ACS Guidelines for Cancer Surgeries During COVID-19 Epidemic

The American College of Surgeons (ACS) released guidelines for triaging surgeries of patients with cancer during the coronavirus disease 2019 (COVID-19) pandemic.^1-2

Though nothing can replace sound medical judgement and local adjudication, it has generally been advised that hospitals discontinue elective surgery based on an Elective Surgery Acuity Scale provided by Sameer Siddiqui, MD, FACS, of St. Louis University. 

“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 ICU beds, respirators, transfusion capacity as well as protective gear (e.g. PPE) that is vital for protecting patients and staff from unnecessary exposure and intra-hospital transmission,” ACS wrote. “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.”

Local authorities responsible for the preparedness of their facilities managing patients with COVID-19 should be regularly sharing information regarding local resource restraints, such as protective gear for providers and patients. This will afford providers the opportunity to understand the potential impact each decision could have on limiting the hospitals capacity to respond to the epidemic. 

For elective cases that have a high likelihood of postoperative ICU or respirator utilization, it is imperative that the risk of delay to the individual patient is balanced against the imminent availability of resources for patients with COVID-19. However, such elective cases might need to be evaluated on a frequent basis as the impact of COVID-19 on various communities grows exponentially, with different baselines for different communities. 

Further, oncologic caregivers should be handling cancer care coordination as much as possible using virtual technologies. For those institutions with tumor boards, it may be helpful to gather virtually in this context as well to consider either individual cases or for institutions with high case volumes to establish triage criteria based on local circumstances, COVID-19 prevalence and/or the availability of alternative, non-surgical therapies. 

“As much as possible we encourage shared decision making,” ACS wrote. “Further, we highly recommend multidisciplinary virtual discussions regarding priority for non-urgent cancer surgery. At a minimum, patients should be informed that decisions regarding non-urgent 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.”

Acknowledging that the COVID-19 situation might be highly variable and fluid in various communities across the country, ACS organized decision-making into 3 phases within specific cancer surgeries that describe the acuity of the local COVID-19 situation. Hospitals will likely progress through these phases over the next several weeks to months, and then will de-escalate after. 

“It is important that decisions regarding provision of cancer care are made in the context of these phases and that leaders of the cancer care team are updated regularly and frequently by hospital leadership to understand their particular environment at any given time during the crisis,” ACS wrote.

Additional overarching principles detailed by ACS included:

• Be cognizant that while some of the triaging guidelines for specific cancer surgeries include a “Level 1” (e.g., lowest level of COVID-19 acuity) in the recommendations, the rates of COVID-19 are predicted to skyrocket in the next few weeks, and the overarching recommendation is to prepare for markedly increased rates when triaging elective cases at present.

• Patients should receive appropriate and timely surgical care, including operative management, based on sound surgical judgment and availability of resources.

• Consider nonoperative management whenever it is clinically appropriate for the patient.

• Consider waiting on results of COVID-19 testing in patients who may be infected.

• Avoid emergency surgical procedures at night when possible due to limited team staffing.

• Aerosol generating procedures (AGPs) increase risk to the health care worker but may not be avoidable. For patients who are or may be infected, AGPs should only be performed while wearing full PPE including an N95 mask or powered, air-purifying respirator (PAPR) that has been designed for the OR.

• There are currently insufficient data to recommend for or against an open versus laparoscopy approach; however, the surgical team should choose an approach that minimizes OR time and maximizes safety for both patients and healthcare staff.

Reference:

1. ACS. COVID-19 Guidelines for Triage of Cancer Surgery Patients. ACS website. Published March 24, 2020. facs.org/covid-19/clinical-guidance/elective-case/cancer-surgery. Accessed March 27, 2020. 

2. ACS. COVID-19: Elective Case Triage Guidelines for Surgical Care. ACS website. Published March 24, 2020. facs.org/covid-19/clinical-guidance/elective-case. Accessed March 27, 2020.