The COVID-19 global pandemic is changing the practice of oncologic surgery. Accustomed to fighting cancer with all available means, surgeons are now being asked to delay treatment or make use of alternate strategies to conserve resources. Telemedicine is being widely employed. We present our thoughts on this topic and where we might be in the next several months.
The COVID-19 outbreak has affected healthcare systems on an unprecedented worldwide scale. Though it is not primarily a surgical disease, the impact COVID-19 has on the availability of healthcare resources has had a profound impact on the delivery of surgical care. As surgeons we are accustomed to treating our oncologic patients with all available means. Timely aggressive surgery, chemotherapy or radiation are all modalities that we employ after multidisciplinary discussion and collaboration. The reality that COVID-19 patients can overwhelm our hospitals and fully consume resources like ventilators and personal protective equipment has changed how we care for our oncology patients. The physical distancing measures needed to curtail the spread of the virus have changed how we meet our patients and collaborate with our colleagues.
A number of societies have released guidelines for oncologic surgical care including the American College of Surgeons (ACS) and the Society for Surgical Oncology (SSO) [1, 2]. We recommend that all surgeons review the guidelines that pertain to their areas of practice. These guidelines represent expert opinion assuming a 3–6 month “pause” on normal surgical practice . They triage oncologic surgery including consideration of available critical resources (i.e. beds, ventilators, transfusion capacity, personal protective equipment) and coordination of care . It is becoming clearer that COVID-19 is having a variable impact on national and regional levels. The delivery of oncologic surgery must then be considered in the context of each hospital individually.
One aspect of the pandemic that may ultimately be of value to the surgical community is the expanded role of audio and video office visits. Currently we, and many others, are doing much of our typical in-office patient visits virtually [3, 4]. In general, the adoption of this format by the US medical community has been slow . Out of necessity we have embraced it rapidly and widely. Although less than ideal for some situations (palpating a rectal cancer), we are finding that so much can be done virtually. Wounds can be reasonably examined for infection. The ability to place-shift the patient encounter also has potential huge upsides. Rural patients have the ability to be “seen” at major academic teaching centers. Complex patients could more easily search out additional opinions. The barriers we have had for this technology (i.e. reasonable reimbursement) have been dramatically lowered. Our state is one of eight that does not have parity laws in place requiring insurance coverage of telemedicine services; however, the Telemedicine Act has been proposed which would require coverage of telemedicine services that would be covered when delivered in person by the same provider . Now that this has become the new normal, when we roll back physical distancing measures, we anticipate continuing these practices for an expanding portion of our patients and hope to see improvement in the regulation and reimbursement of telemedicine services.
Another area that is unique to oncologic surgery is the involvement of many different specialties on tumor boards and how they function to influence patient care. These meetings have very quickly moved to the online virtual format. On a much more frequent scale, discussions are considering neoadjuvant treatments where possible, including discussion of alternatives to surgery whenever appropriate. We have noticed more participation in our tumor boards, as members are no longer required to be physically present. As we begin to reopen our operating rooms, it is important to discuss the priority of how the backlog of oncologic cases gets cleared.
Questions remain about surgical technique in the COVID-19 era. There have been questions raised about the conduct of laparoscopic or robotic surgeries, given that there is evidence that other viruses can be aerosolized in surgical smoke or into insufflation gas used to maintain pneumoperitoneum [6, 7]. However, there is no evidence that the COVID-19 virus aerosolizes in this manner. Consensus recommendations currently suggest treating the virus as though it does aerosolize in order to best protect patients and staff and to perform open, not laparoscopic or robotic surgery, on any known or suspected COVID-19 patients. Recommendations also include testing all potential surgical patients for COVID-19, as testing becomes available. Unfortunately, our ability to rapidly and reliably test or screen our patients for COVID-19 remains a challenge, though we are typically seeing improvements each week. Precautions to consider for laparoscopic and robotic surgery include using the lowest possible insufflation pressure and electrocautery settings, minimizing or eliminating the use of energy devices, minimizing Trendelenburg positioning, not venting gas from ports into the room and using smoke evacuator or suction devices to clear smoke and to desufflate at the end of a case prior to port removal or specimen extraction [6–8].
Our institution has continued to perform oncologic surgery without modification. We were fortunate enough to have maintained an adequate supply of protective equipment and have not seen the full depletion of our ventilators or ICU patient capacity. We realize that many other facilities have not been as fortunate. We have yet to encounter performing oncologic surgery on patients known to be infected with COVID-19. Eventually this will happen, and we need to monitor how this disease impacts our patients’ outcomes.
Fear of coming to the hospital during this pandemic is a major issue for many patients. We continue to observe patients delaying their own surgical care; however, it is not yet certain if this is statistically significantly increased from usual rates in our patient population. This phenomenon may be contributed to by the large increase in unemployment rates leading to many patients losing their healthcare coverage, as we have seen this factor into patients postponing surgeries since the start of the pandemic. In the final 2 weeks of March 2020, nearly 10 million people filed new claims for unemployment benefits . By the end of June 2020, it is projected that an additional 47 million will become unemployed. Of these 47 million people, it is estimated that more than 7 million of them will lose their health insurance, not including the millions of family members that are covered on the same insurance plan. Thus, it is inevitable that loss of health insurance will impact patients’ access to timely medical and surgical care.
As before the introduction of the COVID-19 pandemic, there should continue to be a multidisciplinary approach to deciding individual patient care plans involving the temporal relationship between chemotherapy, radiation and surgery. While the ACS guidelines include the discontinuation of elective surgery, it remains necessary for oncologic treatment and intervention to be timely in order to prevent the progression of disease and prevent delays to definitive treatment. Questions remain to be answered regarding the correct approach to oncologic surgery within the COVID-19 pandemic: how long can “elective” oncologic surgeries be delayed? Should there be changes to the sequence of treatment that would be done in the absence of COVID-19, in order to delay surgery? Should the operative plan be altered to decrease operating time even if it means additional surgery for the patient in the future or the sequelae of living with an ostomy? Virtual tumor boards are likely here to stay, as are virtual office visits. As we learn more about COVID-19 and encounter more surgical patients infected with it, guidelines will continue to change and some of these questions may be answered.