This week, the American College of Surgeons issued guidelines on triage of patients undergoing elective cancer surgery during the COVID-19 pandemic.
During the current COVID-19 pandemic, hospital leadership and individual providers are facing increasingly difficult decisions about how to conserve critical resources, such as hospital and intensive care unit (ICU) beds, respirators, and transfusion capacity, as well as protective gear (PPE) that is vital for protecting patients and staff from unnecessary exposure and intrahospital transmission. While nothing will replace sound medical judgement and local adjudication, it has generally been advised that hospitals discontinue elective surgery, and guidance on the triage of nonemergent surgical procedures during the pandemic is available. Guidance on the triage of elective surgery is based on an Elective Surgery Acuity Scale provided by Sameer Siddiqui, MD, FACS, of St. Louis University.
Triage guidelines contained herewith add another level of specificity on triage of elective cancer surgery patients during the COVID-19 pandemic. This information is intended to help institutions and providers who are facing a rising burden of hospitalized COVID-19 patients and a higher prevalence of community infection. Not all cancer conditions can be outlined; this document will focus on how to manage the more common cancer types during the pandemic.
Guiding Principles for Cancer Care Triage
- Resource Considerations
Individual provider decisions about proceeding with elective surgeries should not be made in isolation, but rather, should take into consideration what is known about the availability of local institutional resources. Local authorities responsible for the preparedness of their facility for managing coronavirus patients should be sharing information frequently about local resource constraints, especially PPE for providers and patients. This will allow providers to understand the potential impact each decision may have on limiting the hospitals’ capacity to respond to the pandemic. For elective cases with a high likelihood of postoperative ICU or respirator utilization, it will be more imperative that the risk of delay to the individual patient is balanced against the imminent availability of these resources for patients with COVID-19. These kinds of cases may need to be adjudicated on a frequent basis as the impact of COVID-19 on communities grows exponentially, with different baselines for different communities.
- Cancer Care Coordination
The basic tenets of cancer care coordination should be followed as much as possible using virtual technologies. Institutions with tumor boards may find it helpful to virtually gather their multidisciplinary experts in order to consider either individual cases. For institutions with high case volumes, it may be helpful to establish triage criteria based on local circumstances, COVID-19 prevalence, and/or the availability of alternative nonsurgical therapies. As much as possible, we encourage shared decision-making. Further, we highly recommend multidisciplinary virtual discussions regarding priority for nonurgent cancer surgery. At a minimum, patients should be informed that decisions regarding nonurgent cancer surgery are consensus-based, and based on local and projected resources and disease prevalence as well as tumor characteristics and expected outcomes from delays.
