The world is passing through a critical phase of uncertainty in public health which
is of a magnitude which we have never faced before. This pandemic of the deadly Coronavirus
was unprecedented, catching even the most developed countries in a state of total
unpreparedness. Our Medical and paramedical fraternities stand today on the frontline
of the battlefield and we must be aptly prepared to deal with our patients most effectively.
Needless to say, we are in a huge shortfall of resources and manpower.
Cancer is also a life-threatening condition that should be dealt with very early and
treated holistically with all the armamentarium of different Oncological disciplines
based on certain evidence-based guidelines for the best possible outcomes. The problem
in the present days is we have to weigh the benefits of cancer treatment against the
risks of getting infected with corona virus, which can be more lethal. There are no
clear guidelines and different Oncological societies (like SSO, NHS, NCCN) in the
developed worlds that have tried to create some which are mostly based on their resources
and their profile of patients. Not all of these can be applied in a country like India
where Healthcare infrastructure, the Manpower and the patient profiles are all very
heterogeneous.
We hope the crisis will be over in the coming weeks, especially with some bold steps
taken by the Government of India and the State Governments.
IASO has taken inputs from many Senior Members of the fraternity and had tried to
formulate some guidelines applicable for the first 3 wks of lockdown subject to revisions
in the future as per the new situation. It will be the final prerogative of the clinician,
based on his scientific understanding to make decisions in the best interest of the
patient and the whole nation in general. The decisions must be made on a case-by-case
basis based upon the knowledge and understanding of the biology of each cancer, with
the help of a multidisciplinary team, and institutional policies. Any suggestions
from our side may be overruled by any Orders or diktats which may come from the local
or national government authorities from time to time.
Broad Guidelines
General
All the surgical procedures should be chosen with the intent of better survival and
optimal minimal therapy possible as per the stage of the disease and clinical condition.
All emergency must be attended even in the present circumstances like tracheostomy,
obstruction, bleeding, perforation, sepsis, mechanical respiratory emergencies like
Pneumothorax/ pleural effusion etc.
All terminal care treatment must be optimized.
Semi-elective cancer Surgeries, if planned, must be simple and short and with low
morbidity with minimal blood loss.
Prioritize Surgeries with high chances of cure when given early treatment.
Avoid surgery with doubtful benefits and for poor prognostic diseases.
Avoid the surgical time and manpower associated with extensive surgery like microvascular
reconstruction, laparoscopic lengthy procedures, breast reconstruction, major Liver
& Esophageal Resections.
Choose surgeries associated with morbid conditions and requiring prolonged ICU care
with due diligence.
Anytime, the need for ventilators for COVID-19 patients may arise. In those times
of crisis, the ventilators shouldn’t be blocked by Surgical Oncology patients.
We need to be very judicious and must have a clear mechanism to rationalize the use
of PPE including Masks, Manpower, Hospital beds, Ventilators, Blood products among
others.
Some Suggested Guidelines
Biopsies
being the 1st step in confirming the diagnosis, and being a minor procedure, should
be considered early. Management decisions can be based on these reports.
Breast Cancer
ER,PR positive patients can be delayed with Neoadjuvant hormonal therapy.
Locally advanced cases may be offered neoadjuvant chemotherapy if they are Hormone
Receptor negative.
Treatment for very early cancers can be delayed until the crisis subsides.
Surgery may be justified in poor responders to Neo-adjuvant treatment or where Chemotherapy
and Hormone therapy are not an option (eg elderly ER negative patient), or Malignant
Phylloides, sarcomas.
Head and Neck
Emergencies like Stridor, bleed, dysphagia need to be treated appropriately. Procedures
like Tracheostomy, Carotid Artery ligation, Endoscopic NG tube insertion, stenting
need to be considered in such cases.
Advanced and palliative patients should be counseled to remain at home with minimal
therapy ensuring adequate symptomatic medical treatment.
Surgeries, when done should be simple involving minimal manpower and material. Cosmetic
reconstruction can be delayed.
T1, T2 lesions can be operated with minimal hospitalization.
Cases that have equivalent results with radiation should be given Radiation.
Anyone who is a candidate for neoadjuvant therapy must be dealt with accordingly.
Treatment for slow cancers like Thyroid, Parotid, Basal cell Carcinoma can be delayed.
However, Thyroid cancers which are locally aggressive and have a local invasion or
airway compression should be taken up for early surgery.
Uncontrolled Hyperparathyroidism may also be a candidate for early surgery.
Thoracic Malignancies
It is prudent to avoid surgery which is likely to require ventilators for long periods
and can have high risks of chest complications.
Esophagus cancers are preferably given Neo-adjuvant radiotherapy and or chemotherapy
and those who have already completed Neo-adjuvant treatment, surgery can be delayed
for another 3 weeks.
Lung cancers are mostly inoperable and get Non-surgical treatments like Chemotherapy,
Radiotherapy, Targeted therapy. A multidisciplinary decision should be taken after
full work up to rationalize surgery versus Non-surgical Neo-adjuvant treatment in
Stage I-III Cancers.
Thymomas are mostly slow-growing and surgery can be delayed.
Metastatic resections are preferably deferred.
Upper GI, Hepatopancreatico Biliary Cancers
All obstruction, bleeding, and perforations need to be operated on without delay.
Neo-adjuvant chemotherapy should be considered in Gastric malignancies.
Stenting can be done in patients with Esophageal stricture or gastric outlet obstruction
in advanced cases for palliation.
Complex Cases like Whipples and Segmental Liver resections should preferably be done
only at high volume Centres in otherwise uncomplicated cases.
Surgeries for Gallbladder cancer should be done sooner rather than later for its aggressive
nature.
RFA may be considered to treat small HCCs and Colo-rectal Liver metastases (up to
3 cms). For larger lesions, systemic therapy should be considered.
TACE /TARE may be also be considered for treating HCC.
GIST can be treated with neo-adjuvant TKIs unless they are bleeding actively which
will necessitate surgery.
Treatment for PNET, IPMN, etc. can be delayed.
Colorectal Cancers
Cancer of the rectum can be staged and planned preferably with neoadjuvant RT and
CT followed by definitive surgical procedures (8 to 12 weeks after completion of RT).
In cases of obstructive lesions a diversion procedure (stoma can be considered before
starting the treatment).
Colonic obstructions, bleeding and impending perforation should be relieved early
with a resection/ stoma. Definitive surgery may be delayed by Endoluminal stenting
for obstructing lesions.
Neo-adjuvant chemotherapy may be considered for locally advanced colonic cancers.
Colectomies should be done early as delays may significantly affect the outcome.
Sarcomas and Bone Cancers
Low -grade sarcomas (eg Low-grade Retroperitoneal Liposarcoma) can have deferred Surgery.
Those cases which need Radiation and Chemotherapy, are preferably given in the Neo-adjuvant
setting especially in the extremities.
Aggressive malignant sarcomas are to be operated upon without much delay.
Peritoneal Surface Malignancy
Consider Chemotherapy for all fresh cases.
Those who are responding to chemotherapy may be further delayed with additional chemotherapy.
Those due for surgery or those not responding to chemotherapy must be delayed by a
minimum of 2 weeks. Those with surgical complications like obstructions need to be
operated immediately.
Avoid HIPEC procedures during COVID-19 pandemic.
Avoid primary and secondary cytoreductive surgery during COVID 19 pandemic.
Cancer Cervix/Vulva
Select young patients who can undergo surgery with minimal morbidity. Prefer early
discharge with.
Telephonic support and utilize telemedicine consultation.
Renal Cancers
Renal cancers are relatively slow-growing and surgery can be delayed for 2–3 weeks,
unless associated with any complications or bleeding.
Adrenal Tumors
Surgery may be deferred unless the patient is having uncontrolled symptoms in Pheochromocytomas/
Paragangliomas/ Cushings.
Testicular Cancers/Ca Penis
Simple procedures to be done on day care basis. RPLND to be delayed or avoided in
favor of chemotherapy. Elective groin dissections to be delayed.
Melanoma
Early surgery should be considered in Stage I & II.
Neo-adjuvant therapy should be considered in Stage III.
Premalignant Cases
Avoid therapy for now.
Statutory Guidelines Must for Surgeons and Anesthetists
The experience of China strongly suggests High morbidity (40%) and mortality (20%)
of patients after Elective surgery for florid COVID infection post-operatively. Also,
there is a high risk of Corona infection among the Surgeons and Anesthetists when
operating on a confirmed/ suspected COVID 19 case.
All patients who are selected for Surgery should have COVID testing done. Please bear
in mind that there can be false negative reports during the Incubation period. Recommendations
from Institutes in China and some European countries are to put the patients on quarantine
for 14 days and if they remain symptom- free, to take them up for surgery on the 15th
day. This may not a practical solution in India.
Full protection with PPEs is strongly recommended for all OT staff. Special care should
be taken during Intubation by the Anesthetists or Head & Neck surgeons and Endoscopists.
Laparoscopic surgeries should be avoided as much as possible. Electrocautery should
be used in a minimal setting and should be accompanied by suction. Avoid needle stick
and stab injuries.
After the surgery is over the OT should be cleaned with PerOxyacetic acid, High-efficiency
filter should be changed and OT should be closed for at least 2 h thereafter.
Also, it is advisable to keep the OT personnel to minimum and club the operations
on specific dates.
Work with teams that don’t mix with other teams.
Healthcare workers should be educated and informed to take adequate preventive measures,
not to carry infection to the outside world including there home.
Follow up
Follow up visits can be delayed and any problems to the patient can contact through
online services. If an emergency visits the hospital.
All patients and their families should be educated on COVID-19 infection and the responsibilities
of the caretakers. Keep patients aware of COVID-19 and their responsibilities.
These are recommended guidelines from the associations and final decisions have to
be taken after consultation with the individual institution and their policies. The
patient is the priority and every treatment to be planned considering the risk and
benefits of cancer treatments during COVID-19 pandemic.
While utilizing these guidelines do not forget to keep in mind governmental statutory
guidelines. This may not have any validity in the Court of Law.