A Multidisciplinary Team Approach for Triage of Elective Cancer Surgery at the Massachusetts General Hospital During the Novel Coronavirus COVID-19 Outbreak.

Over the last few weeks, the surge in novel COVID-19 coronavirus cases in the United States has resulted in unprecedented disruptions to daily life in hospitals and beyond. Among elements in hospitals that have come under major disruption are elective surgical cases, defined as cases that are planned in advance and not urgent (require operation within hours) or emergent in nature.

Recently, in an attempt to preserve hospital resources, including ventilators, personal protective equipment, critical care resources, and blood product availability, the American College of Surgeons has provided guidance for triage of elective surgical procedures (Elective Surgery Acuity Scale).[1] In addition, nonoperative treatment of common urgent surgical conditions such as appendicitis, cholecystitis, and diverticulitis has been proposed, including antibiotics or nonsurgical intervention as the mainstay of therapy.[2]

However, what has not fallen neatly into these categories is the approach to surgical management of oncologic operations. While most cases being admitted to the operating room today fall under the auspices of life-threatening or limb-threatening operations, cancer surgery is arguably life-threatening if not conducted within a “reasonable” time-frame. In addition, prioritization of resources away from cancer patients, who themselves are immunocompromised and debilitated, continues to raise major ethical dilemmas that continue to evolve. Finally, for these same reasons, questions arise as to the COVID-19 risk to cancer patients undergoing surgical procedures.

Fortunately, the availability of alternative perioperative and neoadjuvant therapies for some cancer patients, such as cytotoxic systemic therapy, immunotherapy, radiation, and regional treatments, allows for safe deferment of operation, and may even be utilized as definitive therapies with respectable outcomes. Unfortunately, however, these are sophisticated decisions that require an individualized and tailored, multidisciplinary, approach and with serious consequences for patients, including both short-term and long-term outcomes and their emotional state.

As such, we aim to provide a basic outline of our approach to the management of gastrointestinal (GI) and hepatopancreatobiliary cancers at the Massachusetts General Hospital. In the hope of providing a reproducible framework based on our early experience, we are using this approach to aid with decision-making for our patients. It is important to note, however, that the situation remains fluid, and continues to rapidly evolve as the pandemic evolves and resources dwindle. As such, the approach will likely continue to evolve.

At this time, all GI oncology patients for whom a surgeon proposes an operation in the next 7 to 10 days are submitted for a 2-hour multidisciplinary midweek video conference. In attendance at the virtual conference are medical oncologists, radiation oncologists, surgeons, gastroenterologists, interventional radiologists, and other providers (eg, residents, nurse practitioners, ward managers, etc.) with a vested interest in presented cases. The conference is open to all hospital affiliates including regional satellite facilities. The individual surgeon leads the clinical discussion with a radiologist providing the review of images, which are projected across the virtual main platform screen. A thorough discussion of alternative therapies, consequences of delay of surgery, and resource utilization ensues. The conversation is moderated by a senior member of the multidisciplinary team. Finally, the chief of the department or section makes the final decision as to approval or denial of each case based on the consensus recommendation from the multidisciplinary panel.

In accordance with the Massachusetts General Hospital hospital guidelines that were devised based on the Massachusetts of Department of Public Health guidelines, current recommendations for proceeding with oncologic surgery include:

Cancers in patients who have completed their neoadjuvant therapy and are in the window of resectability, and for whom nonoperative temporizing maneuvers are not possible.

Aggressive cancers that will grow significantly in 2 months for which other therapies cannot be used to temporize (eg, triple-negative breast cancer).

Second part of staged procedures in which the first stage has been completed (eg, patient has an open wound awaiting reconstruction).

Diagnostic procedure required to allow initiation of appropriate cancer therapy (eg, diagnosis of lymphoma or diagnosis of metastatic cancer).

Acute symptoms (eg, GI bleeding, bowel obstruction, dysphagia and/or aspiration risk, airway encroachment) for which alternative therapy is not appropriate.

Additional guidelines serve to guide the conversation, such as those provided recently by the Society of Surgical Oncology.[3] The advantage of our approach includes 1) providing patients with a consensus recommendation at an unprecedented time, and 2) offloading the decision-making responsibility from individual surgical providers given the ethical and personal considerations associated with patient care. This strategy increases objectivity, transparency, and consistency across all cases presented. In addition, the approach to cases is current, reflects resources at the hospital during that period of time, and may change on a week-to-week basis (eg, fluctuations in bed capacity and blood product availability). The multidisciplinary committee does not currently involve an ethics expert or subcommittee, although may benefit from inclusion of one in coming weeks as decisions become more difficult and resources become more limited.

COVID-19 testing guidelines differ among hospitals and regions, and are dependent on many factors that continue to evolve on a national scale. Active COVID-19 patients are not considered for surgery unless that surgery is thought to be life-saving during that admission. We are not yet actively screening asymptomatic, ambulatory, patients routinely prior to cancer surgery. However, in operations with significant risk of “aerosolization of respiratory secretions,” preoperative testing is provided. At this time, this has not included laparoscopic cases, although such cases are discouraged if open techniques can be performed.

At this time, we continue to accept referrals for new cancer patients, most commonly using a virtual telehealth platform. Established patients are also incorporated into the virtual platform and both new visits and established patients continue to receive our standard multidisciplinary care. The telemedicine multidisciplinary platform has been extremely well received by all participating providers.

Despite the severe consequences of the pandemic, we continue to feel a responsibility to address cancer care for our existing patients and new referrals. We are hopeful that sharing our efforts will allow other systems facing limited resources due to COVID-19 to address the surgical needs of their cancer patients.