How COVID-19 Affected Management of Lung Nodule Programs

When the COVID-19 pandemic was declared, care of pulmonary patients, particularly those at high risk for developing lung cancer, was forced to change dramatically. Routine lung cancer screenings were no longer considered safe and put on hold for 3 to 6 months. Unfortunately, the run of the pandemic has been longer than 6 months, and routine screenings have been slow to return to normal. Follow-up screenings for patients with identified pulmonary nodules came at considerable risk, and the guidelines for these screenings also changed.

The care needed in the management of patients with pulmonary nodules identified prior to the COVID-19 pandemic has become somewhat controversial. As caregivers for this patient population, we wish to give the best quality care possible. But what defines best quality care at this time? There needed to be a balance of risk vs harm of continuing scanning programs over the potential for contact with the COVID-19 virus, possibly resulting in hospitalization with respiratory failure.

A CHEST expert panel including pulmonologists, thoracic surgeons, and thoracic radiologists was formed to review existing guidelines related to lung screening and nodule evaluations and to make recommended changes.¹ Their recommendations for routine lung screenings were fairly simple: Defer enrollment in lung cancer screening programs for 6 months or more as needed, and delay annual screening follow-ups for Lung-RADS® 1 or 2 patients, as they were considered nonemergent cases. For Lung-RADS 3 patients, the patient and their treating physicians would make a decision together regarding continued care.

The remainder of the team’s recommendations were regarding the care of patients with previously detected pulmonary nodules and included an array of changes such as delaying follow-up scans for nodules smaller than 8 mm. For nodules larger than 8 mm, estimate the probability of malignancy or a Lung-RADS 4 value, and when possible, delay surveillance scans for 3 to 6 months. If this was not possible, biospy needed to be considered.

Then a new patient population joined in the discussion: patients with a positive COVID-19 diagnosis. COVID-19 manifested as ground glass opacities within 2 weeks of diagnosis in approximately 90% of patients infected with SARS-CoV-2 virus, and 5% showed solid nodules or lung thickening.^2,3 Six-month follow-up scans, a recommended standard of care for these patients, showed a significant drop in the number of patients with nodules.⁴ However, at least one-third of patients who survived a severe case of COVID-19 continued to show fibrotic changes in their lungs. A limitation of this study and others at this time is that only 1 follow-up scan at the 6-month postdisease point has been obtained.⁴

The questions now become: What follow-up will be considered the standard for this patient population as time moves forward? How many of these new pulmonary nodules are actually COVID-19 related vs preexisting pulmonary nodules not previously identified because the patient did not meet eligibility criteria for screening? Several reports have described lung cancers being found on scans obtained as follow-up for patient complaints of shortness of breath, prolonged coughing, or positive COVID-19 test results.

There are no answers for these questions at this time, but I propose lung nodule program managers and patient navigators begin to identify how to add these new patients to their rosters and databases. Primary care and internal medicine physicians need to be informed of these issues and be offered the opportunity to have their patients followed by the program, as well as by the physician. Pulmonologists will also continue to be involved, but will welcome back-up as they have with their other patients.

The potential numbers of new patients entering a nodule program may be so large that additional personnel may be needed over time. Program managers will need to consider this as new budgets are developed. The ongoing education for the program and the follow-up care of these patients, in addition to those patients already enrolled in a nodule program, will continue to be addressed by navigators.

COVID-19 has challenged us all, and it seems that it will for some time to come. The way lung screening and nodule follow-up programs manage care will not only impact patient care, but the reputation of the hospitals that sponsor them.

References

1. 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(1):406-415. doi:10.1016/j.chest.2020.04.020
2. Sultan OM, Al-Tameemi H, Alghazali DM, et al. Pulmonary ct manifestations of COVID-19: changes within 2 weeks duration from presentation. Egypt J Radiol Nucl Med.2020;51(1):105. doi:10.1186/s430550920-00223-0
3. Zheng Y, Zhang Y, Wang Y, Huang Z, Song B. Chest CT manifestations of new coronavirus disease 2019 (COVID-19): a pictorial review. Eur Radiol. 2020;30(8):4381-4389. doi:10.1007/s00330-020-06801-0
4. Han X, Fan Y, Alwalid O, et al. Six-month follow-up chest CT findings after severe COVID-19 pneumonia. Radiology. 2021;299(1):E177-E186. doi:10.1148/radiol.2021203153.