Safe cancer surgery during the COVID- 19 pandemic.

To the editor.

As the global incidence of COVID- 19 disease is increasing dramatically, healthcare systems worldwide started to suffer in terms of its capability to manage affected people and the ability to provide standard treatment for critically ill patients in a safe environment. Healthcare resources have been rearranged to manage the influx of a large number of patients requiring intensive monitoring and mechanical ventilation. Thus, as many other countries, Turkey Ministry of Health published a circular informing to all physicians to discontinue every intervention, except urgent and cancer surgeries. As health care providers, we are currently facing a great challenge to assist all infected patients and, at the same time, treat urgent and cancer patients. Liang et al reported that patients with cancer are more likely to be infected by the virus because of their immunodepressed state induced by their cancer, their chemotherapy and their surgery. Authors proposed postponing of adjuvant chemotherapy or elective surgery in endemic areas. The question is on how the oncological impact of deferring surgical care can be balanced against the added mortality risk of a severe respiratory infection with COVID- 19.

On March 11, the first COVID- 19 patient was officially declared in Turkey. Since then, everything has changed at our hospital. All scheduled surgeries have been suspended except cancer surgeries. Our hospital has 412 beds, 42 of which are in intensive care units. We reserved a 25 service beds and 12 intensive care beds for urgent and cancer patients. Other wards and intensive care units served full capacity COVID- 19 patients.

Between March 17 and April 17, 1447 COVID- 19 patients were treated in our hospital. At the same time, forty patients with cancer were operated safely. The median age of the patients was 63 years (range 31–91 years); 60% of the patients were male. Six patients were operated due to gastric cancer, seven were colorectal cancer, 10 were breast cancer, two were pancreas cancer, two were thyroid cancer, one was esophageal cancer and other 12 were liver metastases (colorectal cancer). Three patients with colon cancer had emergency surgery due to obstruction. One patient with gastric cancer was operated urgently due to perforation. All patients were followed for 30 days after surgery. No patient resulted COVID- 19 positivity nor had respiratory symptoms and nor positive chest X-ray or CT.

We hope our findings inform the global community about management of oncological surgery during a pandemic. Safe cancer surgery is possible during the pandemic when necessary precautions are taken. Otherwise postponed cancer surgery can lead to conditions, such as bowel obstruction or perforation and also lead to undesirable results such as opening a colostomy.

Finally, ideal management for cancer patients during the COVID- 19 outbreak is not evident; the approach to cancer patients can be flexible and tailored to patients' status, hospitals' capacities and physicians’ experience. Physicians must keep in mind that beyond any scientific predictions, the risk of unavailability of necessary care in cancer treatment might be harmful than the COVID- 19 infection for the cancer patients.

Declaration of competing interest

All authors declare that no potential financial and non-financial conflicts of interest.