Lung Cancer Under Siege in Spain: Timeliness, Treatment, and Survival Before and After the COVID-19 Pandemic

<b>Background</b>: The COVID-19 pandemic prompted concerns about delays in cancer diagnosis and treatment, particularly for lung cancer (LC). We assessed the impact of the pandemic on lung cancer care, diagnostic efficiency, treatment timelines, and short-term survival in a Spanish tertiary hospital. <b>Methods</b>: We performed a retrospective cohort study including 530 patients diagnosed with primary lung cancer from March 2019 to March 2022. Patients were grouped into three cohorts: pre-pandemic (2019), first pandemic year (2020), and second pandemic year (2021). Key intervals-referral-to-diagnosis and diagnosis-to-treatment-along with survival outcomes were compared across cohorts. Multivariate Cox regression identified independent predictors of mortality. <b>Results</b>: LC diagnoses declined by 19% in 2020, rebounding by 42% in 2021. The proportion of patients receiving the first definitive treatment remained stable (~70%). Diagnostic timeliness improved: the median referral-to-diagnosis interval shortened from 19 to 14 days (<i>p</i> < 0.0001), with >80% of patients diagnosed within 30 days throughout all periods. Molecular testing turnaround increased (median 11 to 15 days, <i>p</i> = 0.0226). The diagnosis-to-treatment interval remained unchanged (median 34-35 days). One-year survival improved from 37% (2019) to 43% (2020-2021), and two-year survival from 22% to 30%. In multivariate analysis, only advanced stage and poor ECOG performance status independently predicted mortality; delays in diagnosis or treatment had no significant impact. <b>Conclusions</b>: Despite pandemic-related disruptions, essential LC care and short-term outcomes were largely maintained in our center. Early stage at diagnosis and favorable performance status outweighed the effect of moderate delays. Health system resilience and streamlined care pathways proved critical for sustaining cancer outcomes during the COVID-19 crisis. These findings offer actionable lessons for the Spanish healthcare system and may help guide national preparedness strategies for future oncologic crises.