As an extension of previously published recommendations from the American College of Surgeons (ACS) regarding surgical triage within the context of the current COVID-19 pandemic,1 expert opinion from the Thoracic Surgery Research Network (ThORN), the Commission on Cancer (CoC), and ACS leadership was recently published in The Annals of Thoracic Surgery.2
Given the risks of COVID-19 infection, as well as the limited availability of hospital resources during this crisis, many hospitals are not currently performing elective surgeries or have sharply reduced the number of elective surgeries performed.
Although delays in oncologic surgery can be associated with survival detriments for patients with cancer, the associated risks of surgeries that both impair lung function and potentially expose the surgical team to aerosolized COVID-19 particles also need to be taken into account when surgical triage decisions are made for patients with thoracic malignancies. Other factors that must be weighed in the context of this setting are the older age and high level of comorbidities that frequently characterize patients with these types of cancers.
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Outlined in this consensus document are 3 triage categories: 1) surgery performed as soon as possible, 2) surgery deferred for 3 months (the estimated time for restrictions on elective surgery), and 3) alternative treatments considered, which vary depending on the “phase” of the COVID-19 crisis.
For example, during phase 1 of the crisis — which corresponds to a situation where few hospital resources are diverted to the care of patients infected with COVID-19 — patients with thoracic malignancies classified as having disease that would compromise their survival if surgery were delayed for 3 months or longer would be placed in category 1. Patients that would likely be included in this category could include all patients with esophageal cancers staged TIb or higher, for example.
However, during phase 2 of the crisis, representing a situation where the hospitalized patients are infected with COVID-19 and there is an escalating COVID-19 infection rate, thoracic procedures would be performed as soon as possible only for those patients whose survival over the next several days would be compromised without surgery. Regarding patients with esophageal cancer, only those with an associated perforation would be placed in category 1.
Finally, during phase 3, which describes a hospital system with severely limited resources devoted mostly to patients with COVID-19 patients, only emergent thoracic surgeries — including patients with perforated esophageal cancer characterized by sepsis, would be performed as soon as possible.
This consensus statement emphasized the importance of multidisciplinary input, and inclusion of the patient, in decisions related to the operative management of those with thoracic malignancies during the COVID-19 pandemic. In addition, creation of a registry or database was also recommended. This database could be used to track the timing of reassessment, case priority, and treatment history of patients for whom thoracic surgery was delayed or deferred.
In light of the many uncertainties associated with the current health crisis, the authors of this consensus document stated that “these should not be considered rigid guidelines,” and added that “this guide is not intended to supplant clinical judgement or the development of consensus regarding institutional approaches to cancer treatment.”
References
- American College of Surgeons. COVID-19 and Surgery. Resources for the Surgical Community. https://www.facs.org/covid-19 . Accessed April 13, 2020.
- Thoracic Surgery Outcomes Research Network, Inc. COVID-19 guidance for triage of operations for thoracic malignancies: A consensus statement from Thoracic Surgery Outcomes Research Network [published online April 4, 2020]. Ann Thorac Surg. doi: 10.1016/j.athoracsur.2020.03.005
