Surgical management of cancer during the COVID-19 pandemic

摘要

The ongoing pandemic of COVID-19 has swept the world, infecting >1.2 million and killing >65,000 people worldwide so far.[1] In India, as of now, >3800 people are confirmed to be infected, and 105 have died because of COVID-19.[2] 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.”[3] 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.[3] 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 con