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Management of Cancer Surgery Cases During the COVID-19 Pandemic: Considerations

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Management of Cancer Surgery Cases During the COVID-19 Pandemic: Considerations Ann Surg Oncol https://doi.org/10.1245/s10434-020-08461-2 EDITORIAL – HEALTH SERVICES RESEARCH AND GLOBAL ONCOLOGY Management of Cancer Surgery Cases During the COVID-19 Pandemic: Considerations David L. Bartlett, MD1, James R. Howe, MD2, George Chang, MD, MS3, Aimee Crago, MD, PhD4, Melissa Hogg, MD5, Giorgos Karakousis, MD6, Edward Levine, MD7, Ajay Maker, MD8, Eleftherios Mamounas, MD9, Kandace McGuire, MD10,11, Nipun Merchant, MD12, David Shibata, MD13, Vance Sohn, MD14, Carmen Solorzano, MD15, Kiran Turaga, MD, MPH16, Richard White, MD17, Anthony Yang, MD18, Sam Yoon, MD19, and for the Society of Surgical Oncology 1Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA; 3Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX; 4Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; 5Surgery, NorthShore University HealthSystem, Evanston, IL; 6Department of Surgery, University of Pennsylvania, Philadelphia, PA; 7Surgical Oncology/ General Surgery, Wake Forest University, Winston-Salem, NC; 8Surgery, University of Illinois Cancer Center, Chicago, IL; 9Surgery, Orlando Health UF Health Cancer Center, Orlando, FL; 10Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA; 11Massey Cancer Center, Virginia Commonwealth University, Richmond, VA; 12Department of Surgery - Surgical Oncology, University of Miami School of Medicine, Miami, FL; 13Surgery, University of Tennessee West Cancer Center, Memphis, TN; 14General Surgery, Madigan Army Medical Center, Lakewood, WA; 15Surgery, Vanderbilt University, Nashville, TN; 16University of Chicago, Chicago, IL; 17Carolinas Medical Center, Charlotte, NC; 18Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; 19Memorial Sloan-Kettering Cancer Center, New York, NY In these unprecedented times of COVID-19, surgical The Society of Surgical Oncology (SSO) asked each of oncologists are being forced to consider triage and ration- the SSO Disease Site Work Group Chairs and Vice Chairs ing of cancer surgery cases, for a number of reasons: to provide their recommendations for managing care in their specialties, assuming a 3- to 6-month delay in care. • the potential shortage of personal protective equipment, These recommendations are summarized below. such as masks, gowns, gloves; The SSO supports the need for treatment decisions to be • the potential shortage of hospital personnel due to made on a case-by-case basis. The surgeon’s knowledge sickness, quarantine, and duties at home; and understanding of the biology of each cancer, alterna- • the potential shortage of hospital beds, intensive care tive treatment options, and the institution’s COVID-19 unit (ICU) beds, and ventilators; policies in place at the time the patient will be scheduled • the desire to maximize social distancing among our for surgery all need to be taken into consideration. patients, colleagues, and staff. The information below is based on the opinions of individuals who are experts within their respective areas of cancer and who are members of the Society’s various Disease Site Work Groups. BREAST CANCER Ó Society of Surgical Oncology 2020 Defer surgery for at least 3 months for atypia, prophy- First Received: 31 March 2020 lactic/risk-reducing surgery, reconstruction, and benign breast disease. D. L. Bartlett, MD e-mail: [email protected] D. L. Bartlett et al. Ductal Carcinoma In Situ • For rectal cancer, neoadjuvant radiation component, highly consider a short-course (5 9 5 Gy) regimen • Defer for 3–5 months. (versus standard long-course chemotherapy). • Treat estrogen receptor (ER)? ductal carcinoma in situ • Delay surgery for locally advanced rectal cancer post- (DCIS) with endocrine therapy. neoadjuvant therapy for 12–16 weeks. • Monitor monthly for progression. • ER- DCIS high priority for surgery when deemed safe by the health system. ENDOCRINE TUMORS Most uncomplicated endocrine operations can be Estrogen Receptor? Invasive Breast Cancer (Stage I– delayed. III) Diseases and presentations that might qualify for more • Treat with endocrine or chemotherapy in a neoadjuvant urgent surgery (i.e. within approximately 4–8 weeks during fashion as deemed appropriate by multidisciplinary the current pandemic), include the following. tumor board recommendations. Thyroid Triple-Negative/HER2? Invasive breast cancer • Thyroid cancer that is a current or impending threat to life, those that are threatening morbidity with local • Treat with neoadjuvant chemotherapy for t2? and/or invasion (e.g. trachea, recurrent laryngeal nerve), n1? disease. aggressive biology (rapidly growing tumor or recur- • Consider primary surgery as urgent if the patient is rence, rapidly progressive local-regional disease, unable to undergo chemotherapy or the tumor is small including lymph nodes). and surgical information could inform chemotherapy • Severely symptomatic Graves’ disease that has not decisions. responded to medical therapy. • Goiter that is highly symptomatic or is at risk for Post-neoadjuvant Chemotherapy impending airway obstruction. • Open biopsy with diagnostic intent for suspected • Delay post-chemotherapy surgery for as long as pos- anaplastic thyroid cancer or lymphoma. sible (4- to 8-week window) in those patients for whom adjuvant systemic therapy is unclear/not indicated. Parathyroid Unusual Cases/Surgical Emergencies/Special • Hyperparathyroidism with life-threatening hypercal- Considerations cemia that cannot be controlled medically. • Patients with progressive disease on systemic therapy, angiosarcoma, and malignant phyllodes tumors should Adrenal be considered for urgent surgery and should not be • Adrenocortical cancer or highly suspected adrenocor- delayed. tical cancer. • Pheochromocytoma or paraganglioma that is unable to COLORECTAL CANCER be controlled with medical management. • Cushing’s syndrome with significant symptoms that is • Defer surgery for all cancers in polyps, or otherwise unable to be controlled with medical management. early-stage disease. • Generally, functional adrenal tumors that are medically • Operate if obstructed (divert only if rectal), perforated, controlled, and asymptomatic non-functional adrenal or acutely transfusion-dependent. adenomas, can be delayed. • Proceed with curative intent surgery for non-metastatic colon cancer. • Consider all options for neoadjuvant therapy, including Neuroendocrine Tumors utilization of total neoadjuvant therapy for rectal can- • Symptomatic small bowel neuroendocrine tumors cer, and to consider neoadjuvant chemotherapy for (NETs; e.g. obstruction, bleeding/hemorrhage, signifi- locally advanced and metastatic colon cancer. cant pain, concern for ischemia). Management of Cancer Surgery Cases During the COVID-19 Pandemic • Symptomatic and/or functional pancreatic NETs that carefully documented (e.g. photography, marking of the cannot be controlled medically. site by the patient or caregiver) to facilitate identifica- • Lesions with significant growth or short doubling times. tion at a later time. • Cytoreductive operations and metastasectomy should • Surgical management of T3/T4 melanomas ([ 2mm generally be delayed but should be considered on an thickness) should take priority over T1/T2 melanomas individual basis. (B 2 mm thickness). The exception is any melanoma that is partially/incompletely biopsied in which a large clinical residual lesion is evident. Gross complete GASTRIC AND ESOPHAGEAL CANCER resection is recommended in this case. • cT1a lesions amenable to endoscopic resection should • Sentinel lymph node biopsy is reserved for patients preferentially undergo endoscopic management. with lesions [ 1 mm and, as resources become scarce, • cT1b cancers should be resected. set aside for 3 months. • cT2 or higher tumors and node-positive tumors should • Manage clinical stage III disease with neoadjuvant be treated with neoadjuvant systemic therapy. systemic therapy. If resources permit and the patient is • Patients finishing neoadjuvant chemotherapy can stay not suitable for systemic therapy, consider resection of on chemotherapy if responding to and tolerating clinical disease in an outpatient setting. treatment. • Metastatic resections (stages III and IV) should be placed on hold unless the patient is critical/symp- Defer surgery for less biologically aggressive cancers, tomatic or unresponsive to systemic therapies such as gastrointestinal stromal tumors (GISTs), unless (assuming surgical resources are available). Single- symptomatic or bleeding. dose palliative radiation may be considered for bulky disease to alleviate symptoms if OR capacity is limited. HEPATO-PANCREATO-BILIARY CANCER Operate on all patients with aggressive hepato-pancre- PERITONEAL SURFACE MALIGNANCY ato-biliary malignancies as indicated. • Operate on patients with malignant bowel obstruction if • Including pancreas adenocarcinoma, gastric cancer, a palliative procedure is feasible. cholangiocarcinoma, duodenal cancer, ampullary can- • As cytoreductive surgery/hyperthermic intraperitoneal cer, metastatic colorectal to the liver. chemotherapy (CRS/HIPEC) can take unique levels of • In cases where systemic chemotherapy is indicated in resources, special consideration should be made for addition to surgery, consider neoadjuvant chemother- proceeding with these cases. apy as a means of postponing surgery. • Defer CRS/HIPEC for low-grade appendiceal muci- • If responding to and tolerating neoadjuvant nous neoplasms
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