Safety and Feasibility of Lung Cancer Surgery under the COVID-19 Circumstance

Abstract

The current coronavirus disease 2019 (COVID-19) pandemic has forced healthcare providers worldwide to adapt their practices. Our understanding of the effects of COVID-19 has increased exponentially since the beginning of the pandemic. Data from large-scale, international registries has provided more insight regarding risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and has allowed us to delineate specific subgroups of patients that have higher risks for severe complications. One particular subset of patients that have significantly higher risks of SARS-CoV-2 infection with higher morbidity and mortality rates are those that require surgical treatment for lung cancer. Earlier studies have shown that COVID-19 infections in patients that underwent lung cancer surgery is associated with higher rates of respiratory failure and mortality. However, deferral of cancer treatments is associated with increased mortality as well. This creates difficult situations in which healthcare providers are forced to weigh the benefits of surgical treatment against the possibility of SARS-CoV-2 infections. A number of oncological and surgical organizations have proposed treatment guidelines and recommendations for patients planned for lung cancer surgery. In this review, we summarize the latest data and recommendations for patients undergoing lung cancer surgery in the COVID-19 circumstance.

Lung cancer surgery during COVID-19: keep calm and operate on

“…However, the substitution of unproven “workaround solutions” for standard-of-care does warrant circumspection. For starters, even beyond questions of efficacy, it is not at all clear to what extent, if any, multiple “non-operative therapeutic encounters” ( 12 ) decreased COVID-19 exposure (or in fact increased exposure) compared to an operation with a short in-hospital stay in a protected environment ( 2 , 12 ). And indeed there is some evidence to suggest that, for example, delayed surgery may still outperform “timely” non-surgical alternatives such as stereotactic radiotherapy in terms of overall cancer prognosis ( 5 ).…”

“…Nevertheless, the net result was a significant reduction in thoracic surgical volume in the early weeks of the pandemic in different institutions, even in specialized high volume centers ( 7 , 10 ). However, as the initial wave of the pandemic endured and surgical delays grew, the risk of upstaging and increased cancer mortality became an increasing concern, even for early-stage lesions ( 2 , 9 ). It was even suggested that lung cancer mortality may begin to outweigh the risks of COVID-19 mortality when surgical delays exceed 8 weeks ( 4 , 14 ), but the threshold of COVID-19 risk where this holds true remains difficult to define.…”

“…Strict infection control measures were put in place for elective surgical patients. Such measures included the establishment of dedicated COVID-19-free wards ( 2 , 3 , 7 ) and protected COVID-19-free pathways( 8 ); the adoption of strict COVID-19 screening programs for patients and staff, including PCR-testing as it became available ( 2 , 8 , 11 ); restrictions on the movements of personnel to minimize the amount and direction of comings and goings between high risk and low risk areas within the hospital ( 10 , 11 ); and restrictions on hospital visits, which were in many cases completely forbidden early on in the pandemic ( 2 , 3 ).…”

“…The beginning of the COVID-19 pandemic was characterized by marked uncertainty and a rapidly increasing strain on healthcare systems, as material and human resources were quickly overwhelmed (2)(3)(4). A reorganization of hospital wards was required both to insure the proper care of COVID-19 patients and to minimize the risk of viral propagation within the hospital and consequent nosocomial spread to vulnerable patients and staff (5,6).…”

Surgical treatment of lung cancer during the coronavirus disease 2019 (COVID-19) pandemic: lessons learned

“…Since 2019 the coronavirus disease (COVID) pandemic has had a huge impact on health-care systems worldwide, with most of the resources redirected to the treatment of the millions of patients infected by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus. Besides causing over six million of deaths mainly due to respiratory complications, the coronavirus disease 2019 (COVID-19) pandemic has also had relevant consequences in the treatment of neoplastic diseases, particularly of lung tumors ( 1 ). Especially in the first phases of the emergency hospital resources dedicated to the treatment of lung cancer were significantly reduced and reallocated to the treatment of COVID-19.…”