Pulmonary Complication Rates After Elective Cancer Surgery in Hospitals With vs Without COVID-19–Free Surgical Pathways

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In an international cohort study reported in the Journal of Clinical Oncology, Glasbey et al found that pulmonary complication rates after elective cancer surgery were lower in hospitals with vs without COVID-19–free surgical pathways during the COVID-19 pandemic.

As stated by the investigators, “As cancer surgery restarts after the first COVID-19 wave, health-care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway.”

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Study Details

The study included patients from 447 hospitals in 55 countries who underwent elective surgery for 10 solid cancer types with no preoperative suspicion of SARS-CoV-2 infection. The participating hospitals included patients seen from time of local emergence of SARS-CoV-2 infection through April 19, 2020. Hospitals were defined as having a COVID-19–free surgical pathway at the time of surgery if they had complete segregation of the operating theater, critical care, and inpatient ward areas. Hospitals were defined as having no defined pathway if they had incomplete or no segregation and areas shared with patients with COVID-19. The primary outcome was 30-day postoperative pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected ventilation.

Key Points

Among 9,171 patients, 2,481 underwent surgery in COVID-19–free surgical pathways. These patients were younger and had fewer comorbidities compared with those undergoing surgery in hospitals with no defined pathway. Rates of major surgery were similar (76% vs 78%).

The overall 30-day pulmonary complication rate was 2.2% for surgeries performed in COVID-19–free pathways vs 4.9% for surgeries performed in hospitals with no defined pathway (unadjusted odds ratio [OR] = 0.49, 95% confidence interval [CI] = 0.36–0.66). The difference remained significant after adjustment for age, sex, and American Society of Anesthesiologists (ASA) grade (adjusted OR = 0.62, 95% CI = 0.44–0.86).

In sensitivity analyses, COVID-19–free surgical pathways remained associated with reduced odds of pulmonary complications among:

  • Low-risk patients (ASA grade 1 or 2, n = 6,489; adjusted OR = 0.58, 95% CI = 0.36–0.93)
  • In a propensity score–matched analysis (2,449 patients in each group; adjusted OR = 0.65, 95% CI = 0.44–0.96)
  • Among patients with negative preoperative SARS-CoV-2 test results (n = 2,447; adjusted OR = 0.52, 95% CI = 0.29–0.91).

The postoperative SARS-CoV-2 infection rate was lower in COVID-19–free surgical pathways (2.1% vs 3.6%, adjusted OR = 0.53, 95% CI = 0.36–0.76), with the finding being consistent among hospitals in high (3.9% vs 8.2%) and low (1.6% vs 3.1%) SARS-CoV-2 incidence areas. SARS-CoV-2 infection was associated with increased pulmonary complication rates vs no infection (33.8% vs 1.8%, OR = 29.78, 95% CI = 22.4–39.6).

The investigators observed, “It is likely that differences in SARS-CoV-2 transmission rates are responsible for differences in pulmonary complications between hospitals with COVID-19–free surgical pathways and those with no defined pathway.”

They concluded, “Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.”

Aneel Bhangu MBChB, PhD, FRCS, of the NIHR Global Health Research Unit on Global Surgery, Institute of Translation Medicine, University of Birmingham, is the corresponding author for the Journal of Clinical Oncology article.

Disclosure: The study was supported by the UK National Institute for Health Research (NIHR) Global Health Research Unit and others. For full disclosures of the study authors, visit

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.