key: cord-0906345-qyh1vkgi authors: nan title: COVID-19 Guidance for Triage of Operations for Thoracic Malignancies: A Consensus Statement from Thoracic Surgery Outcomes Research Network date: 2020-04-09 journal: Ann Thorac Surg DOI: 10.1016/j.athoracsur.2020.03.005 sha: 451da2eda2039c3d4d8e28a80e08870b07800731 doc_id: 906345 cord_uid: qyh1vkgi Abstract The extraordinary demands of managing the COVID-19 pandemic has disrupted the world’s ability to care for patients with thoracic malignancies. As a hospital’s COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted - forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical and research organizations have come together to provide a guide for triaging patients with thoracic malignancies, as the impact of COVID-19 evolves as each hospital. The COVID-19 pandemic has forced hospitals to progressively reduce surgical volumes to both minimiie disease transmission within the hospital, and to preserve human and Personal Protectve EEquipment (PPE) and other resources needed to care for COVID-19 patents. In response, many hospitals have abruptly reduced or eliminated electve surgeries. As the COVID-19 burden on a hospital increases, procedures that improve survival may similarly have to be reduced or eliminated (i.e. semi-electve, urgent, and perhaps some emergent operatons). For some cancer patents, surgery may be delayed for months, or even years without negatve conseEquences. However, in other scenarios, failure to perform an indicated cancer surgery in tmely fashion may have long term implicatons on a patent's survivorship or signifcant permanent defcits in their Equality of life. Therefore, cancer patents and the oncology teams that treat them are likely to face difcult decisions between suboptmal management strategies. Thoracic oncology decisions are further complicated by the fact most of the patents with lung, esophageal and other thoracic malignancies would be considered to be a "high risk" group for poor outcomes with COVID-19 (advanced age, emphysema, heart disease). Further, the indicated therapeutc procedures can both impair lung functon (i.e. lung isolaton, removal of lung tssue), and expose clinical teams to aerosoliied viral load (bronchoscopy, double-lumen endotracheal tube placement , airway surgery, laparoscopy and possibly lung surgery partcularly with parenchymal lung leaks). We have assembled a document to ofer guidance, intended to facilitate these difcult decisions when caring for patents with thoracic malignancies during the COVID-19 pandemic (Table 1) . Much of the impact, tmeline, duraton, risks and ultmate recovery from the COVID-19 pandemic remain unknown. In an efort to give context to this triage guide, several assumptons have been made: -Risk of nosocomial infecton (patents and clinicians infected while in hospital) 1-5 and competton for resources (surgical and medical patents) will increase in proporton to the prevalence of hospitaliied COVID-19 patents -The duraton of restricton on electve surgery will last approximately 3 months -Each facility's progression through the phases of care restricton will be variable, but surgeons should be prepared for rapid changes in hospital status (i.e. consider what eligible surgeries could or should be performed as soon as possible) -Surgical leadership are provided with daily updates regarding a hospital's COVID-19 populaton and resource status There are nuances to each patent's management approach (i.e. proceeding with surgery, delaying surgery, or pursuing alternatve treatment) that will impact risk tolerance for both patent and surgeon. Ideally, when traditonal cancer treatment is not logistcally feasible, a patent's care plan will be made with input from a group of clinicians with expertse in thoracic malignancies (i.e. case conference or tumor board). We encourage the use of this multdisciplinary strategy as guidance as appropriate for each individual hospital or clinic setng. Several consideratons may cause a group's consensus approach to difer from what is proposed in Table 1 : -Risk of delay may not be specifcally captured by the outlined descriptors (i.e. tumor may have aggressive growth kinetcs or histology). -Resource limitatons (clinicians, supplies, facilites) afectng surgical, medical and radiaton oncology departments may pose heterogeneous restrictons from hospital to hospital -Clinicians will need to keep in mind the important concept of social distancing in modifying management to limit the number of visits to the hospital for any reason. In additon, because the duraton of surgical volume restricton is unknown (3 months is presumed), patents who are delayed or deferred should be tracked (i.e. a patent registry or database). Consideratons for the database should include the following: -Indicaton if reassessment during the period of delay could infuence care plan (i.e. follow up CT scan). This should be extremely selectve, as access to imaging will likely be increasingly restricted with increased COVID-19 prevalence. -An indicaton of case priority (i.e. frst group, second group, third group) for rescheduling when restrictons are lifed, to best care for patents whose survival may be most impacted by additonal delay. -Preoperatve evaluaton is likely to be impacted (i.e. pulmonary functon testng), and preoperatve screening for COVID-19 is evolving (survey for symptoms, temperature assessment, possible selected testng for COVID-19 where available). -It is possible that the strategies outlined in this document could be replaced as our understanding of uniEque challenges that COVID-19 poses within each country, state, and healthcare environment evolves. -This document is not intended as a guide for other clinical scenarios, epidemics, or pandemics. Transparency regarding the potental risks of deferring or proceeding with an operaton remains a priority. Surgeons should discuss these decisions individually with their patents. Multdisciplinary teams are encouraged to develop alternatve treatment strategies if surgical resecton is declined or infeasible. This initatve is an extension of the American College of Surgeons and Commission on Cancer ters) or patent status (i.e. emergent, urgent, semi-urgent) to avoid confusion, and have instead organiied recommendatons based on the conditons that exist within each hospital ("phases"). There are tmes when the right decision becomes easier -as the impact of the decision evaporates. This is one of those tmes. We hope that this document facilitates the tmely executon, of what are sure to be increasingly difcult decisions. Thoracic 7 . Smaller insttutonal studies have not revealed a clear associaton between the diagnosis-treatment interval and long-term outcomes in patents with esophageal cancer 8 . A delay of greater than 8 weeks between neoadjuvant therapy and surgery for esophageal cancer is not associated with decrement in long-term survival 9 . b Availability of alternatve treatments may vary across health systems and over tme. The decision to pursue alternatve treatment must balance risk of deferring alternatve treatment (chemotherapy and radiaton) with risk of exposure of both patents and staf to COVID-19 infecton. In Phase I, alternatve treatments predominately considered in patents felt to be harmed by delay (i.e. the frst column of table). C At the tme of writng, the risk of mortality with COVID-19 infecton is felt to be higher among patents receiving chemotherapy, but the data is incredibly limited (18 cancer patents in China) 10 . d Although the accuracy of the clinical staging examinaton may be enhanced by invasive staging procedures, the magnitude of survival beneft from superior staging, may be considered by some to be modest. In the setng of strained resources and potental exposure risk to clinical staf from staging procedures (bronchoscopy and mediastnoscopy), treatng a patent based exclusively on a noninvasive staging evaluaton (i.e. imaging alone) is reasonable. e These procedures are currently felt to be associated with a partcularly high potental to disseminate COVID-19. They should be done selectvely, and ideally in patents that have been screened for actve COVID-19 infecton. f There is incomplete data comparing surgery to SABR for early stage lung cancer in patents eligible for surgery. Observatonal data, which is likely biased with patents that were not surgical candidates, suggests a modest survival advantage of surgery (5-15% higher 5-year survival) [11] [12] [13] . g Among presumably highly selected patents, salvage resecton has been associated with reasonable survivorship afer defnitve nonsurgical therapy for esophageal cancer, partcularly if the patent has had a good response by imaging 14, 15 . h Recommended for patents in whom a delay would likely compromise survival (i.e. frst column from Phase I secton) COVID-19: towards controlling of a pandemic Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia Clinical Characteristcs of Coronavirus Disease 2019 in China Characteristcs and Outcomes of 21 Critcally Ill Patents With COVID-19 in Washington State Minimise nosocomial spread of 2019-nCoV when treatng acute respiratory failure Efects of Delayed Surgical Resecton on Short-Term and ong-Term Outcomes in Clinical Stage I Non-Small Cell ung Cancer Defning the Ideal Time Interval Between Planned Inducton Therapy and Surgery for Stage IIIA Non-Small Cell ung Cancer Delay in diagnostc workup and treatment of esophageal cancer Does the tming of esophagectomy afer chemoradiaton afect outcome? Cancer patents in SARS-CoV-2 infecton: a natonwide analysis in China A systematc review and meta-analysis of stereotactc body radiaton therapy for colorectal pulmonary metastases obectomy versus stereotactc body radiotherapy in healthy patents with stage I lung cancer Survival of Primary SBRT Compared to Surgery for Operable Stage I/II Non-Small Cell ung Cancer Surveillance versus esophagectomy in esophageal cancer patents with a clinical complete response afer inducton chemoradiaton Outcome of delayed versus tmely esophagectomy afer chemoradiaton for esophageal adenocarcinoma