Providing cancer surgery in the COVID-19 crisis.

Editor

Cancer surgery is evolving rapidly during the COVID-19 pandemic. Provision of optimal cancer care must be balanced with safe practices for staff and patients. The rapid diversion of resources means inevitable delays in diagnosis and treatment, resulting in a potential increase in preventable cancer deaths. Local hospital policies, government advice and international guidelines regarding cancer management during the COVID-19 crisis have led to an abundance of information that can be overwhelming.

Australia has had a relatively low infection rate with an increased lag-time, allowing increased preparation time. Specific plans for elective cancer surgery have been created in our tertiary cancer centre, using up-to-date information available from countries further along the infection curve. We must balance the increased risk of death from COVID-19 exposure with preventable deaths from undertreating cancer patients. Lack of screening, reduced referrals and limited access to medical staff mean patients will present later. Lack of regular clinical follow-up and surveillance imaging may result in delayed diagnosis of recurrences and missed treatment opportunities.

We advocate continuing with cancer surgery where possible. Priority should be given to symptomatic patients, who may become inoperable if surgery is delayed, and those with cancers lacking alternative modalities. We recommend rationalization of staging and preoperative investigations alongside use of video consultations where possible to limit hospital attendance. Treatment decisions must be individualized to each centre and its available resources but should take into consideration: patient performance status, co-morbidities and the cancer biology; the potential treatment side effects and availability of resources to manage them; the likely therapeutic benefit and possible risks of delaying therapy; and the individualized risk assessment for developing severe complications of COVID-19 infection. Screening for COVID-19 prior to surgery in accordance with local policy is advised. Preoperative testing strategies will evolve as access to rapid testing improves[2,3].

We predict major shifts in diagnostic and follow-up patterns post pandemic. Cancer surgery providers will need to upscale services quickly to deliver care for patients with decreased access during the pandemic peak. Maintaining robust databases and hospital records will limit further delays in care and minimize loss to follow-up. Cancer surgery providers in resourced settings are faced with choices that were unthinkable only months ago. The provision of safe cancer care should be tailored to the patient, the tumour biology and the local COVID-19 burden.