key: cord-0967220-tlmntkhe authors: Gazivoda, Victor; Greenbaum, Alissa; Roshal, Joshua; Lee, Jenna; Reddy, Lekha; Rehman, Shahyan; Kangas‐Dick, Aaron; Gregory, Stephanie; Kowzun, Maria; Stephenson, Ruth; Laird, Amanda; Alexander, H. R.; Berger, Adam C. title: Assessing the immediate impact of COVID‐19 on surgical oncology practice: Experience from an NCI‐designated Comprehensive Cancer Center in the Northeastern United States date: 2021-03-25 journal: J Surg Oncol DOI: 10.1002/jso.26475 sha: e9ffa018163ae52a4fde96e5f626500ba2f31293 doc_id: 967220 cord_uid: tlmntkhe BACKGROUND: The effects of the coronavirus disease 2019 (COVID‐19) pandemic on surgical oncology practice are not yet quantified. The aim of this study was to measure the immediate impact of COVID‐19 on surgical oncology practice volume. METHODS: A retrospective study of patients treated at an NCI‐Comprehensive Cancer Center was performed. “Pre‐COVID” era was defined as January–February 2020 and “COVID” as March–April 2020. Primary outcomes were clinic visits and operative volume by surgical oncology subspecialty. RESULTS: Abouyt 907 new patient visits, 3897 follow‐up visits, and 644 operations occurred during the study period. All subspecialties experienced significant decreases in new patient visits during COVID, though soft tissue oncology (Mel/Sarc), gynecologic oncology (Gyn/Onc), and endocrine were disproportionately affected. Telehealth visits increased to 11.4% of all visits by April. Mel/Sarc, Gyn/Onc, and Breast experienced significant operative volume decreases during COVID (25.8%, p = 0.012, 43.6% p < 0.001, and 41.9%, p < 0.001, respectively), while endocrine had no change and gastrointestinal oncology had a slight increase (p = 0.823) in the number of cases performed. CONCLUSIONS: The effects of the COVID‐19 pandemic are wide‐ranging within surgical oncology subspecialties. The addition of telehealth is a viable avenue for cancer patient care and should be considered in surgical oncology practice. physicians (58.6% surgeons) from March 27 to April 10, 2020 found that a majority of physicians had altered cancer treatment plans. 11 The primary reasons for surgeons altering care were conservation of personal protective equipment, institutional mandates, and professional society recommendations. Several retrospective studies of this initial period of the pandemic confirm alterations in treatment, a decrease or delay in oncologic surgical procedures, cancer screening, clinic visits, and a significant decline in newly identified patients with the six most common types of cancer (breast, colorectal, lung, pancreatic, gastric, and esophageal). [12] [13] [14] [15] [16] [17] The prognostic outcomes of these alterations of cancer practice have yet to be determined. The purpose of this study was to measure the immediate impact of the COVID-19 pandemic on surgical oncology clinical practice and operative volume amongst subspecialties. We hypothesized that surgical subspecialties including a large proportion of outpatient or same-day operations would be disproportionately affected. Endocrine. "Pre-COVID" era was defined as the months before the pandemic (January and February 2020) and "COVID" was defined as the initial months when COVID precautions were instituted (March and April 2020). Institutional guidelines for surgical deferment were created based on national surgical society guidelines. A virtual weekly conference call with hospital administration was initiated in March 2020 to prioritize operations from all surgical services. The primary outcomes were clinic visits and operative volume by surgical oncology subspecialty. Secondary outcomes included proportion of in-person versus telehealth clinic visits, patient demographics, benign versus malignant indications, hospital disposition, resident or fellow operative involvement, and inpatient length of stay. Descriptive statistics were performed and when appropriate, χ 2 , Fisher's exact, and Student's t-test were used to compare pre-COVID and COVID cohorts. (390 pre-COVID and 307 COVID, 21.3% reduction) and Gyn/Onc (776 pre-COVID and 683 COVID, 12% reduction). Follow-up visits in Melanoma/Soft Tissue (215 pre-COVID and 122 COVID, 43.3% reduction), Breast (322 pre-COVID and 178 COVID, 44.7% reduction) and Endocrine specialties (48 pre-COVID and 33 COVID, 31.2% reduction) were more impacted ( Figure 3 ). All specialties experienced statistically significant decreases in the number of new patient visits in the COVID period (ranging from 14.5% to 42.1%), with the greatest decreases seen in Breast, Melanoma/Soft Tissue, and Endocrine specialties ( Figure 4 decrease in the number of surgeries scheduled at the initial visit evaluation in the COVID months (p < 0.001). New clinic patient demographics, diagnoses, and disposition within each subspecialty can be found in Table S1 . The statistically significant decreases in the proportion of benign disease encounters were seen in Gyn/Onc and Table 2 . There were no major changes in age, sex, or ethnicity between the two groups. The number of cases performed for benign disease decreased significantly (13.9% from 20.0%; p = 0.049) as did the number of outpatient operations (63.1% from 71.9%; p = 0.018). There were no changes in resident or fellow surgeon involvement in cases in the COVID period. Operative patient demographics, diagnoses, operation type, and disposition within each subspecialty are documented in Table S2 . The Both the Surgical Society of Oncology (SSO) and the COVID-19 Pandemic Breast Cancer Consortium released guidelines for breast cancer management and triage. 5, 7 Based on these recommendations, our institution implemented a protocol for breast cancer care. Recommendations were to proceed with cancer surgery as indicated, encouraging the following when appropriate: breast conservative therapy over mastectomy, same day discharge for mastectomy, neoadjuvant endocrine therapy, and to combine multidisciplinary visits with medical and radiation oncology. During the immediate COVID period, we found a decrease in total patient visits in Breast surgery, with a 42.1% decrease in new patient visits, as well as a decrease in follow-up visits. There was a significant decrease in benign disease encounters (32.7% vs. 17.5%, p = 0.021) and 12 patients week (p = 0.010). 12 In addition, a study published by a group from Massachusetts General Hospital demonstrated that breast imaging, breast surgery, and genetic counseling experienced significant declines after the COVID-19 outbreak. 18 In this study, the decline in breast surgery began first, with an average weekly decline of 20.5%, yet breast imaging experienced the most significant overall reduction. Consistent with these findings, our institution also saw large Initial data from MDACC demonstrated that median gynecologic oncology case volume per week decreased from 25 to 7 (p < 0.001) during the COVID-19 pandemic. 12 In a retrospective study of three affiliated New York Presbyterian hospitals, 39% of patients with gynecologic cancer experienced modification (delay, change, or cancellation) to their treatment during the first 2 months of the pandemic. 13 Of the patients who received modifications to therapy, those scheduled for surgery were the largest group affected (67.4%), followed by those scheduled for systemic treatment (21.5%), and those scheduled for radiation (18.8%). In a survey of over 300 members of the SGO, practice volume reportedly dropped 61.6% since the beginning of the pandemic, with most cancellations being provider initiated. 19 It was also reported that more than 94% of responders proceeded with gynecologic cancer operations with the exception of Grade 1 endometrioid endometrial adenocarcinoma. When evaluating our practice patterns pre and post-COVID restrictions, there was no difference in the percent of patients scheduled for surgery after initial clinic visit (38.6% vs. 40.0%). This most likely reflects those patients who met criteria for gynecologic cancer operations who proceeded to surgery. The significant decrease in total gynecologic oncology surgical volume is likely explained by the few high acuity patients who were able to undergo acceptable alternative oncologic treatment or delay referral and therefore surgery due to benign or undetermined disease. Our institution utilized resources from the SSO and a consortium of major US cancer centers to develop our protocol for melanoma, squamous cell carcinoma, basal cell carcinoma, and soft-tissue sarcomas. 5, 6 For low-risk cutaneous malignancies, definitive procedures were generally deferred for at least 3 months. For indeterminate or high-risk cutaneous lesions, in-office procedures were advised when possible. Low- The SSO and American Association of Endocrine Surgeons released recommendations and statements during the COVID-19 pandemic for triaging elective endocrine surgery, which were utilized to create an institutional endocrine specific COVID protocol. 5 Telehealth is defined as the use of electronic information and communications technologies to provide and support health care There are several important limitations to our study. First, we are reporting retrospective data from a single institution during the initial months of the COVID-19 pandemic in the United States, which may not be generalizable to all populations or to the subsequent months. Results were largely based on chart review of institutional data, so findings are influenced by the degree and accuracy of documentation by healthcare providers. Lastly, this is a descriptive report of initial trends in response to change in management and practice in surgical oncology at an NCIdesignated cancer center during the COVID-19 pandemic, long term sequalae of these interventions are currently unknown. The initial impact of the COVID-19 pandemic on surgical oncology practice appears to be disproportionate within various surgical oncology subspecialties. Future studies should correlate these immediate effects with long-term oncologic outcomes. National, local, and institutional guidelines have impacted standards of care and aided providers in the management of patients in both the inpatient and outpatient settings. Telehealth services are a feasible method to provide outpatient oncologic care and should be strongly considered in surgical oncology practice. The authors have no disclosures and there is no funding source. The data that support the findings of this study are available from the corresponding author upon reasonable request. Victor Gazivoda http://orcid.org/0000-0002-2923-6573 Clinical features of patients infected with 2019 novel coronavirus in Wuhan United States COVID-19 Cases and Deaths by State ASCA Foundation. State Guidance on Elective Surgeries COVID-19: Recommendations for Management of Elective Surgical Procedures Management of cancer surgery cases during the COVID-19 pandemic: considerations Short-Term Recommendations for Cutaneous Melanoma Management During COVID-19 Pandemic Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium Surgical Considerations for Gynecologic Oncologists During The COVID-19 Pandemic American Association of Endocrine Surgeons. Thoughts on elective endocrine surgery from AAES members COVID-19 guidance for triage of operations for thoracic malignancies: a consensus statement from Thoracic Surgery Outcomes Research Network Cancer management during the COVID-19 pandemic in the United States Flattening the curve in oncologic surgery: impact of Covid-19 on surgery at tertiary care cancer center Gynecologic oncology care during the COVID-19 pandemic at three affiliated New York City hospitals Changing practice patterns in head and neck oncologic surgery in the early COVID-19 era Head and neck oncologic surgery in the COVID-19 pandemic: our experience in a deep south tertiary care center Impact of COVID-19 on cancer care: how the pandemic is delaying cancer diagnosis and treatment for American seniors Changes in the number of US patients with newly identified cancer before and during the coronavirus disease 2019 (COVID-19) pandemic Breast imaging, breast surgery, and cancer genetics in the age of COVID-19 Adjusting to the new reality: evaluation of early practice pattern adaptations to the COVID-19 pandemic Current use of telemedicine for post-discharge surgical care: a systematic review Telemedicine: patient-provider clinical engagement during the COVID-19 pandemic and beyond Safety of surgical telehealth in the outpatient and inpatient setting Telehealth provides a comprehensive approach to the surgical patient Telemedicine based remote home monitoring after liver transplantation Randomized clinical trial of accelerated enhanced recovery after minimally invasive colorectal cancer surgery (RecoverMI trial) Additional Supporting Information may be found online in the supporting information tab for this article.