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Page 6 of 13 Piñeiro et al. J Cancer Metastasis Treat 2021;7:10 I http://dx.doi.org/10.20517/2394-4722.2020.115
In patients treated with immunotherapy, pneumonitis may appear. In these cases, chest CT usually shows
ground-glass opacities, consolidations, and mixed multifocal lesions, predominantly in the lower lobes.
The most frequent radiological pattern (following the ATS/ERS classification) is that of an organizing
pneumonia in up to 65%-70% of cases, but other patterns can be seen, including non-specific interstitial
pneumonia, hypersensitivity pneumonitis, or interstitial acute pneumonia (diffuse alveolar damage or
[52]
respiratory distress syndrome) . Both the pattern of organizing pneumonia and diffuse alveolar damage
are indistinguishable from COVID-19 infection and in these cases, it is important to know the time of
[53]
onset of the symptoms .

Development of technology, artificial intelligence and deep machine learning may provide a useful tool in
the future for COVID-19 and lung cancer radiological diagnosis, as it has shown to improve the diagnostic
[54]
efficiency of lung cancer .
ACCESS TO HEALTH CARE FOR PATIENTS WITH LUNG CANCER DURING THE COVID-19

PANDEMIC: INITIATIVES IN HEALTH INSTITUTIONS
The health crisis situation due to COVID-19 has caused hospitals and health care systems across different
regions of the world to recommend delaying and reducing outpatient follow-ups to minimize the exposure
to SARS-CoV-2. Patients with cancer in general and with lung neoplasm in particular require periodic
follow-ups and have close contact with the hospital environment. In addition, the complications derived
from cancer treatments and the underlying disease itself often need hospitalization.

[55]
According to a recent study that used a large medical claim database in the United States , cancer-related
procedures (screening, biopsies, therapy) significantly dropped during the year 2020 when compared to the
previous year 2019. Specifically, lung biopsies dropped by 58% and 47% during April 2020 and July 2020,
respectively; lung cancer screening dropped by 75% in April 2020 and outpatient visits dropped by 74% in
April 2020.

[56]
Regarding lung cancer diagnosis, the ASCO recommends strategies such as prioritizing transthoracic
biopsies over transbronchial techniques in order to minimize aerosol generating procedures, and avoiding
invasive approaches such as endobronchial ultrasound for staging, when possible.

The scheduled follow-ups of cancer patients are carried out based on recommendations that often leave
a margin period to the physician´s criteria. In a survey conducted by the Collegio Italiano dei Primari
[57]
Oncologi Medici on 122 oncologists, it was corroborated that the delay in non-urgent outpatient visits
was a widely adopted proactive measure in Italy. Similarly, Wang et al. , published their experience
[58]
of a hospital setting in the province of Sichuan (China) in which outpatient visits were reduced by 71%
and there were no cases of COVID-19. Although it seems logical to think that reducing the frequency of
visits and patient contact with the hospital environment are beneficial measures, long-term studies will
be necessary to evaluate the impact that these protocols will have on the prognosis and survival of cancer
patients.

When deferring follow-ups and scheduled radiologic tests in lung cancer patients, communication is key,
and patient preferences, worries and risk perceptions must be taken into consideration. Evidence-based
and objective information must be given to patients, and decision-making must be individualized. This
aspect was highlighted by the authors of a recently published paper , which discusess the conclusions of
[59]
an expert panel on lung nodule management during the COVID-19 pandemic.