Outcomes of Cancer Surgery During the COVID-19 Pandemic: Preparedness to Practising Continuous Cancer Care

The COVID-19 pandemic has placed unprecedented pressure on healthcare services. Deprioritisation of nonemergency clinical services and growing concerns of adverse outcomes of COVID-19 in cancer patients is having a deleterious impact across oncologic practice. We report cancer surgery outcomes taking into account the acuity of the COVID-19 situation. A prospectively maintained database of the Department of Surgical Oncology was analysed from 1st May to 30th June, 2020, to evaluate the perioperative outcomes, morbidity and mortality following major surgical procedures. A total of 359, preoperatively, tested negative for COVID-19 underwent surgery. Median age was 52 years with 26.7% (n = 96) above the age of 60 years. Sixty-one percent (n = 219) patients were American Society of Anaesthesiology grades II–III. As per surgical complexity grading, 36.8% (n = 132) cases were lower grades (I–III) and 63.2% (n = 227) were complex surgeries (IV–VI). 5.3% (n = 19) had ≥ grade III Clavien-Dindo complication, and the postoperative mortality rate was 0.27% (n = 1). Major complication rates in patients > 60 years were 9.3% in comparison to 4.1% in < 60 years (p = 0·63). The median hospital stay was 1–10 days across subspecialties. Postoperatively, repeat COVID 19 testing in 2 suspected patients were negative. Our study showed that after screening, triaging and prioritisation, asymptomatic cases may undergo cancer surgeries without increased morbidity during COVID-19 pandemic.


Introduction
Coronavirus disease 2019 (COVID-19), an emerging and evolving situation, has ensued unprecedented pressure on hospitals and ICU's necessitating rapid redeployment of staff and resources towards the management of COVID-19 cases with deprioritisation of nonCOVID-19-related nonemergency clinical services; concurrently, lockdown, public anxiety, disruption of primary care services and hospital referrals of symptomatic cases have caused significant collateral damage to cancer care [1,2].
Modest delay in diagnosis and timely interventions in patients with cancer may result in tumour progression and may result in the likelihood of metastasis [3]. Recent safety concerns regarding aerosol generation from endoscopy, cystoscopy and surgery [4,5] have further exacerbated cancer care.
Several cancer centres drastically deescalated their services after preliminary reports from China showed that Covid-19 outcomes are significantly worse among patients with cancer, hence outcome data following cancer surgery are sparsely reported from COVID hotspots around the world. We aimed to report outcomes of 359 cancer surgeries from a COVID hotspot geographical location.

Materials and Methods
A prospective database of the department of surgical oncology was analysed from 1st May to 30th June, 2020.

Hospital Preparedness, Patient-Directed Initiatives, Screening and Prioritization of Patients for Surgery
We were cognizant of the magnitude of the problem in neighbouring states and early ringfencing of substantial resources during the nationwide lockdowns of varying intensity from 25th March to 30th June 2020, helped to mitigate the coercion caused by COVID-19 pandemic.
We were quick to adopt best practices and guidelines (PRINT ISSN No. 2277-8179/doi: 10.36106/ijsr) for cancer treatment during the pandemic as prescribed by Indian Association of Surgical Oncology (IASO)COVID-19 guidelines [6] and the Tata Memorial Centre COVID-19 working group [7].
Good responders to neoadjuvant treatment, who were likely to benefit from potentially curative resections and patients with fewer comorbidities, were given the highest priority. Surgery was avoided for poor prognostic diseases and in whom interventions were expected to have marginal benefits.
A COVID-19 testing lab was set up in the campus, and a routine preoperative COVID 19 testing was performed in all patients from 1st May 2020. The test was performed on nasopharyngeal as well as the oropharyngeal swabs by real-time reverse transcriptase polymerase chain reaction (RT-PCR) method.

Data Collection and Statistical Analysis
The demographic, perioperative and postoperative recovery data were obtained from the prospectively maintained database. All statistical analyses were carried out with the Statistical Package for the Social Sciences version 21 (SPSS Chicago, IL, USA). Continuous variables are described as median unless stated otherwise. Distribution of variables was identified by descriptive analysis. A 2-tailed independent proportion test (Z test) with 5% level of significance was used to calculate the difference between two proportions with respect to age group, American Society of Anaesthesiology (ASA), surgical complexity grading versus complications.

Ethics
The data of the present study were collected in the course of common clinical practice, and, accordingly, the signed informed consent was obtained from each patient for any surgical and clinical procedures. The study protocol conforms to the ethical guidelines of the World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, as revised in Tokyo 2004. No approval of the institutional review committee was needed.
Ninety-six patients were above 60 years age, of which 9.3% developed major complication in comparison to 4.1% in < 60 years (p = 0·63). Twelve percent of patients with ASA I developed ≥ grade III complications in comparison to 14% in ASA II-III (p = 0.06).
All the preoperative patients underwent testing for COVID 19. Postoperatively, two patients were suspected to have contracted COVID-19; as determined by clinical and chest X-ray findings, a repeat RT PCR-based COVID testing in these two patients were negative. None of the operated patient in the study period had a detrimental postoperative course.

Discussion
The global pandemic of respiratory disease caused by the novel human coronavirus (SARS-CoV-2) has caused untold suffering, loss of life and upheaval in society. The pandemic has led to massive redirection of health care resources to treat the surge of COVID-19 patients, hence delivery of health care to the nonCOVID-related diseases including cancer patients has been significantly disrupted.
Patients with cancer might be immunocompromised by the effects of antineoplastic therapy, supportive medications such as steroids, and the immunosuppressive properties of cancer itself, additionally, patients with cancer are often older (i.e., aged ≥ 60 years) with one or more comorbidities, making them vulnerable to increased risk for COVID-19-related morbidity and mortality. Initial reports suggested that patients with a history of or active cancer might be at an increased risk of contracting the virus and developing COVID-19-related  Cancellations of cancer surgeries has resulted in pandemic driven protocol modifications in an attempt to bridge the intersection of COVID-19 and cancer treatment because suspending cancer treatment will have untoward consequences. An understanding of the disease course of COVID-19 and factors influencing clinical outcomes in patients with cancer is urgently needed for treating cancer patients effectively through turbulence.
Bengaluru was not the first city in India, to see a surge of COVID19 cases, but it has had the most rapid increase in case numbers and currently has the most cases overall in Karnataka State. Our city has been described accurately as the hotspot of the pandemic in the state. Currently, some other institutions are dealing with the same challenges we are facing, and many others undoubtedly will face these challenges in the weeks and months to come.
At Kidwai Memorial Institute of Oncology (Regional Cancer Centre at Bengaluru, India) despite having to deescalate operations by about one-third, the department of surgical oncology and allied specialities made the decision to continue graded response in providing cancer care based on, for a centre with an annual registration of more than 25,000 new patients even a slowdown in clinical services is likely to have a deleterious impact on outcomes and a high plausible that surges of population infection, lock downs, resource competition and diagnostic bottlenecks could recur over the next few years and augment the delay in oncological care and its consequences [11].
GLOBOCAN 2018 projected national cancer incidence of 1.1 million and 0.78 million cancer deaths with a case fatality rate of 22.9% [12]. It is pertinent to note that, in India, close to 1.3 million COVID-19 confirmed cases prevail (till date of submission of the manuscript) with 30,659 deaths, having a case fatality rate of 2.35% [13]. The projected national cancer incidence burden in 2020 will be 98.7 per 100,000 population (1,392,179 patients) as a conservative estimate [14]. It is important to be mindful that, with case fatality rate of about 22.9%, the cancer mortality in absence of definitive surgery will far exceed the mortality due to infection with COVID-19. These observations also compelled us to continue cancer surgeries during the pandemic.
Triaging, prioritisation of surgical cases and rationalization of services were key instrumental in continuing the surgeries uninterruptedly. During the initial phase of pandemic, low risk patients, i.e., young age, patients with fewer comorbidities and in whom potentially curative resection can be performed were given a priority.
The median age in the present series is 52 years. ASA I patients constituted 31%. There was no difference in 30 days CD complications when patients over 60 years were compared to those younger than 60 years of age and when ASA I was compared with ASA II-III. Our results reflect a cautious approach adopted initially that has gradually widened in scope with increasing confidence.
The low rates of major complications in our series reflect appropriate case selection and early adoption's best surgical practices and stringent standard operating procedures. Our surgical outcome experience is in concordance as reported by Shrikhande et al. [15].
The applicability of our experience to the COVID positive cancer patients is yet to be established.
Administrational rationale of having an in campus COVID testing laboratory, early in the course of pandemic, strengthened case selection and segregation of nonCOVID-19 patients. Till date of submission of the manuscript 79,266  As per clinical parameters and radiological findings, two patients were suspected to have contracted COVID-19 during the postoperative period; they were subsequently nursed in isolation, and repeat RT-PCR test was negative, and the morbidity was attributed to nonCOVID causes.
Laparoscopy can lead to aerosolisation of blood borne viruses [16][17][18]. Specific evidence to COVID-19 and the risk for aerosol transmission during laparoscopy are lacking; a conscious decision was taken to err on the side of safety, hence minimally invasive surgeries (laparoscopic and robotic services) are temporarily suspended until the operative rooms are equipped with a closed smoke evacuation/filtration system with ultra-low particulate air filtration (ULPA) capability.

Conclusions
The surgical outcome measures of our study, i.e., ICU stay and major morbidity validates, continuing elective cancer surgeries. Our reproducible approach and results serve as a springboard for continuing cancer surgeries during the pandemic. Until an effective vaccine becomes available for widespread use, it is imperative that surgical oncologists remain focused on providing optimal care for cancer patients, while managing the demands that the COVID-19 pandemic will continue to impose on our health system.

Compliance with Ethical Standards
The study protocol conforms to the ethical guidelines of the World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, as revised in Tokyo 2004. No approval of the institutional review committee was needed.

Conflict of Interest
The authors declare that they have no conflict of interest.
Consent to Participate All patients had consented for the proposed surgery. This is a retrospective analysis of prospectively maintained database which does not necessitate consenting for analysis.

Consent for Publications All authors have consented for publication.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.