Fatal Massive Hemoptysis in a Patient with Delayed Diagnosis of Lung Adenocarcinoma Due to COVID-19 Pandemic

Abstract

Since 2005, the number of lung cancer deaths in the United States has decreased1 due to advances in therapeutics and early detection. The COVID-19 pandemic has affected the prognosis of patients with lung cancer by delaying elective diagnostic procedures. A 66 year old man with past medical history of tobacco and polysubstance abuse initially presented to the emergency department with bilateral pedal edema. Chest imaging showed a right apical, spiculated cavitary mass. The patient missed his initial scheduled biopsy appointment and wanted to wait until pandemic subsided to reschedule. Ten weeks later, he presented to the hospital with rightsided sharp chest pain, associated with hemoptysis. CT-guided biopsy confirmed the diagnosis of adenocarcinoma. Cardiothoracic surgery was consulted, and the patient was initially planned to undergo surgical resection, however his functional status declined while pursuing pre-operative workup. He had progressive worsening hemoptysis, despite radiation treatment, requiring multiple transfusions of blood products. Interventional radiology performed bronchial artery embolization with interval improvement, however he progressed requiring endotracheal intubation with endobronchial blocker placement. Bleeding continued despite local treatment and family decided on palliative extubation. The COVID-19 pandemic contributed to delayed diagnosis of lung cancer. Analysis of 20 institutions in the United States showed a 46.8% decrease in new lung cancer diagnoses in April 2020 versus April 20192. In Korea, three university hospitals found a significant increase in patients with stage III-IV non-small cell lung cancer compared to prior years3. UK Health Service data modeling predict 4.8-5.3% increased lung cancer related mortality from pandemic delayed diagnosis5. In our case, the diagnosis was delayed due to the patient's uncertainty about accessing the medical system during a pandemic. This is not uncommon-the pandemic has been cited as a reason for refusing breast lesion biopsy4. Clinicians need to be aware of this fear and make efforts to reassure patients of the additional safety protocols in place. The American College of Surgery recommends that procedures for high risk cancers, such as lung cancer, are high acuity on the Elective Surgery Acuity Scale and diagnosis and staging to start treatment not be delayed, if feasible, during the pandemic6,7. Lung cancer may be uniquely impacted by pandemic staffing shortages as pulmonologists are deployed to surging ICUs. Our patient delayed care during a surge and did not have a risk/benefit discussion with a clinician. This highlights the need to develop additional patient outreach systems to ensure timely access to care during a pandemic.