Modeling the Impact of Delaying the Diagnosis of Non-Small Cell Lung Cancer during COVID-19

Shipe, Maren E.; Haddad, Diane N.; Deppen, Stephen A.; Kozower, Benjamin D.; Grogan, Eric L.

Background The novel coronavirus (COVID-19) pandemic has led surgical societies to recommend delaying diagnosis and treatment of suspected lung cancer in lesions <2 cm. Delaying diagnosis can lead to disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a suspicious lung nodule <2 cm. Methods A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker with COPD presenting for surgical biopsy of 1.5-2.0 cm lung nodule highly suspicious for cancer during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after three months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival. Results Immediate surgical resection resulted in a similar but slightly higher 5-year overall survival when compared to delayed resection (0.77 versus 0.74), due to the risk of disease progression. However, if the probability of acquired COVID-19 infection is greater than 13%, delayed resection is favorable (0.74 vs 0.73). Conclusions Immediate surgical biopsy of lung nodules suspicious for cancer in hospitals with low COVID-19 prevalence likely results in improved 5-year survival. However, as the risk of perioperative COVID-19 infection increases above 13%, a delayed approach has similar or improved survival. This balance should be frequently re-examined at each healthcare facility throughout the curve of the pandemic.