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Previous work found that during the first wave of the COVID-19 pandemic, 34% of patients with lung cancer treated with curative-intent radiotherapy (RT) in the UK had a change to their centre’s usual standard of care treatment (Banfill et al. 2021). 17.5% of patients had a different RT dose/fractionation, generally increased hypofractionation as was recommended by UK guidelines (Faivre-Finn et al. 2020). 10.7% of patients with stage 3 lung cancer considered for chemotherapy had it omitted, and 6.7% had a reduced dose. We present the impact of these changes on patient outcomes.

The COVID-RT Lung database was a prospective multicentre UK cohort study including patients with stage 1-3 lung cancer referred for and/or treated with radical RT between April and October 2020. Data was collected on patient demographics, RT and systemic treatments, toxicity, recurrence, and death. The effect of having a change to RT dose/fractionation and developing ≥ grade 3 acute toxicity was assessed using logistic regression and survival was assessed using cox regression, both adjusting for age, sex, performance score, chemotherapy and dose per fraction. The effect of omitting chemotherapy and developing distant relapse or death was assessed using cox regression, adjusting for age, sex, performance score, RT change and dose per fraction.

Complete records for 1280 patients were available. 18 (2.5%) stage 1-2 NSCLC, 48 (10.5%) stage 3 NSCLC and 11 (9.5%) SCLC developed ≥ grade 3 acute toxicity. Patients with stage 3 NSCLC who had a change to their RT dose/fractionation had increased odds of developing ≥ grade 3 acute toxicity (aOR=4.31 (1.96, 9.33), p<0.001), but not death (HR=0.980 (0.688, 1.40), p=0.912). These patients received fewer fractions (mean 17.35 vs 20.53 p<0.001) compared to patients who had no change.

59 (8.4%) stage 1-2 NSCLC, 87 (19.1%) stage 3 NSCLC and 34 (29.3%) SCLC patients had distant relapse, and 90 (12.7%), 123 (27.0%), 34 (29.3%) died respectively. For stage 3 NSCLC patients considered for chemotherapy, 48 (18.1%) had their chemotherapy omitted and 35 (13.2%) had a reduced dose. The patients who had their chemotherapy omitted had a higher rate of distant relapse compared to those who had no change (31.2% vs 14.8%), however multivariable analysis demonstrated no significant increase in distant relapse (HR=1.91 (0.947, 3.84), p=0.0706) or death (HR=1.71 (0.913, 3.19) P=0.0938). Kaplan-Meier curves are presented in Figures 1 and 2.

Our data suggest changes to RT made during the COVID-19 pandemic led to increased ≥ grade 3 acute toxicity for patients with stage 3 NSCLC, but did not affect survival. Patients with stage 3 NSCLC who had their chemotherapy omitted had double the rate of distant relapse, but this was not significant in the multivariable analysis. This data is important as it can inform practice in the context of potential future emergency situations requiring a need to reduce hospital attendances.