|Year : 2021 | Volume
| Issue : 1 | Page : 38-40
Advances in surgery in 2020: The impact of the COVID-19 pandemic on cancer surgeries and cancer care - a brief overview
Department of Surgical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
|Date of Submission||24-Nov-2020|
|Date of Decision||02-Dec-2020|
|Date of Acceptance||14-Dec-2020|
|Date of Web Publication||24-Mar-2021|
Department of Surgical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnamurthy A. Advances in surgery in 2020: The impact of the COVID-19 pandemic on cancer surgeries and cancer care - a brief overview. Indian J Cancer 2021;58:38-40
|How to cite this URL:|
Krishnamurthy A. Advances in surgery in 2020: The impact of the COVID-19 pandemic on cancer surgeries and cancer care - a brief overview. Indian J Cancer [serial online] 2021 [cited 2021 Apr 12];58:38-40. Available from: https://www.indianjcancer.com/text.asp?2021/58/1/38/311845
The coronavirus disease-2019 (COVID-19) pandemic has taken a heavy toll on the health of all the economies worldwide. The reorganization of the public health services in response to the unrelenting pandemic has resulted in significant disruptions in the delivery of healthcare across all specialities. Patients with cancers are believed to be highly vulnerable to COVID-19 infections because of their inherent immunocompromised status, side-effects of anti-cancer therapies, among other adverse factors. The impact of the disruptions in cancer care and the collateral damage caused due to the ongoing COVID-19 pandemic is now becoming clearer with the emergence of new evidences.
Cancer care delivery amidst the COVID-19 pandemic was initially challenging for clinicians given the competing risks of death from the cancer itself as compared to some of the life-threatening morbidities and occasional deaths resulting from COVID-19 infection. A recent systematic review which included 15 studies with 3019 patients reported a higher case fatality rate in COVID-19 patients with cancer as compared to COVID-19 patients without cancer. The management of any cancer patient with an active COVID-19 infection would logically depend on the severity of the infection. There seems to be a broad consensus to defer non-emergency cancer therapies, especially active chemotherapy in patients who test positive for COVID-19 infection, barring certain exceptions. A large observational study reported the short-term surgical outcomes of 1128 cancer patients who had a confirmed COVID-19 infection (within a week prior or a month following surgery). The 30-day mortality rate from the study was unusually high at 24%, which significantly exceeded the mortality rates noted in cancer surgeries performed in the pre-COVID-19 era. The study results suggested that the thresholds for surgery during the COVID-19 pandemic should be higher than those during the normal practice. It must be noted that there are no universally accepted guidelines as to when to safely restart cancer therapies after recovery from COVID-19 infection.
The treating oncologists have over time realized that the lower-case fatality rate of COVID-19 infection par se meant that the benefits of treating well selected cancer patients far outweighed the risks of dying from COVID-19 infection. A vast majority of the oncology guidelines have rightly suggested against postponing cancer treatments in patients who are negative for COVID-19 in the early stages of the pandemic unless there were compelling reasons to consider a deviation. This is especially true for certain cancer surgeries i.e., surgeries of the brain, breast, colon, kidney, pancreas, liver, bladder and lung, which are regarded as “essential” rather than elective surgeries. Recent evidence also suggests that providing dedicated COVID-19-free surgical pathways in hospitals (complete segregation of the operating theatre, intensive care, and inpatient services) can provide safer and better outcomes as compared to performing cancer surgeries without such dedicated pathways. Establishing such dedicated COVID-19 free surgical pathways would necessitate certain core modifications, including changes in the infrastructure and processes, having standard operating procedures (SOPs) for management of staff and patients' pathways, screening and triage strategies and for establishment of the updated clinical and infection control protocols among others. Further, there are emerging recent evidences to suggest that delaying cancer surgeries by over a month can result in a 6.8% increased risk of cancer related mortality. The study further showed that delaying cancer therapies by 8-12 weeks could further increase the risk of cancer mortality. The clear take home message of this study is the potential to save lives by minimizing system level delays in cancer treatment initiation.
The treating oncologists have realized that there is a no “one size fits all” approach to delivering oncology care amidst the COVID-19 pandemic. The ultimate decision for starting, interrupting, delaying (including starting neoadjuvant treatment) or deviating from the standard oncology guidelines should ideally be made as a part of a shared, individualized, multi-disciplinary decision-making process.
The COVID-19 pandemic and the ensuing lockdown had led to a significant decrease in patient footfalls across oncology centers in India. The cancer patients who did manage to reach the oncology centers had to face major diagnostic and therapeutic delays due to multiple issues ranging from infrastructure and manpower shortages due to reorganization for COVID-19, frequent outbreaks of COVID-19 infection affecting both the patients as well as the healthcare workers, escalating treatment costs among other factors. The healthcare delivery during the COVID-19 pandemic thankfully witnessed a major transformational change with the growing popularity and utilization of telemedicine services in clinical practice. This technology has provided the oncology community, a safe environment to interact with their cancer patients as well as with each other in multidisciplinary tumor boards. The COVID-19 pandemic has further disrupted the conduct of global clinical trials, both existing as well as new, thereby posing a threat to the development of new cancer therapies. The silver lining of the pandemic is that it has brought various global research teams across many diverse specialities to work together for a common cause. The research emanating from these global collaborative efforts has resulted in generating practice impacting, real-world observational data on patterns of cancer care during the COVID-19 pandemic, as well as practice changing, well-designed pragmatic, randomized controlled trials. This practice of global networking and open data sharing is a welcome step and must be strongly patronized.
In conclusion, due to the novelty and heterogeneity of COVID-19 infections, the mystery revolving around its association with cancer and cancer therapies is only gradually beginning to unravel, with increasing number of scientific publications in this regard. The need of the hour is for the global research teams to learn from this unprecedented experience and continue to collaborate in an attempt to identify risk factors and also design effective therapies that can potentially influence cancer morbidity and mortality. The output of these research initiatives should additionally aid both the clinicians as well as the policy makers to effectively implement the primary public health measures, in an attempt to make this planet as safer and a healthier place for the present and the future generations.
This article was peer-reviewed by an external referee.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Harvey-Jones E, et al
. Mortality due to cancer treatment delay: Systematic review and meta-analysis. BMJ 2020;371:m4087.
Krishnamurthy A, Gopinath KS. The need for prioritizing cancer surgeries amidst the COVID-19 pandemic. Indian J Surg Oncol 2020;11:1-2.
Zhang H, Han H, He T, Labbe KE, Hernandez AV, Chen H, et al
. Clinical characteristics and outcomes of COVID-19-infected cancer patients: A systematic review and meta-analysis. J Natl Cancer Inst 20202:djaa168. doi: 10.1093/jnci/djaa168.
Park R, Lee SA, Kim SY, de Melo AC, Kasi A. Association of active oncologic treatment and risk of death in cancer patients with COVID-19: A systematic review and meta-analysis of patient data. Acta Oncol 2020:1-7.
COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet Lond Engl 2020;396:27-38.
Hanna TP, Evans GA, Booth CM. Cancer, COVID-19 and the precautionary principle: Prioritizing treatment during a global pandemic. Nat Rev Clin Oncol 2020;17:268-70.
COVID19 Subcommittee of the O.R. Executive Committee at Memorial Sloan Kettering. Cancer Surgery and COVID19. Ann Surg Oncol 2020;27:1713-6.
Glasbey JC, Bhangu A; COVIDSurg Collaborative. Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study. J Clin Oncol 2020:JCO2001933.
Shrikhande SV, Chaudhary A, Krishnamurthy A, Rao GV, Chaturvedi H, Kar M, et al
. Surgical oncology practice in the wake of COVID-19 crisis. Indian J Surg Oncol 2020;11:1-7.
Gachabayov M, Latifi LA, Parsikia A, Latifi R. Current state and future perspectives of telemedicine use in surgery during the COVID-19 pandemic: A scoping review protocol. Int J Surg Protoc 2020;24:17-20.
Kuderer NM, Choueiri TK, Shah DP, Shyr Y, Rubinstein SM, Rivera DR, et al
. Clinical impact of COVID-19 on patients with cancer (CCC19): A cohort study. Lancet Lond Engl 2020;395:1907-18.
Best J, Starkey T, Chatterjee A, Fackrell D, Pettit L, Srihari N, et al
. Coronavirus disease 2019: The pivotal role of UK clinical oncology and the UK coronavirus cancer monitoring project. Clin Oncol (R Coll Radiol) 2020:S0936-6555;30233-8.
Tikkinen KAO, Malekzadeh R, Schlegel M, Rutanen J, Glasziou P. COVID-19 clinical trials: Learning from exceptions in the research chaos. Nat Med 2020;26:1671-2.