Bridging Lung Cancer Treatment During COVID-19
By B. R. Hartle
In the Spring of 2020, Dr. Garry Austman was diagnosed with lung cancer. It was a shock to him and his family. He wasn’t a smoker. He took good care of himself. Following a distinguished career in dentistry, the diagnosis upended his retirement plans of travel and time with grandkids. But in the early days of his diagnosis, it wasn’t just what was growing in his lung that had him worried, it was what was growing around him.
His diagnosis came as the COVID-19 pandemic was declared.
“The cancer was caught at the right time,” he said from his home in Steinbach. “But in many ways, it was the worst time.”
To be sure, his tumour was caught early. Dr. Austman would have been a good candidate for surgical removal of the cancer, which in normal times would be the first step in the established standard of care.
But these weren’t normal times.
His Thoracic Surgeon, Dr. Biniam Kidane, sat Dr. Austman down and walked through the many ways the pandemic complicated what would be an otherwise more straightforward treatment plan.
Surgical resources across the health system were now strained, and even if limited operating room resources were available, growing evidence showed that lung surgery could result in deadly complications if a person had COVID at the time of surgery. Any surgical intervention for lung cancer would require access to a patient’s airways, meaning the surgery was an aerosol generating medical procedure (AGMP). AGMPs were not recommended given how they exposed health practitioners to the virus, something made clear by horrific reports then emerging from hospitals worldwide. There was also the risk of vulnerable patients catching COVID-19 following surgery, which would increase the likelihood of post- operative respiratory failure. Vaccines were a long way off, and the ability to reliably test for the virus was in its infancy.
The dire situation faced by lung cancer patients consumed Dr. Kidane. He was part of an international thoracic surgery group who convened a series of emergency meetings to discuss ad-hoc treatment guidelines, working to determine how to safely triage and manage lung cancer surgery during the pandemic. At the time, the group considered recommending delays to surgeries for four months, hoping that by then the pandemic would wane. But this measure was far from ideal. It would put patients at risk of the cancer growing, and it was anyone’s guess how the pandemic would unfold.
One day, Dr. Kidane was speaking with colleague Dr. Julian Kim, a Radiation Oncologist with CancerCare Manitoba. They commiserated about how horrible this situation was for lung cancer patients. They couldn’t get over the helpless, morally injurious, feeling of pointing to a tumour on a scan and telling their patients, sorry, but there’s nothing we can do right now.
“That whole experience made me go grey,” joked Dr. Kim.
But they didn’t dwell on that hopeless feeling. They got to work, driven by an idea to challenge the established standard of care, just for the short term, and allow patients to get radiation therapy immediately instead of waiting for surgery.
Specifically, they discussed the use of stereotactic ablative radiotherapy, or SABR, where a very precisely focused shot of high dose radiotherapy would be used as an alternative to surgery. This procedure had been used in Manitoba since 2013 for early stage lung cancers, primarily used for patients who were not candidates for surgery, and had proven effective.
The idea was to use SABR as a way to bridge patients over the limitations on surgery early in the pandemic, managing the cancer until the standard-of-care surgery was available.
It was a controversial suggestion. There was an ongoing debate amongst their professions about whether ablative radiation can offer equivalent cancer control as surgery in the long-term. Despite that debate, the more they discussed the idea the more the benefits became clear.
For the patient, the benefits were that they could access a good treatment and do it as an out-patient, lowering their overall contacts and risk of COVID-19. The risk of COVID-related surgical complications were also avoided.
To the system, the benefits were that it was an effective treatment and staff avoided exposure to an AGMP. It also eased operating room demands for patients that had no immediate alternatives to surgery.
Then there was the broader pursuit of scientific knowledge. Due to the unique approach of using SABR upfront and then removing the cancer surgically at a later date, they could investigate how successful SABR actually was at completely eradicating the cancer, providing data that would otherwise have not been possible outside of the pandemic.
Dr. Kidane and Dr. Kim took this idea to Dr. Bashir Bashir, also a Radiation Oncologist who is head of the Thoracic Disease Site group at CancerCare Manitoba. Dr. Bashir became an immediate champion of the SABR Bridge protocol. Together, the trio of physicians presented the concept to medical leadership, framing it as a revised treatment protocol to meet the demands of the time. They laid out the benefits to patients, the system, and science, and lobbied hard. Shared Health and the University of Manitoba both got behind the idea. They helped with the regulatory side of setting up this protocol and aligning resources between departments. Thanks to the support of the Department of Surgery, Dr. Kidane also secured funding to study the outcomes.
Dr. Austman was one of the first patients to be treated under the SABR Bridge protocol. It did exactly what was hoped, controlling his cancer until surgery was available. “The SABR procedure shrunk the lesion by a third,” he said. “Dr. Kidane was able to perform surgery a few months later, before the second wave overwhelmed hospitals in Manitoba.”
Many patients in Manitoba have since benefited from the SABR Bridge protocol, and the global lung cancer community has taken note.
Dr. Kidane presented preliminary findings last year at the World Lung Cancer Conference, as part of a panel discussion, and in September of 2022 will present the team’s further findings.
Results remain embargoed, but there are a range of benefits he hopes to outline. For one, there was a drive to safely reduce the fractions of radiation required in treating patients with the SABR Bridge. If a patient would normally get three to four doses pre-pandemic, the desire during the pandemic to reduce health system contacts facilitated the adoption of a growing trend to deliver the radiation in one dose. The more reduced the number of fractions, the less patients had to come in contact with the health system. They also looked at the viability of surgery after radiation, and the overall ability of SABR to delay, or to one day potentially eliminate, the need for surgery.
For the team behind the SABR Bridge Protocol, in addition to the benefits to patients, the health system and science, there is also pride in the fact that this homegrown, made- in-Manitoba idea is being watched and adopted by the worldwide thoracic oncology community. If the results are promising, this protocol, born out of the necessity of the pandemic, could challenge the long-held standard treatment of care and speed the adoption of new scientific and treatment paradigms in lung cancer treatment by a decade.
For Dr. Austman, it’s much more personal.
“I am thankful to these fine doctors for their collaboration, their innovation, their skill, and their caring manner. So far, I am 19 months cancer-free, and owe them a great deal of gratitude.”