Table Info

Table 1.

The recommendation in lung cancer management

Setting	Recommendation
Lung cancer screening (LCS)	1- The screening might be delayed 2- Invasive procedures and surgery for patients with intermediate-risk nodules should be deferred and a PET scan and/or nonsurgical biopsy should be preferred 3- For high-risk nodules proceed with an empiric treatment decision without further diagnostic testing
Lung cancer outpatients management	1- Temperature check and questionnaire for detecting symptoms of COVID-19 for patients accessing to the hospital 2- Patients with signs and symptoms highly suspected of lung cancer should be managed within standard pathways, avoiding delays, while radiological investigations can be delayed in other cases 3- Visits may be converted into telemedicine visits during follow up and in patients on active treatment with oral drugs 4- Psychosocial support should be assured and, when possible, converted to telemedicine
Lung cancer diagnosis	1- Diagnostic imaging (e.g., CT, PET) should be scheduled on the same day while preoperative full lung function testing should be avoided 2- Bronchoscopy should be avoided if not necessary and percutaneous procedures should be preferred 3- Mediastinoscopy should be performed at the same time as surgery 4- Virtual modality for the multidisciplinary meeting should be preferred
Management of localized disease in NSCLC patients	1- All patients with a high suspicion or histological diagnosis of lung cancer should undergo surgical resection to avoid delays 2- Patients should be referred to the nearest thoracic surgery center, except for patients with locally advanced lung cancer that should be addressed to high-volume thoracic surgery centers 3- Minimally invasive access should be considered as the first option whenever possible 4- A telephone triage is strongly recommended as well as a nasopharyngeal swab testing for SARS-CoV-2 in the previous 48 h 5- In non-urgent patients affected by COVID-19 infection, surgery should be deferred for at least 14 days and until infection resolution is demonstrated with the repeated negative nasopharyngeal swab test 6- The indication for adjuvant chemotherapy should be strongly considered in young patients (< 65 years old) with resected pT3/T4 tumors or in case of pN2 disease or the presence of negative prognostic features 7- The use of G-CSF a priori in patients treated with platinum-based chemotherapy in neoadjuvant and adjuvant settings could be considered
Management of stage III NSCLC	1- Therapeutic strategies should be set up within a multidisciplinary team 2- For patients who are candidates for perioperative chemotherapy, a neoadjuvant approach should be preferred 3- Concomitant or sequential chemoradiotherapy and possible maintenance with durvalumab (repeated every 4 weeks instead of 2 weeks) should be ensured without delay
Follow-up	1- For stage I NSCLC follow-up imaging and visits should be postponed 2- For stage II or III NSCLC treated with a curative intent with no new symptoms, follow-up imaging can be postponed while visits and clinical check-ups should be maintained preferring telemedicine 3- For stage II or III NSCLC treated with palliative intent with no new symptoms follow-up imaging and visits can be postponed up to 6 months; however, when feasible, telemedicine follow-up visits are recommended almost every 3 months
Lung cancer radiotherapy	1- Radiotherapy treatment should not be delayed, especially when is part of a multimodal approach for curative purposes or represent a palliative treatment while PORT in patients with completed resected NSCLC and PCI in patients with SCLC may be postponed 2- Hypo-fractionating should not replace usual fractionation except for palliative treatment 3- Operable patient with stage I NSCLC should receive SBRT when access to surgery is not available due to surgical capacity issues 4- COVID-19 positive patients should delay radiotherapy until the test for COVID-19 is negative
Management of metastatic disease in NSCLC	1- First-line and second-line cancer treatments in symptomatic patients should not be delayed considering the use of G-CSF 2- At diagnosis, the biological characterization of the disease remains fundamental to direct the correct therapy 3- The schedule of ICIs should be modified to limit clinical visits and in patients treated with ICIs for more than 12–18 months, the delay or omission of some cycles might be considered to evaluate the possibility to stop ICIs after two years 4- In oncogene-addicted diseases, treatment with TKI must be continued preferring telemedicine visits 5- In patients undergoing chemotherapy treatment, it is preferable to switch from intravenous to oral formulations 6- For antiresorptive bone-protective therapy (zoledronic acid, denosumab) a temporary withdrawal should be considered 7- Oncological treatments with a low probability of efficacy should be carefully evaluated and discussed on a case-by-case basis evaluating the risk-benefit ratio 8- Transfusion of blood or platelets should be avoided using dose reduction or delay in chemotherapy administration 9- Imaging assessment: slots for imaging within 6 months from treatment start or in case of suspected progression disease should be performed
SCLC patients’ management	1- Treatment of SCLC remains a priority 2- Oral etoposide can be considered instead of intravenous etoposide to reduce time in hospital 3- In first-line treatment, the addition of the maintenance treatment with an ICI (atezolizumab or durvalumab) might be omitted due to the imitated improvement in OS 4- G-CSF support is strongly recommended for patients with a high or medium risk of febrile neutropenia 5- PCI should be postponed in patients with limited-stage and replaced by close follow-up in patients with the extensive disease while consolidation thoracic irradiation should be avoided 6- The start of a second line should be evaluated case by case with a risk-benefit balance
Palliative care	1- Patients with recurrent pleural effusions should receive evacuative thoracentesis or thoracoscopy with talc poudrage, when indicated 2- In patients with severe dyspnea for central or endobronchial lung cancer, mechanical dilatation, laser to remove obstructions, and airway stenting are recommended 3- Home palliative care should be preferred, whenever possible, through virtual contact with patients, their family members, and home care staff
Management of thoracic NENs	1- Multidisciplinary management remains fundamental in using virtual platforms 2- Home treatments and local pharmacies for drugs supply should be preferred for performing locally radiological or laboratory investigations 3- In patients with active COVID-19 infection, anticancer treatment should be delayed until swab negativization 4- Curative surgery should take precedence over metastasis resection and debulking procedures 5- Palliative radiotherapy should be delayed in asymptomatic patients 6- A cycle delay or omission of a cycle should be individually considered in patients treated with PRRT

PET: positron emission tomography; G-CSF: granulocyte-colony stimulating factor; PORT: post-operative radiotherapy; PCI: prophylactic cranial irradiation; SBRT: stereotactic body radiation therapy; ICIs: immune checkpoint inhibitors; TKI: tyrosine kinase inhibitors; PRRT: peptide radionuclide receptor therapy; OS: overall survival

Declarations

Author contributions

MT and RB contributed conception and design of the study; MT performed literature research; MT, VA, LC, CL, FM, SR and LS wrote the first draft of the manuscript; MT and RB revised the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Ethical approval

Not applicable.

Consent to participate

Not applicable.

Consent to publication

Not applicable.

Availability of data and materials

Not applicable.

Funding

Not applicable.

Copyright

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