Incidence of Brain Metastases in Patients Diagnosed With Stage IV NSCLC During the COVID-19 Pandemic

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Computed tomography and/or magnetic resonance imaging demonstrated that 39% of patients diagnosed with stage IV non–small cell lung cancer (NSCLC) presented with de novo brain metastases during the COVID-19 pandemic. This percentage was higher than the historic rate of 25%, and many of these patients were asymptomatic for brain metastases. These findings were presented by Cui et al at the European Lung Cancer Virtual Congress 2021 (Abstract 180P).

Study Methods

Researchers investigated whether reduced diagnostic procedures and late presentation during the COVID-19 pandemic may have led to late diagnosis of NSCLC and an increase in diagnoses of de novo brain metastases.

The investigators defined the baseline incidence of brain metastases in asymptomatic patients among the consecutive patients with stage IV NSCLC referred to the Royal Marsden Hospital from June to November 2020. This study was a descriptive analysis of prospectively collected data.

Among the 172 patients with NSCLC identified, 95 (55%) patients underwent brain imaging and 77 (45%) patients did not.

Comparison of these cohorts showed that more patients undergoing brain imaging had good Eastern Cooperative Oncology Group performance status (ECOG PS) and received systemic therapy compared to those without brain imaging.

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In the imaging cohort, 17%, 72%, and 11% of patients were PS 0, 1 to 2, or 3 to 4, respectively, whereas in the nonimaging cohort 6%, 48% and 35% were PS 0, 1 to 2, or 3 to 4. PS data were not available for 10% of patients in the nonimaging cohort.

Patients in the imaging and nonimaging cohort were of similar age; the median age was 70 (range = 34–95) vs 74 (range = 47–91) years. Regarding smoking history in the imaging vs nonimaging cohorts, 21% vs 16% of patients were never-smokers, 78% vs 66% were ex- or current smokers, and data were not available for 1% vs 18% of patients. In the respective cohorts, 72% vs 58% of patients had adenocarcinoma, 12% vs 16% had squamous cell carcinoma, 11% vs 5% had other subtypes, and 5% vs 21% did not have available subtype data.

A genomic variant was detected in 55% of patients undergoing imaging whereas a variant was observed in 32% of those not receiving imaging; no variant was detected in 29% vs 40%, and variant data were not available for 16% vs 27%.

Presence of Brain Metastases

Of the patients undergoing imaging, 37 (39%) patients had brain metastases on imaging. Of these, 65% had brain metastases symptoms and 35% were asymptomatic. In patients with one to five brain metastases, 44% of patients were asymptomatic, as compared to 10% of patients with six or more brain metastases (P = .07).

Of the 95 patients undergoing brain imaging, 34% had brain metastases symptoms; of those patients, brain metastases were confirmed on imaging in 66% of patients. However, brain metastases were detected on imaging in 21% of asymptomatic patients.

Regarding treatment, 27% of patients with brain metastases received stereotactic radiosurgery; in this cohort, five patients were asymptomatic. Among the remaining 27 patients with brain metastases, 12 were treated with a tyrosine kinase inhibitor, 4 received palliative radiotherapy, and 1 patient was monitored. In addition, eight of these patients were unfit for treatment and two died.

No systemic treatment was administered to 30% of patients with brain metastases due to poor ECOG PS in 17 patients and patient wishes in 4.

In the cohort of patients not receiving imaging, systemic treatment was administered to 42% of patients; no systemic treatment was given due to poor ECOG PS in 28 patients and due to patient wishes in 2.

6-Month Follow-up

By February 1, 2021, after a median follow-up period of 6.2 months, 57 (33%) patients had died. In patients with baseline brain imaging, there was no difference in survival between patients with de novo brain metastases and those without (hazard ratio [HR] = 1.38, 95% confidence interval [CI] = 0.72–2.97, P = .37). In patients with de novo brain metastases, there was no difference in survival between those who were symptomatic vs asymptomatic (HR = 0.46, 95% CI = 0.16–1.30, P = .14). There was also no difference in survival between those who had baseline brain imaging and those that did not (HR = 0.85, 95% CI = 0.50–1.46, P = .56).

In total, 3 of 10 (30%) patients with brain metastases who received stereotactic radiosurgery died, compared to 12 of 27 (44%) patients with brain metastases who did not receive stereotactic radiosurgery (P = .48). In patients with brain metastases who received tyrosine kinase inhibitor therapy only, 2 of 12 (17%) died. In total, 26 (15%) patients underwent subsequent brain imaging, of which 4 (15%) confirmed development of new brain metastases.


During this period of the COVID-19 pandemic, the incidence of de novo brain metastases was higher: 39% in patients with stage IV NSCLC compared with historical rates of 25%, the investigators found.

In addition, many patients (35%) with brain metastases were asymptomatic.

These findings suggest that brain imaging should be considered in all patients with a new diagnosis of stage IV NSCLC. The investigators proposed that further study should be given as to whether early diagnosis and treatment of brain metastases affects survival.

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