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

Ann Thorac Surg. 2021 Jul;112(1):248-254. doi: 10.1016/j.athoracsur.2020.08.025. Epub 2020 Oct 19.


Background: The novel coronavirus (COVID-19) pandemic has led surgical societies to recommend delaying diagnosis and treatment of suspected lung cancer for lesions less than 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 less than 2 cm.

Methods: A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker with chronic obstructive pulmonary disease presenting for surgical biopsy of a 1.5 to 2 cm lung nodule highly suspicious for cancer during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 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 with delayed resection (0.77 versus 0.74) owing 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 reexamined at each health care facility throughout the curve of the pandemic.

Publication types

  • Case Reports
  • Comparative Study

MeSH terms

  • Aged
  • Biopsy
  • COVID-19* / epidemiology
  • COVID-19* / mortality
  • Carcinoma, Non-Small-Cell Lung / etiology
  • Carcinoma, Non-Small-Cell Lung / mortality
  • Carcinoma, Non-Small-Cell Lung / pathology
  • Carcinoma, Non-Small-Cell Lung / surgery*
  • Computer Simulation
  • Decision Support Techniques
  • Delayed Diagnosis / adverse effects
  • Delayed Diagnosis / mortality*
  • Disease Progression
  • Humans
  • Lung Neoplasms / etiology
  • Lung Neoplasms / mortality
  • Lung Neoplasms / pathology
  • Lung Neoplasms / surgery*
  • Male
  • Pandemics*
  • Pulmonary Disease, Chronic Obstructive / etiology
  • Risk
  • SARS-CoV-2*
  • Smoking / adverse effects
  • Time Factors