By José Francisco Corona-Cruz, MD
We are living in an uncertain world in which the impact, timeline, and duration of the COVID-19 pandemic remain mostly unknown. This has led to dramatic changes in medical practice, with an unbalanced competition between SARS-CoV-2 on one side and most diseases on the other.1
For many patients with lung cancer, local treatments such as surgery or stereotactic body radiation therapy (SBRT) are the only opportunity for cure, and thoracic oncology teams may have the difficult decision of weighing the utility of these interventions against the risk of inadvertent COVID-19 exposure for patients and medical staff.
Providing Safe Lung Cancer Surgery During the COVID-19 Pandemic
Surgery remains the standard of care for early-stage lung cancer2; however, it is important to remember that surgery requires a lot of human and health care resources, including much personal protective equipment. Evidence has emerged suggesting that patients with lung cancer are at high risk of mortality with COVID-19 and are especially vulnerable to adverse outcomes after lung surgery.3 Additionally, a patient undergoing surgery will require clinic visits, laboratory and imaging tests, and an inpatient stay that will result in a considerable number of personal contact points, which increases the chances of SARS-CoV-2 transmission.
With these facts in mind, a question arises: Should we avoid lung cancer surgery during this pandemic? The answer is a resounding no. We have learned that potentially curative cancer surgery is essential rather than elective, and delaying procedures only contributes to cancer burden and mortality.4
There is no doubt that we need to make adjustments to minimize the need for hospital attendance and stay while maintaining an appropriate and effective surgical pathway. Our goals must be to reduce the risk of infection and to optimize the use of resources. Many consensuses and guidelines have been published to date, providing a modifiable framework to guide thoracic surgery services on the required adjustments to continue with surgical care for patients with cancer.5-7 For example, it is well known that minimally invasive surgery has been associated with fewer complications and decreased length of hospital stay than traditional open thoracotomy,8 and during this pandemic, we have the opportunity to encourage a wider use of this practice.
Multidisciplinary teams will always make the final decision about the most appropriate action for individual patients, and we surgeons must use our experience and judgement regarding not only which patients are better surgical candidates, but also who is at higher risk of complications and who could be better cared for with a non-surgical approach. All of these decisions, including the risk of proceeding or deferring an operation, must also always be discussed with the patient.
In this time of uncertainty, we must work to ensure that patients with lung cancer are offered treatment according to the accepted standard of care, including an indicated surgery in timely fashion. Strong leadership from surgeons is needed to ensure quick implementation of protocols and changes to provide the continuity and best surgical care for our patients.
About the Author: Dr. Corona-Cruz is a thoracic surgical oncologist at Instituto Nacional de Cancerología, Mexico.
References:
1. Kutikov A, Weinberg DS, Edelman MJ, et al. A war on two fronts: Cancer care in the time of COVID-19. Ann Intern Med. 2020;172(11):756-758.
2. National Comprehensive Cancer Network. Non-Small Cell Lung Cancer (Version 6.2020). https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed July 29, 2020.
3. Cai Y, Hao Z, Gao Y, et al. Coronavirus disease 2019 in the perioperative period of lung resection: A brief report from a single thoracic surgery department in Wuhan, People´s Republic of China. J Thorac Oncol. 2020;15(6):1065-1072.
4. Bartlett DL, Howe JR, Chang G, et al. Management of Cancer Surgery Cases During the COVID-19 Pandemic: Considerations. Ann Surg Oncol. 2020;27(6):1717-1720.
5. Thoracic Surgery Outcomes Research Network, Inc, COVID-19 Guidance for Triage of Operations for Thoracic Malignancies: A Consensus Statement from Thoracic Surgery Outcomes Research Network Ann Thorac Surg. 2020;110(2):692-696.
6. Dingemans A-MC, Soo RA, Jazieh AR, Rice SJ, Kim YT, Teo LL, et al. Treatment guidance for lung cancer patients during the COVID-19 pandemic. J Thorac Oncol. 2020;15(7):1119-1136.
7. Corona-Cruz JF, Guzmán-de Alba E, Iñiguez-García M, López-Saucedo R, Olivarez-Torres C, Rodríguez-Cid J, et al. Surgical care of thoracic malignancies during the COVID-19 pandemic in México: An expert consensus guideline from the Sociedad Mexicana de Oncología (SMeO) and the Sociedad Mexicana de Cirujanos Torácicos Generales (SMCTG). Thoracic Cancer. 2020;11:2370-2375
8. Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg.2010;139(2):366-378.
