Table 1

Patient, disease, and COVID-19 related factors suggested for consideration for immunotherapy

Suggestions/considerationsAdditional notes
Disease/Tumor-related
Tumor typeEmbedded Imagerisk with NSCLC as compared with RCC and melanoma
Tumor histologyEmbedded Imagerisk with non-adenocarcinoma (including squamous NSCLC) as compared with adenocarcinomas
Disease statusEmbedded Imagerisk with progressive / refractory disease
Burden of diseaseEmbedded Imagerisk with bulky / metastatic disease
Prior receipt of chest radiotherapyEmbedded Imagerisk with history of prior radiotherapy
Genetic markersEmbedded Imagerisk in patients with NSCLC with EGFR mutation. Consider if alternative therapies available
Embedded Imagerisk of HPD with MDM/EGFR gene mutations
Immunotherapy-related
Indication (disease/setting)
Intent of treatmentCurative potential, alternative treatment options
Combination vs monotherapyTwice as much risk with combination immunotherapy regimen
Risk of immunotherapy -related pneumonitisPD-1i > CTLA-4 or PD-L1i; Among PD-1i (pembrolizumab > nivolumab)
Consider FDA-approved four weekly nivolumab for select indications and six weekly pembrolizumab for all indicationsMonitor closely in the initial post-immunotherapy period for harsher irAE
Infection-related
Recent travel, exposures
Ongoing symptom review
Baseline chest CTWhenever applicable
Prevalence of COVID-19 in the area
Baseline (pre-immunotherapy) CD4+Whenever applicable
Baseline (pre-immunotherapy) IgGWhenever applicable
Two COVID-19 NP PCR swab negative (at least 48 hours apart), prior to initiation
Ct value > 30 (and uptrending) among those with prior COVID-19Caution advised when applying published correlations of Ct values with disease severity or as a predictor of active infection and transmissibility
Weekly surveillance COVID-19 PCR testing while on immunotherapy
Patient-related
AgeHigher risk in the elderly
Performance status
Comorbidities
Underlying pulmonary architectureAsthma, COPD
Smoking statusNon-smoker>prior smoker>active
  • COPD, chronic obstructive pulmonary disease; COVID-19, Coronavirus Disease 2019; CT, computed tomography; Ct, Cycle threshold; CTLA-4, cytotoxic T-lymphocyte antigen-4; EGFR, epidermal growth factor receptor; HPD, hyperprogressive disease; IgG, immunoglobulin G; irAE, immune-related adverse events; NP, nasopharyngeal; NSCLC, non-small cell lung carcinoma; PCR, polymerase chain reaction; PD-1i, programmed cell death–1 inhibitor; PD-L1i, programmed cell death ligand 1 inhibitor; RCC, renal cell carcinoma.