|Year : 2020 | Volume
| Issue : 5 | Page : 119-122
Surgical management of cancer during the COVID-19 pandemic
Amar Prem, Swapnil Patel, Esha Pai, Durgatosh Pandey
Department of Surgical Oncology, Tata Memorial Centre, HBCH and MPMMCC, Varanasi, Uttar Pradesh, India
|Date of Submission||03-Apr-2020|
|Date of Decision||05-Apr-2020|
|Date of Acceptance||07-Apr-2020|
|Date of Web Publication||25-Apr-2020|
Department of Surgical Oncology, Tata Memorial Centre, HBCH and MPMMCC, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Prem A, Patel S, Pai E, Pandey D. Surgical management of cancer during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3, Suppl S1:119-22
The ongoing pandemic of COVID-19 has swept the world, infecting >1.2 million and killing >65,000 people worldwide so far. In India, as of now, >3800 people are confirmed to be infected, and 105 have died because of COVID-19. This pandemic is leading to a situation where hospital leadership and individual providers are facing difficult decisions regarding the conservation of hospital resources such as hospital and intensive care unit (ICU) beds, ventilators, transfusion capacity, personal protective equipment (PPE), and workforce.
Continuing cancer care amidst this in a developing country like India calls for a completely unique situation. Cancer cells continue to multiply, while decisions of withholding elective treatments are taken. With no timeline in sight, it is a difficult decision for the oncologists to balance the decision to defer treatment with the risk of the disease progression in an individual patient. Nowhere is this dilemma more than in the decision to operate or not for curable cancer even in times of COVID-19 pandemic. The current scenario poses the challenge of risk-benefit analysis of decreasing treatment because of a still-evolving pandemic with unknown epidemiological parameters versus continuing cancer care, which is intensely resource-driven. We herein describe the dilemma, challenges faced, ongoing solutions, and proposed cancer care algorithms in a tertiary cancer center in India.
| Dilemma: Should We Operate at All?|| |
The European Society for Medical Oncology writes, “So far, no systematic reports are available about a higher incidence of COVID-19 infections in patients with cancer.” However, available data indicate that older people, especially with chronic illnesses like cancer, are more vulnerable. Oncological societies of the developed nations have provided guidelines based on their own resources and patient profile, which may not be applicable for resource-constrained countries like India that have an understaffed, overburdened health-care delivery system. Continuing the services needs to strike the right balance between operating with adequate PPEs with a certain accepted risk of exposure.
No clear guidelines are available at present. Responding to the confusion and broad calls for postponing elective surgeries during this pandemic, the American College of Surgeons (ACS) has come up with a document that provides guidance on the management of elective surgeries. An Elective Surgery Acuity Scale has been developed that categorizes elective surgeries into several tiers (from 1a to 3b), depending on the acuity of the surgery and the general health of the patient. Most cancer surgeries fall in the group of tier 3a surgeries; and the recommendation by ACS is not to postpone them. However, this needs to be individualized according to the site, stage, and the potential for disease progression, keeping in mind the resource limitation and workforce shortage in each hospital.
There may be differences in decision making approaches depending on the nature of the hospital or the health-care setting too. The approaches to care in a multispecialty hospital and in a dedicated cancer center would be different. Multispecialty hospitals need to be geared to receive COVID-19 patients and to respond to a potential situation of increasing numbers of patients who would require critical care for COVID-19 pneumonia. In such hospitals, conservation of resources and workforce for such a purpose is critical. In contrast, the dedicated cancer centers are not expected to deal with COVID-19 patients, except those cancer patients who incidentally have also got infected. Such centers may continue to deliver cancer care as per resource and workforce availability. However, oncologists need to be well aware that there might be severe resource constraints in the case of a pandemic outbreak at their local place. Hence, a graded response is perhaps the optimal response to an evolving situation. A dedicated cancer center may continue to deliver elective cancer care (including performing surgeries) in a limited fashion based on resource or workforce availability but should be prepared to respond to an extraordinary situation as and when it arises.
Cancer surgeries being elective are not essentially non-emergent always. There is always a chance of disease progression in case of postponement. Hence, decisions need to be rationalized. For example, patients with differentiated thyroid cancers, parotid tumors, premalignant lesions like dysplastic colonic polyps can wait for a few weeks to months without much alteration in their outcome. Similarly, patients with hormone-sensitive breast and prostate cancers can be started on hormonal therapy, and surgery can be deferred. However, patients with visceral cancers such as those of lung, esophagus, stomach, and pancreas have a smaller window of opportunity; and making a decision to postpone such surgeries may result in a greater ethical and moral dilemma.
Similar dilemmas arise while making a decision in patients with early stage versus locally advanced operable malignancies. Those with early-stage disease can wait in this pandemic period with less risk of progression to inoperability; at the same time, they are the cohort of patients who derive the maximum benefits from timely surgery. Locally advanced cases where there is a chance of progression to inoperability or involvement of important organs need to be addressed on priority. Overall, the picture calls for rational decision making on a case-to-case basis, considering the local factors affecting patient management.
| Challenges at Hand|| |
- The limited supply of resources (PPEs for caregivers, ventilator and ICUs) which might be required in case of an uncontrolled pandemic
- Limited cancer centers across a nation which have been locked down indefinitely making access to cancer care difficult
- Never-ending surgical waitlist of patients having completed neoadjuvant therapy versus the ones awaiting upfront surgery
- Difficulty in basic necessities such as travel, accommodation, and food both for the patients and their accompanying persons
- Difficulty in diagnostic facilities, especially nuclear medicine (positron-emission tomography scans) due to limited isotope availability
- Heterogeneity of the disease across different organs and histologies requiring specific changes in individual management algorithms
- Managing surgical emergencies such as intercostal drainage, tracheostomy, bleeding, and obstructions
- Difficulty in liaising with ancillary services and inter-departmental referrals
- Preoperative testing of patients undergoing surgery with already limited testing facilities in the community
- Limited availability of blood products with decreased routine blood donations.
Shared decision-making in multidisciplinary meetings has its importance now much more than ever before. High volume centers providing cancer care need to come up with institutional policies which need to be dynamic and compliant with instructions from local and national government authorities.
| What We Have Done So Far?|| |
- Holding interdisciplinary meetings everyday-formulating and reviewing policies which are dynamic. We decided to have a graded response as per the need rather than a one-time decision
- Have formed a medical COVID response team which screens the patient and family at the entrance. Any patient or attendant found suspicious of COVID-19, according to the Indian Council of Medical Research guidelines is sent in an ambulance to the nearby designated COVID testing center [Figure 1]
- Offering teleconsultation to the scheduled patients and triaging leading to reduced outpatient department visits, thus reducing travel
- Continuing diagnostic services for patients who are undergoing diagnostic and staging workup
- Holding multidisciplinary team discussions with a minimum number of doctors, one from each discipline, with the patient being called in only in cases where clinical examination directly impacts the decision-making. We ensure the regular safety measures of sanitization, masks, and adequate distancing at all times. At some centers, such discussions are being carried on the virtual network using e-applications like Zoom. We have yet not resorted to such measures but will consider it in future when the need arises
- Reducing interdepartmental referrals as far as possible
- Continuing surgeries for patients with fewer/controlled comorbidities which require limited postoperative stay
- Continuing emergency surgical services
- Avoiding laparoscopic surgeries unless essentially indicated, due to suspected aerosol generation though the evidence is still being generated for the same
- Robotic surgery can be considered an option as it reduces direct contact with the body fluids with a requirement of fewer personnel in the operation theater (OT). Early postoperative recovery and discharge after robotic surgery (in some cases) can be beneficial in terms of low bed occupancy during a time when every resource is valued. However, this might be a challenge in a developing country like ours, where robotically trained personnel are few with this facility being available at very few centers. The evidence for oncological adequacy of this approach is still being generated for most malignancies currently. Hence, given our situation and resource availability, we do not propose robotic surgery, especially when there is proven exposure inside the OT at the time of intubation, irrespective of the surgical approach
- Rescheduling patients requiring major surgeries with anticipated intraoperative blood requirements and probable prolonged postoperative stay like pancreatoduodenectomy, hepatectomy, esophagectomy, etc. This is the most contentious issue and a painful decision
- Voluntary blood and blood product donations from hospital staff
- Staggering and reducing the workforce to decrease the chances of exposure-have formed two teams with one team working for a week at a time.
|Figure 1: Workflow for the management of COVID 19 cases and suspects at Homi Bhabha Cancer Hospital, Varanasi HBCH, Varanasi: Homi Bhabha Cancer Hospital, Varanasi, SSH, BHU: Sir Sunderlal Hospital, Banaras Hindu University, DDU: Pandit Deen Dayal Upadhyay Hospital, Varanasi. OPD: Outpatient department, IPD: Inpatient department, VTM: Viral transport media; VRDL: Viral Research and Diagnostic Laboratory, at IMS, BHU (Institute of Medical Sciences, BHU)|
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| When Operating a Patient With Suspected Covid-19 Infection?|| |
- Ensuring complete protective gear and PPEs across all caregivers inside the OT and ICU
- Minimum required staff in the OT with minimal mobility
- Specific precautions while intubation like using image-guided systems like C-MAC®
- Laparoscopy surgeries should be avoided
- Electrocautery should be used with minimum setting and should be accompanied by continuous suction
- OT needs to be cleaned with peroxyacetic acid following surgery
- OT needs fumigation for an hour, at least.
| Unaddressed Issues|| |
- Gallbladder and pancreatic malignancies requiring major resource utilizing surgeries which have a narrow therapeutic window cannot be postponed for a long time given the low response rates to neoadjuvant treatment strategies
- Running the risk of operating asymptomatic but potentially COVID-infected patients until the lack of routine testing of all preoperative patients
- No consensus on adequate PPE for health-care personnel manning the outpatient clinics
- Uncertain timeline of the COVID-19 pandemic.
| When the Pandemic Settles|| |
- Need for increased work hours and operative facilities to address the postponed operative load with the already overburdened system
- Organizing blood donation camps
- Need for appropriate referral and continued triage among the various cancer facilities sharing the workload.
We all need to understand that this is an unprecedented situation, which is worsened with the unpreparedness. No one knows the best way forward. We need to keep the morale of patients and health-care workers high during this time. Hopefully, as a team, we will come out of this pandemic in a much better way.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kimmig R, Verheijen RH, Rudnicki M, for SERGS Council. Robot assisted surgery during the COVID-19 pandemic, especially for gynecological cancer: A statement of the Society of European Robotic Gynaecological Surgery (SERGS). J Gynecol Oncol 2019;31:e59. [doi: 10.3802/jgo. 2020.31.e59].