key: cord-0994614-uc225mhn 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: J Thorac Cardiovasc Surg DOI: 10.1016/j.jtcvs.2020.03.061 sha: debb8d8cd3b3ab5b4fbf750f7719df004956225b doc_id: 994614 cord_uid: uc225mhn 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 minimize disease transmission within the hospital, and to preserve human and Personal Protective Equipment (PPE) and other resources needed to care for COVID-19 patients. In response, many hospitals have abruptly reduced or eliminated elective 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-elective, urgent, and perhaps some emergent operations). For some cancer patients, surgery may be delayed for months, or even years without negative consequences. However, in other scenarios, failure to perform an indicated cancer surgery in timely fashion may have long term implications on a patient's survivorship or significant permanent deficits in their quality of life. Therefore, cancer patients and the oncology teams that treat them are likely to face difficult decisions between suboptimal management strategies. Thoracic oncology decisions are further complicated by the fact most of the patients 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 therapeutic procedures can both impair lung function (i.e. lung isolation, removal of lung tissue), and expose clinical teams to aerosolized viral load (bronchoscopy, double-lumen endotracheal tube placement , airway surgery, laparoscopy and possibly lung surgery particularly with parenchymal lung leaks). We have assembled a document to offer guidance, intended to facilitate these difficult decisions when caring for patients with thoracic malignancies during the COVID-19 pandemic (Table 1) . Much of the impact, timeline, duration, risks and ultimate recovery from the COVID-19 pandemic remain unknown. In an effort to give context to this triage guide, several assumptions have been made: -Risk of nosocomial infection (patients and clinicians infected while in hospital) 1-5 and competition for resources (surgical and medical patients) will increase in proportion to the prevalence of hospitalized COVID-19 patients -The duration of restriction on elective surgery will last approximately 3 months -Each facility's progression through the phases of care restriction 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 population and resource status There are nuances to each patient's management approach (i.e. proceeding with surgery, delaying surgery, or pursuing alternative treatment) that will impact risk tolerance for both patient and surgeon. Ideally, when traditional cancer treatment is not logistically feasible, a patient's care plan will be made with input from a group of clinicians with expertise in thoracic malignancies (i.e. case conference or tumor board). We encourage the use of this multidisciplinary strategy as guidance as appropriate for each individual hospital or clinic setting. Several considerations may cause a group's consensus approach to differ from what is proposed in Table 1 : -Risk of delay may not be specifically captured by the outlined descriptors (i.e. tumor may have aggressive growth kinetics or histology). -Resource limitations (clinicians, supplies, facilities) affecting surgical, medical and radiation oncology departments may pose heterogeneous restrictions 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 addition, because the duration of surgical volume restriction is unknown (3 months is presumed), patients who are delayed or deferred should be tracked (i.e. a patient registry or database). Considerations for the database should include the following: -Indication if reassessment during the period of delay could influence care plan (i.e. follow up CT scan). This should be extremely selective, as access to imaging will likely be increasingly restricted with increased COVID-19 prevalence. -An indication of case priority (i.e. first group, second group, third group) for rescheduling when restrictions are lifted, to best care for patients whose survival may be most impacted by additional delay. -Preoperative evaluation is likely to be impacted (i.e. pulmonary function testing), and preoperative screening for COVID-19 is evolving (survey for symptoms, temperature assessment, possible selected testing for COVID-19 where available). -It is possible that the strategies outlined in this document could be replaced as our understanding of unique 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 potential risks of deferring or proceeding with an operation remains a priority. Surgeons should discuss these decisions individually with their patients. Multidisciplinary teams are encouraged to develop alternative treatment strategies if surgical resection is declined or infeasible. This initiative is an extension of the American College of Surgeons and Commission on Cancer There are times when the right decision becomes easier -as the impact of the decision evaporates. This is one of those times. We hope that this document facilitates the timely execution, of what are sure to be increasingly difficult decisions. 7 . Smaller institutional studies have not revealed a clear association between the diagnosis-treatment interval and long-term outcomes in patients 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 alternative treatments may vary across health systems and over time. The decision to pursue alternative treatment must balance risk of deferring alternative treatment (chemotherapy and radiation) with risk of exposure of both patients and staff to COVID-19 infection. In Phase I, alternative treatments predominately considered in patients felt to be harmed by delay (i.e. the first column of table). C At the time of writing, the risk of mortality with COVID-19 infection is felt to be higher among patients receiving chemotherapy, but the data is incredibly limited (18 cancer patients in China) 10 . d Although the accuracy of the clinical staging examination may be enhanced by invasive staging procedures, the magnitude of survival benefit from superior staging, may be considered by some to be modest. In the setting of strained resources and potential exposure risk to clinical staff from staging procedures (bronchoscopy and mediastinoscopy), treating a patient based exclusively on a noninvasive staging evaluation (i.e. imaging alone) is reasonable. e These procedures are currently felt to be associated with a particularly high potential to disseminate COVID-19. They should be done selectively, and ideally in patients that have been screened for active COVID-19 infection. f There is incomplete data comparing surgery to SABR for early stage lung cancer in patients eligible for surgery. Observational data, which is likely biased with patients 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 patients, salvage resection has been associated with reasonable survivorship after definitive nonsurgical therapy for esophageal cancer, particularly if the patient has had a good response by imaging 14, 15 . h Recommended for patients in whom a delay would likely compromise survival (i.e. first column from Phase I section) COVID-19: towards controlling of a pandemic Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia Clinical Characteristics of Coronavirus Disease 2019 in China Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State Minimise nosocomial spread of 2019-nCoV when treating acute respiratory failure Effects of Delayed Surgical Resection on Short-Term and Long-Term Outcomes in Clinical Stage I Non-Small Cell Lung Cancer Defining the Ideal Time Interval Between Planned Induction Therapy and Surgery for Stage IIIA Non-Small Cell Lung Cancer Delay in diagnostic workup and treatment of esophageal cancer Does the timing of esophagectomy after chemoradiation affect outcome? Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China A systematic review and meta-analysis of stereotactic body radiation therapy for colorectal pulmonary metastases Lobectomy versus stereotactic body radiotherapy in healthy patients with stage I lung cancer Survival of Primary SBRT Compared to Surgery for Operable Stage I/II Non-Small Cell Lung Cancer Surveillance versus esophagectomy in esophageal cancer patients with a clinical complete response after induction chemoradiation Outcome of delayed versus timely esophagectomy after chemoradiation for esophageal adenocarcinoma