million cases of COVID-19 worldwide. This week, the US surpassed 4 million cases– while our nation accounts for just over 4% of the world’s population, we make up 25% of virus cases. Another alarming statistic is the rapid pace with which we keep hitting stark new milestones – it took a mere 15 days for our cases to jump from 3 million to 4 million. These numbers reflect the exponential growth of viruses when appropriate public health measures are not heeded by enough members of the population.

SUMMARY OF AACR COVID-19 AND CANCER CONFERENCE

The American Association of Cancer Research held a special virtual conference titled “COVID-19 and Cancer” on July 20-22, 2020. It is increasingly apparent that cancer and COVID-19 present a unique and unfortunate convergence, with lung cancer patients being among the most at risk for severe symptoms from the disease. This conference grew out of the research community’s need to understand the intersection of these two diseases and reflects the rapid mobilization of cancer scientists to apply their talents to finding solutions to this unprecedented global crisis. As one scientist stated, it is our “moral obligation” to help.

The lung cancer advocacy groups had two “poster” presentations at this conference. The first one summarized the origins of our joint COVID-19 statements and their impact on the lung cancer community. The second one discussed patient concerns that have emerged through these updates and how the advocacy groups can develop programs to address them.

1. What is the latest data on risk of COVID-19 for lung cancer patients?

Several real-world studies were presented at the conference that addressed overall risk for cancer patients as well as lung cancer in particular. Real-world studies rely on data collected from patients receiving treatment at their regular cancer centers or hospitals (i.e. patients not receiving treatment through a clinical trial). Currently, real-world data seems to be the richest source of data for learning about how SARS-CoV-2 (as a virus) and COVID-19 (as a disease) impacts cancer patients.

Registry data is entered by the patient’s treating physician after the patient has a confirmed diagnosis of COVID-19. Data from two big registries were presented at this conference.

• The CCC19 registry is a multi-institutional, North American effort for all types of cancer. It reported that lung cancer patients were at higher risk of developing a more severe form of COVID-19. Other factors that predicted worse outcomes included older age, poor performance status, presence of co-morbidities, prior or current history of smoking, and a cancer that was progressing. The CCC-19 study showed an overall mortality of 26% for lung cancer patients with COVID-19, the highest of all the cancer types analyzed.
• The TERAVOLT registry is a multi-institutional, international effort dedicated to thoracic (lung-related) cancers. TERAVOLT data on 400 COVID-19 patients showed overall mortality of 35.5% for patients who had lung cancer and a higher mortality of 41% for patients who have SCLC. This increases the challenges presented by the pandemic to rural communities in the Southeast, where SCLC burden is high. Poor performance status was associated with more severe COVID-19 symptoms for SCLC patients.  The patients in this study are primarily European, where the standard of cancer care may be different than in the US. It is important to keep in mind that SCLC is highly aggressive and has a higher symptom burden than NSCLC.

Single-institution data provide convenient samples to understand the natural history of a specific disease. At the conference, data from Memorial Sloan Kettering Cancer Center in New York City showed that prior immunotherapy for lung cancer did not impact outcomes of SARS-CoV-2 positive lung cancer patients. This data seems to contradict other registry-based efforts which have suggested that immunotherapy may predict worse outcomes. At the height of the pandemic in NYC, 20% of MSKCC’s lung cancer patients with COVID-19 died but many, including those with late-stage cancer, recovered. This study suggests patient-specific factors (such as type of treatment and patient characteristics) may determine overall risk and susceptibility to worse outcomes. It is important to keep in mind that standard of care and patient characteristics may be unique in a specific institution and therefore the results may not be generalizable.

One study presented at the conference that looked at electronic health records of patients in the US showed that an active cancer diagnosis coupled with co-morbidities such as diabetes and hypertension predicted worse outcomes for COVID-19.

Some common themes emerged for lung cancer patients:

• Patient-specific factors such as older age, presence of lung comorbidities such as COPD, and a poor performance status (higher than 1) are associated with a risk of developing a more severe form of COVID-19.
• Certain treatments such as chemotherapy (either alone or in combination) may increase the risk of developing a severe form of COVID-19 due to the immunosuppressive effects of chemotherapy.

We are still learning about how patient-specific factors and treatment-specific factors related to lung cancer can influence the severity of COVID-19. It is best to discuss how an individual patient’s situation will be impacted with the treating physician.

What is abundantly clear at this point is that multiple studies point to increased risk and worse outcomes in lung cancer patients with COVID-19. As the pandemic continues to spread throughout the US, it is imperative that lung cancer patients continue to take the threat seriously and take appropriate steps to protect themselves and those around them:

• limit unnecessary travel (particularly to areas where COVID-19 is prevalent),
• practice social distancing,
• wash hands frequently (or use hand sanitizers when handwashing is unavailable), and
• WEAR A MASK when out in public.

2. How has the COVID-19 pandemic impacted oncologists and the cancer healthcare community?

The impact of the COVID-19 pandemic on the mental health of oncologists cannot be underestimated. Several studies suggest that oncologists will likely suffer from “burn-out” syndrome and post-traumatic stress disorder (PTSD). Two studies documenting the effect of the pandemic on mental health of oncology professionals were presented at the conference.

• One study looked at 300 oncologists in Western Europe and the United States during the first phase of the pandemic. Two biggest fears reported by the oncologists (almost 75% of participants) were “fear that their patients would get sick” and “fear that their family members would get sick.” Several oncologists opted to live away from their families during their oncology service to protect their families (Symposium 7, Dr. Gabriella Pravettoni).
• In the second study reported at the Keynote Symposium, which included 1570 oncologists from 102 countries, more than 75% of the oncologists reported that they feared contracting COVID-19 (July 21 Keynote, Dr. Solange Peters).

Both these studies highlight the importance of developing adequate mental health support services for healthcare professionals as the effects of the pandemic emerge.

As patients and advocates who work regularly and intimately with oncology healthcare professionals, we must not forget to express our gratitude to all members of the patient care team.

Resources and websites:

1. IASLC’s Guide to COVID-19 and Lung Cancer
2. National Cancer Institute website “Coronavirus: What People with Cancer Should Know“
3. We are following updates provided by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC)
4. Johns Hopkins COVID-19 Resource Center
5. Interactive map of US COVID-19 cases by state
6. The One-Two Punch: Cancer And COVID-19 (an important perspective for cancer patients)
7. You can find information specific to your state or city or town on your health department’s website:
   Directory of state department of health websites
   Directory of local health department websites
8. American Medical Association resources for healthcare providers

GO2 Foundation for Lung Cancer (Amy Moore, PhD – amoore@go2foundation.org)
LUNGevity Foundation (Upal Basu Roy, PhD, MPH – ubasuroy@lungevity.org)
Lung Cancer Foundation of America (Kim Norris – KNorris@lcfamerica.org)
Lung Cancer Research Foundation (Cristina Chin, LMSW, MPH – cchin@lcrf.org)
LungCAN (Kimberly Lester – kimberly@lungcan.org)

The post below is shared with permission. It can also be found on the websites of the lung cancer advocacy organizations listed at the end of this blog post.

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As of July 1, 2020, more than 10 million people worldwide have been infected with SARS-CoV-2, the virus that causes COVID-19. In the United States alone, more than 3 million people have tested positive, as of July 10, 2020. Our knowledge about how the virus affects our immune systems and other organs is continuously evolving. Along with this knowledge, doctors are becoming better at managing patients with a confirmed diagnosis of COVID-19. However, it is important to keep in mind that the virus is still infectious.

In this update, we answer some key questions about the current need for public health measures, testing in light of the recent rise in COVID-19 cases, what the test results means, some recent press on “new strains” of SARS-CoV-2, and finally what this means for herd (community) immunity.

What public health measures can help stop the spread of the virus?

 Current data still suggest the virus is most commonly spread person-to-person, via droplets expelled by talking, coughing, or sneezing while in close face-to-face contact. The virus may also spread via aerosols (smaller droplets that remain suspended in air) but at this point, this has not been clearly established. People can have an active case of the virus and show no symptoms (asymptomatic spread). Until a vaccine is available, we need to take action to prevent transmission of SARS-CoV-2 through these strategies:

• Personal hygiene (e.g., hand washing)
• Testing people to identify cases of active infection
• Using distance or physical barriers to reduce the spread of infectious droplets (e.g., staying home, social distancing, wearing masks, isolating people who are infected)
• Contact tracing (e.g., notifying people when they have been in contact with someone who has active infection)
• Government-level actions (e.g., governmental limits on sizes of gatherings or business capacity; school or workplace closures; stay-at-home orders)
• Travel restrictions (e.g., border closure, enforced quarantine on visitors from infected areas) if required

Should I get tested for COVID-19? Which test is right for me? What do the test results mean?

If you or your loved one suspects that they have been exposed to SARS-CoV-2, and/or have developed the three most common COVID-19 symptoms (fever, cough, and shortness of breath), we recommend you get tested.

Currently, three tests are available for COVID-19. The choice of test depends on whether you suspect that you have an active (existing) infection, or you were infected in the past and want to confirm infection.

More testing will help us to identify more people who have an active case of COVID-19 and may be able to spread the disease, whether or not they have active symptoms. An accurate count of active cases tells us where the virus is currently spreading and hopefully helps us to implement prevention measures in time to limit spread of the disease in that area.

Has the SAR-CoV-2 virus mutated? Is this new mutation more infectious? What does this mean for prevention, vaccines, and treatment?

A preliminary manuscript (which has not yet undergone peer review) describes the emergence of a new mutation seen in a specific gene of the SARS-CoV-2 virus. This mutation, which was first discovered in Europe, is called D614G. It causes an increase in the number of spike proteins in the virus. Since the spike protein is how the virus attaches to human cells, the authors concluded that this mutation makes the virus more infectious. However, it does not appear to make the resulting disease more severe or deadly.  Currently, the real-world implications of this mutation and its impact on the development of vaccines and treatments are still unclear.

Are blood tests detecting coronavirus antibodies more frequently? 

Many countries are using blood tests to look for SARS-CoV-2 antibodies in their populations. Testing of blood serum is called serology. The percentage of individuals in a population that have these antibodies in their blood serum is called seroprevalence. As COVID-19 spreads across the globe, different areas will have different levels of seroprevalence.

The CDC is now conducting large-scale geographic seroprevalence surveys at a number of sites across the country. Initial results from the first six sites showed rates of people who tested positive for SARS-CoV-2 antibodies varied from about 1% (in WA state) to about 7% (in greater NYC area).

Several global seroprevalence studies have been published recently. In Spain, which was hit hard by COVID-19 in the spring of 2020, approximately 5% of people in the 36,000 households tested had antibodies against SARS-CoV-2 (they are “seropositive”—their serum tested positive for antibodies). The seropositive rate is closer to 10% near Madrid but only 3% along the coast. Given that 95% of Spaniards do not have antibodies (seronegative), the authors conclude that it is important to maintain the public health measures described above.

A second study from Brazil also found regional variability in seroprevalence, with an overall seropositive rate of 1.4%. However, surprisingly, some cities along the Amazon had some of the highest rates reported so far, approaching 25%. This finding further counters the argument that SARS-CoV-2 is susceptible to heat, since Brazil maintains a hot, tropical climate.

What about herd immunity?

Herd immunity (or community immunity) occurs when a high percentage of the community is immune to a disease through vaccination and/or prior illness. We currently face several challenges to achieving herd immunity. First, seropositivity rates remain significantly below the ~70% required to achieve herd immunity, even in hotspot areas such as NYC. Second, a growing number of reports suggest that antibody levels fall off significantly as early as 8 weeks after infection (though other features of the immune system may provide some protection).

Some have suggested that public health efforts to reduce transmission are only delaying the acquisition of herd immunity. Sweden has been held up as a model for keeping a country open to develop herd immunity.  However, Sweden serves more as a cautionary tale— it experienced much higher death rates than its Scandinavian neighbors yet was not spared the economic impact of the pandemic.  Various models have suggested that efforts to achieve herd immunity by natural infection (ie, letting the virus run its course without vaccines) would result in over 30 million deaths globally

Letting the virus run its course comes at extraordinary cost in terms of human lives. Further, given the low rates of seropositivity among areas hard-hit by the virus and the rapidly declining antibody levels in individuals, it seems unlikely that we will achieve herd immunity WITHOUT a vaccine.

How risky is returning to “normal” activities?

 These updates are intended to give you the latest evidence on what we know and to provide a framework for you to make your own decisions as we all learn how to navigate this new “normal.” In that spirit, we share this recent graphic that helps assess the relative risk of various daily activities:

Resources and websites:

1. IASLC’s Guide to COVID-19 and Lung Cancer
2. National Cancer Institute website “Coronavirus: What People with Cancer Should Know“
3. We are following updates provided by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC)
4. Johns Hopkins COVID-19 Resource Center
5. Interactive map of US COVID-19 cases by state
6. The One-Two Punch: Cancer And COVID-19 (an important perspective for cancer patients)
7. You can find information specific to your state or city or town on your health department’s website:
   Directory of state department of health websites
   Directory of local health department websites
8. American Medical Association resources for healthcare providers

GO2 Foundation for Lung Cancer (Amy Moore, PhD – amoore@go2foundation.org)
LUNGevity Foundation (Upal Basu Roy, PhD, MPH – ubasuroy@lungevity.org)
Lung Cancer Foundation of America (Kim Norris – KNorris@lcfamerica.org)
Lung Cancer Research Foundation (Cristina Chin, LMSW, MPH – cchin@lcrf.org)
LungCAN (Kimberly Lester – kimberly@lungcan.org)