Guidelines for delaying cancer surgery during COVID-19


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March 26, 2020: Cancer surgeries may need to be delayed as hospitals are forced to allocate resources to an increase in patients with COVID-19, says the American College of Surgeons, as it issues a new set of recommendations in reaction to the crisis.
Most surgeons have already reduced or stopped performing elective operations, ACS notes, and recommends that surgeons continue to do so to preserve the resources needed to care for critically ill patients during the COVID-19 pandemic. The new clinical guide for triage of elective surgical cases during the pandemic includes recommendations for cancer surgery, as well as for procedures that are specific to certain types of cancer.
"These triage guidelines and joint recommendations are issued as it appears that we are entering a new phase of the COVID-19 pandemic with more hospitals facing a potential boost beyond their resources to care for critically ill patients," said the Director. ACS Executive David B. Hoyt, MD, in a statement.
"ACS will continue to monitor the landscape for surgical care, but we believe this guidance document provides a good basis for surgeons to begin enacting these classification recommendations today to help them make the best possible decisions for their patients during COVID-19" , said.
For cancer surgery, which is often not elective but essential for treatment, ACS has issued a general guide for evaluating patients, taking into account the acuity of the local COVID-19 situation.
First, decisions about whether to proceed with elective surgeries should consider the resources available from local facilities. The parties responsible for preparing the facility to administer coronavirus patients should share information at regular intervals on the limitations of local resources, especially personal protective equipment (PPE), which is being depleted in many jurisdictions. For example, if an elective case has a high probability of needing postoperative care in the ICU, it is imperative to balance the risk of delay with the need for availability for patients with COVID-19.
Second, the coordination of cancer care should use virtual technologies as much as possible, and facilities with tumor panels may find it useful to locate multidisciplinary experts by virtual means, to assist in decision-making and to establish classification criteria.


Three phases of the pandemic

The ACS has also organized decision-making in three phases that reflect the sharpness of the local situation of COVID-19:

Phase I. Semi-urgent environment (Preparation phase): few patients with COVID-19, hospital resources not exhausted, the institution still has ventilation capacity in the ICU and COVID-19 trajectory not in rapid escalation phase

Phase II. Urgent setup: many patients with COVID-19, limited ICU and ventilator capacity, limited operating room supplies

Phase III All hospital resources are allocated to patients with COVID-19, without ventilation capacity or ICU, operating room supplies exhausted; patients who are likely to die within hours if surgery is postponed

Breast cancer surgery

The ACS also issued a specific guide for various types of tumors, including the guide for breast cancer surgery.
For phase I, surgery should be restricted to patients who are likely to experience compromised survival if not performed within the next 3 months. This includes patients completing neoadjuvant treatment, those with T2 or N1 ERpos / PRpos / HER2 negative stage tumors, patients with triple negative or HER2 positive tumors, discordant biopsies that are likely malignant, and removal of a recurrent lesion.
Phase II would be restricted to patients whose survival is threatened if surgery is not performed in the next few days. These would include incision and drainage of the breast abscess, evacuation of a hematoma, revision of an ischemic mastectomy flap, and revascularization / revision of an autologous tissue flap (autologous reconstruction should be deferred).
In Phase III, surgical procedures would be restricted to patients who may not survive if the surgery is not performed within a few hours. This includes incision and drainage of the breast abscess, evacuation of a hematoma, revision of an ischemic mastectomy flap, and revascularization / revision of an autologous tissue flap (autologous reconstruction should be deferred).

Colorectal Cancer Surgery

The orientation for colorectal cancer surgery is also divided into the three phases of the pandemic.
Phase I would include cases requiring surgical intervention as soon as possible, while acknowledging that the condition of each hospital will likely evolve over the next two weeks. These patients would include those with near-obstructive colon cancer or rectal cancer; cancers that require frequent transfusions; asymptomatic colon cancers; rectal cancers that do not respond to neoadjuvant chemoradiation; malignant tumors with risk of local perforation and sepsis; and those with early stage rectal cancers who are not candidates for adjuvant therapy.

Phase II encompasses patients who need surgery as soon as possible, but acknowledge that the hospital condition is likely to progress in the coming days. These cases include patients with near-obstructive colon cancer where stenting is not an option; those with near-obstructive rectal cancer (must deviate); cancers with high transfusion requirements (hospitalization); and cancers with evidence pending local perforation and sepsis.
All colorectal procedures typically scheduled as routine should be delayed.
In Phase III, if the facility status is likely to progress within hours, the only surgery that should be performed would be for perforated, obstructed, or actively bleeding cancers (dependent on inpatient transfusions) or those with sepsis. All other surgeries must be deferred.

Thoracic cancer surgery

Thoracic cancer surgery guidelines follow those for breast cancer. Phase I should be limited to patients whose survival may be affected if surgery is not performed within the next 3 months. These include:

Cases with solid or predominantly solid lung cancer (> 50%) or suspected lung cancer (> 2 cm), clinical negative node

Lung cancer with positive nodes

Post-induction therapy cancer

T1b or greater esophageal cancer

Chest wall tumors that are potentially aggressive and not manageable by alternative means

Stent to obstruct esophageal tumor

Stages to start treatment (mediastinoscopy, diagnostic VATS for pleural dissemination)

Symptomatic mediastinal tumors.

Patients enrolled in therapeutic clinical trials.

Phase II would allow surgery if survival was affected by a delay of a few days. These cases would include non-septic perforated esophageal cancer, a tumor-associated infection, and the treatment of surgical complications in a hemodynamically stable patient.
All thoracic procedures considered routine / elective would be deferred.
Phase III restricts surgery to patients whose survival will be compromised if they do not undergo surgery in the next few hours. This group would include perforated esophageal cancer in a septic patient, a patient with a threatened airway, sepsis associated with cancer, and management of surgical complications in an unstable patient (active bleeding requiring surgery, airway dehiscence, anastomotic leak with sepsis)
All other cases would be deferred.


Other types of cancer

Although the ACS does not have specific guidelines for all types of cancer, some are included in its general recommendations for the specialty.
For gynecological surgeries, ACS lists cancer or suspected cancer as indications that a significantly delayed surgery could cause "significant harm."
Delays are generally not recommended for neurosurgery, which would include brain cancers. In pediatrics, most cancer surgeries are considered "urgent," where a delay of days to weeks could be detrimental to the patient. This would include all solid tumors, including initial biopsy and resection after neoadjuvant therapy.

Medscape Medical News


American College of Surgeons. COVID-19: Elective Case Classification Guidelines for Online Surgical Care. Published online March 24, 2020.

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