Risks of COVID-19 for surgical cancer patients: The importance of the informed consent process.

RISKS OF COVID‐19 FOR SURGICAL CANCER PATIENTS: THE IMPORTANCE OF THE INFORMED CONSENT PROCESS

Since the World Health Organization (WHO) declared novel coronavirus disease‐2019 (COVID‐19) a global pandemic in March 2020, its rapidly spreading outbreak imposes an unprecedented burden on the effectiveness and sustainability of the health care system all over the world. The global debate regarding the safety and feasibility of continuing to perform elective surgery made most surgical societies suggest that nonessential elective surgery should be postponed. However, now, it is clear that cancer surgery, in general, should not be delayed for most patients. As part of the patients' preparation for surgery, the traditional informed consent now must also address the risks of COVID‐19.

It is unquestioned that, despite the infection effect on practice, the consent process should keep the patient as the main focus. Taking that into consideration, it is the Brazilian Society of Surgical Oncology's (BSSO) objective to present the main aspects that must be covered in a surgical Informed Consent Form (ICF) to properly inform patients how this pandemic have influenced their cancer surgery and perioperative care. Supplement 1 provides the BSSO suggested ICF, adjusted to Brazilian laws and regulations.

THE NEED OF THE SURGERY

The patient must be informed about the necessity of the surgery and all nonsurgical options of treatment. Also, if needed, it is essential to explain to the patient the difference between a time‐sensitive surgery and one that can be safely postponed. Elective procedures can be pragmatically stratified into essential procedures as opposed to no time‐sensitive or discretionary ones. The former implies that there is an increased risk of adverse outcomes by delaying surgical care for an undetermined period. The latter alludes to purely elective procedures.

RISK OF CONTRACTING COVID‐19 DURING HOSPITALIZATION

It is undisputed that consent discussions with patients must cover the added risk of COVID exposure and the potential consequences. Despite the uncertainty regarding the risk of hospital transmission of the novel coronavirus, it seems that the implementation of restricted infectious triage protocols and intentional closure of emergency access may allow some hospitals to be able to remain relatively COVID free. One has suggested that elective surgery should be performed in COVID‐free facilities, and hospital stay should be as short as possible, but most of the centers will have a mixed situation. Surgical patients should be informed that they will be in a “COVID‐free” environment throughout the hospitalization, but patients with COVID‐19 may be hospitalized in separate areas. If surgical patients are going to share the same environment of patients with COVID‐19, they must be informed.

RISK OF WORSE COVID‐19 AND SURGICAL OUTCOMES IF OPERATED DURING THE INCUBATION PERIOD

A retrospective cohort study with 34 operative patients who developed COVID‐19 pneumonia shortly after surgery found that 44.1% needed Intensive Care Unit (ICU), and the mortality rate was 20.5%. Considering only the patients who have had cancer surgery, the mortality rate was 44.4%.

BENEFIT OF PERIOPERATIVE SELF‐ISOLATION

Isolating patients perioperatively reflects an appreciation of the silent phase of COVID‐19, when patients may be contagious, but asymptomatic. The BSSO recommends preoperative self‐isolation to reduce the chances of surgical procedures during the incubation period, especially for patients who will undergo major surgery or have comorbidities. Preoperative self‐isolation also may reduce the chances of a patient infecting the surgical team, especially in head and neck, thoracic, and other high‐risk aerosol‐generating procedures. Preoperative self‐isolation is highly recommended in limited resources areas where preoperative testing for novel coronavirus and/or personal protection equipment is limited.

POSSIBLE RESOURCES AVAILABILITY

Hospitals may face shortage or lack of some provisions because of significant pandemic repercussions at the net of supplies or hospital overload. In general, we recommend not to perform elective surgeries in case there is an undersupply of resources needed for the surgery and postoperative care. Nevertheless, in urgent cases and with the uncertainty of getting all the resources in time, patients must be informed about the facility's capacity (operating rooms, beds, ICUs, and ventilators), health care workers, surgical equipment, and postoperative supplies.

POSSIBLE SURGICAL TEAMS REARRANGEMENT

Health care workers are at risk for coronavirus infections. In Lombardy (Italy), from the country's first case on 31 January to the beginning of March, around 20% of responding health care workers were infected, and some have died. So, team members may be secluded due to COVID‐19 or because of having symptoms while waiting for confirmation. Some hospitals may have a team‐saving policy, and while a surgical team is working, a different one is self‐isolated. Because of that, the patient may be followed by different surgical staff members.

In conclusion, an adequate surgical Informed Consent Form can help to inform patients properly about the risks of COVID‐19 n important part of the surgical cancer patients' preparation.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS

AJAW, APD‐L, and RR: Substantial contributions to the conception and design, analysis, and interpretation of the data; Substantial contributions to the drafting of the article and or critical revision for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved. HSCR, RNP, GB, PHSF, MA, GAL, MJCJ, VND, and AFO: Substantial contributions to the analysis, and interpretation of the data; Critical revision for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved.

Supporting information

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