Cancer Surgery During COVID-19: How We Move Forward.

While the Coronavirus Disease 2019 (COVID-19) pandemic continues to challenge our healthcare system, providers, and patients in a variety of ways, we have collectively taken steps to mitigate its impact. Implementation of societal social distancing, for example, is thought to contribute to diminished “peak” projections of infections and mortality. As several cities are beginning to experience the downslope of the peak surge in incident cases, the task of developing a pathway toward restarting a semblance of normalcy will soon begin. As surgeons and oncologists, we have developed guidelines for our cancer patients during these extraordinary times in which care has been deferred or postponed based on expert recommendations for preventative and protective purposes.[1] However, neither time nor cancer stops, even during a pandemic, and the approach toward moving forward in cancer care as we recover from COVID-19 is perhaps the most paramount challenge that awaits. The most pressing public health issue results from the backlog of diagnostic and therapeutic measures for cancer patients. Here, we highlight various factors integral to decisions regarding cancer surgery during the COVID-19 recovery period and offer our recommendations (Table 1).

TABLE 1

Factors and Solutions For the Expansion of Cancer Surgery During COVID-19 Recovery

CANCER TIMING

The question of when it is “safe” to begin increasing our surgical volume based on epidemiological measures leads to a myriad of questions. Examples include: Who should have surgery first? What types of surgeries should happen? How long is this pandemic “peak” expected to last? How do we prevent secondary “peaks”? To start, certainly, the underlying principles of treatment used to establish current COVID-19 guidelines should not be abandoned.[1] However, we now find ourselves in this unique scenario where a cyclical reassessment of reinitiating cancer surgeries are falling further out of the scope and concordance with current treatment principles and guidelines. Recent data models have projected the actual impact of delaying cancer surgery, describing a “safe postponement period” (SPP) based on hazards ratios beyond current median wait times for surgery.[2] The authors report that for patients with cancers treated with surgery first, the median SPP was 3 weeks, whereas for cancers treated with neoadjuvant chemotherapy, the SPP was 8 weeks.[2] These findings provide a relative framework to aid in determining the urgency of surgical intervention in the context of continually evolving epidemiological data.

INSTITUTIONAL RESOURCES

Upon emergence from the COVID-19 surge, institutions will need to evaluate their operating room resources as well as ongoing potential risks to patients and providers alike when rescheduling the backlog of cancer cases created by pandemic-related restrictions. This backlog will create extra additional strain on surgical departments and operating room resources. In addition, hospital resources for patients requiring a postoperative inpatient stay will need to be considered including the availability of inpatient beds and healthcare staff. Strategies to mitigate the stress while providing needed surgical care include expanding operating room hours, performing weekend surgeries, and the hiring of temporary or locums staff. However, expansion of operating room schedules beyond standard hours (nights, weekends) should be done gradually and thoughtfully as several negative consequences may occur: operations performed during nonstandard hours have the potential to amplify the physical and mental stress already imposed on the entire surgical staff, disrupt work/home responsibilities such as child care, and limit the readily available help of other surgical partners for a complicated intraoperative situation, should the need arise. As such, we suggest “major” cases or those with the highest likelihood for intraoperative surgical complications be performed during standard business hours, whereas low-risk procedures be performed during nonstandard hours.

Decisions have involved dichotomizing surgical procedures as either elective or urgent/emergent. Unfortunately, this terminology can be misleading. A recent publication has coined the term, “Medically-Necessary, Time-Sensitive (MeNTS)” procedures, which reflects a comprehensive scoring system that was developed and implemented at the University of Chicago taking into account patient, disease, and procedure-related factors when scheduling surgery.[3] This composite score supports proceeding with surgical cases that are favorable in terms of resources, personnel risk, and surgical risk while reserving operating room capacity for urgent/emergent cases such as trauma and emergency general surgery.[3] Furthermore, this system applies to all forms of surgery and can be adapted at hospitals throughout the spectrum of care. Specific to cancer patients, scheduling decisions should incorporate the utilization of a tiered system that prioritizes patients based on risk of cancer progression (eg, SPP) and availability of alternative acceptable treatment options.

Coordination of outpatient care is equally essential to moving forward with cancer care during this recovery process. The emergence of telemedicine has allowed us to deliver high-quality cancer care while maintaining physical distancing. Particularly during a time of epidemiologic uncertainty and rapidly changing prediction models, telemedicine practices should be utilized whenever appropriate and available until the incident “peak” has passed. Many medical decisions can be made in lieu of an in-person visit with the aid of laboratory, pathologic, and radiographic findings, and thus reducing the potential infectious exposures while providing high-quality care. The benefit of outpatient cancer telemedicine may extend well beyond the acute phase of the COVID-19 pandemic, as this technology potentially provides a method to reduce disparities in access to care, improve patient satisfaction, and reduce the time and expense of travel for our patients.

MEDICAL STAFF HEALTH AND AVAILABILITY

The most paramount aspect of emergence from the COVID-19 pandemic is maintaining the protection and health of the workforce. The use of personal protective equipment (PPE) is integral to preventing the spread of disease from both symptomatic and asymptomatic carriers, but supplies in many locations and settings may be limited.[4] Thus, PPE resources must be taken into account when proceeding with cancer surgery, given the team members required for perioperative care processes. Ongoing use of PPE, particularly for high-risk patients and high-risk procedures (eg, aerodigestive), is necessary until incident case levels plateau.

In addition, surgical trainee wellness and safety is of vital importance. In addition to preventative measures (eg, staying home if feeling unwell), surgical residency programs have adapted rotation schedules and rounding policies to decrease trainee time in the hospital and potential exposure. As the volume of cancer surgery increases during COVID-19 recovery, we must remain mindful of the effect of increased surgical volume on potential individual trainee wellness and exposure, in addition to introducing stressors to a system consisting of an already-reduced trainee complement. As operating room hours expand, surgical trainees should not be excluded from participating in these cases, as the cases can serve as valuable learning experiences, particularly during this current time of decreased surgical volume. However, in addition to ensuring resident physical and mental well-being, duty hour rules mandated and recently reinforced by the Accreditation Council of Graduate Medical Education should continue to be obeyed. This will likely require alternative strategies for intra- and postoperative surgical assistance, such as the double scrubbing of cases by 2 attending surgeons or increased reliance on advanced practice providers such as nurse practitioners, physician assistants, and surgical first assistants when surgical trainees are unavailable.

COVID-19 TESTING

Certainly, the risks of major morbidity or mortality from COVID-19 itself in a cancer patient undergoing treatment, whether medical or surgical, should not be understated. Data from Wuhan, China demonstrated that the incidence of COVID-19 among cancer patients at 1 hospital was more than double the incidence of diagnosed COVID-19 cases across the rest of the city.[5] The significance of this is 2-fold, as it demonstrates the susceptibility of cancer patients to COVID-19 infection, but also the risks of acquiring the infection in a hospital, as opposed to community setting.[5] In addition to this higher incident rate, data suggest that cancer patients are at increased risk for COVID-19-related complications. As the accessibility to COVID-19 testing has increased, preoperative COVID-19 testing in all cancer patients undergoing major surgery should be considered, as it will aid in the risk stratification process, the management of PPE, and informed consent. This is particularly pertinent to patients with concurrent risk factors for severe sequelae of COVID-19 infection. Furthermore, testing of all surgical staff should be considered when testing availability is no longer scarce, to prevent asymptomatic viral transmission from health care workers.

CONCLUSIONS

As the dynamic landscape of the COVID-19 pandemic continues to evolve, decisions regarding the timing of surgery in cancer patients remain individualized in the context of patients, providers, institutional factors, and available resources. Although much effort has focused on preventing the spread of this disease, an equal and potentially more amount of work and hardship remains during the emergence from the peak of this pandemic. We can move forward, even in these most difficult of times, and continue to provide safe and high-quality cancer care.