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Page 4 of 13 Piñeiro et al. J Cancer Metastasis Treat 2021;7:10 I http://dx.doi.org/10.20517/2394-4722.2020.115

The reason why patients with lung neoplasia have a worse evolution is not known, and it is probably
multifactorial. Pro-inflammatory states appear to be associated with a worse prognosis in COVID-19
infection. In particular, levels of interleukin 6 (IL-6) appear to play an important role in SARS-CoV-2
[29]
®
infection . This hypothesis led to the use of IL-6 inhibitors (Tocilizumab ) as a possible treatment for
[32]
[31]
[30]
COVID-19 . The studies by Dai et al. , and Luo et al. , demonstrated that IL-6 levels in patients with
lung cancer and COVID-19 were higher than in SARS-CoV-2 infected patients without a neoplastic disease.
However, we must not forget that lung cancer causes serious alterations in the lung parenchyma and is
[33]
associated with high mortality , and it is described as a risk factor for worse prognosis in pneumonia due
[34]
to influenza and other viruses .
We must be cautious when concluding facts about COVID-19 prognosis and outcome on cancer patients,
given that different treatments or cancer types may cause different responses to SARS-CoV-2 infection, and
many variables and confounders may play different roles. For example, patients suffering from lymphoid
malignancies with severe lymphopenia may have a poorer response to viral infection, while chemotherapy
[35]
induced neutropenic patients may present an attenuated inflammatory reaction to the virus .

ONCOLOGICAL TREATMENT AND ACTIVE SARS-COV-2 INFECTION
The evidence regarding cancer treatment and COVID-19 infection is mixed and contradictory.

A priori, we could expect that chemotherapy, being an immunosuppressive factor, could increase the risk
of infection or lead to a worse prognosis in patients with COVID-19. Some studies support this hypothesis:
[21]
Liang et al. , reported that patients who had received chemotherapy or surgery in the 30 days before
[36]
presenting with the SARS-CoV-2 infection had an increased risk of severe complications. Zhang et al. ,
reported that receiving cancer treatment within 14 days of being diagnosed with COVID-19 could increase
the probability of a suffering a serious complication.

In contrast, an international multicenter study that recruited patients with both COVID-19 and oncological
[37]
disease from Spain, Canada and the United States , did not show a worse evolution of the infection among
those patients who received a specific cancer treatment in the following 30 days. Similarly, in a recently
[38]
published cohort study, Lee et al. found no relationship between the administration of cancer treatment
in the previous days and mortality from COVID-19, while age and comorbidities were associated with a
worse outcome.

[39]
Currently, the American Society of Clinical Oncology (ASCO) and the Spanish Society of Medical
[40]
Oncology recommend suspending chemotherapy treatment in case of COVID-19 infection and assessing
its continuation once the infection has passed.

There is concern about immunotherapy treatment in lung cancer, since the effects on the immune response
[41]
to SARS-CoV-2 infection are not exactly known . The latest recommendations from the American Society
[42]
of Oncology advise evaluating each case individually and with caution .
Target therapies for lung cancer have revolutionized clinical practice in the last few years and have
[43]
improved patient´s survivall . In the first months of the pandemic, in the absence of reliable information,
clinical reasoning and individualized decision-making have taken on special value. That is why the
individual experiences of each professional are important and help in making clinical decisions, thus
[44]
communication is of vital importance. For example, Zhang et al. , reported the case of a Chinese patient
with lung cancer who was positive for COVID-19 and was receiving immunotherapy with Osimertinib.
The patient received treatment with lopinavir and ritonavir for SARS-CoV-2 infection and showed clinical
improvements within 2 weeks, while also presenting with a negative nasopharyngeal exudate PCR test. In