Endocrine Surgery in the Coronavirus Disease 2019 Pandemic
Facing the realities of the coronavirus disease 2019 (COVID-19) pandemic, governments around the world and in the United States have implemented societal interventions such as “social distancing” measures, “stay at home” orders, border closures, and nationwide lockdowns. The underlying goal is to curtail all non-essential population movement in an attempt to limit the rate of spread of this virus. Similar measures have been undertaken in the medical community to prioritize patient encounters to those necessitating timely evaluation and treatment.
Several populations are considered to be at higher risk for complications of a COVID-19 infection. These include immunocompromised patients such as those undergoing active or recent oncologic treatment. Mortality rates among cancer patients have been reported to be 29%1. In a nationwide analysis of COVID-19 cases in China, cancer patients were noted to have a 39% rate of severe events as compared with 8% in the non-cancer population. These severe events included ICU admissions requiring ventilation or death2.
Cancer care has had to adapt rapidly to the evolving pandemic and accommodate the particular vulnerability of the oncologic patient population to COVID-19. In March 2020, both the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons (ACS) issued recommendations to postpone or cancel elective surgeries3. Increasingly, hospitals have been forced to reallocate resources to the care of the critically ill. The ACS later expanded on their recommendations to triage various oncologic surgeries based on each hospital’s COVID-19 preponderance and availability of local resources, which they divide into 3 phases of care4,5. The National Comprehensive Cancer Network has highlighted the unique challenges of cancer care during this time and has encouraged the coordination of organizational structures to facilitate collaborative, thoughtful care of cancer patients6.
Several large subspecialty societies have recently published surgical guidelines for the care of patients with endocrine tumors during the COVID-19 pandemic7-10. In addition, many medical centers and academic institutions have developed their own clinical practice guidelines to triage oncologic patient care. In preparation for the pandemic, The University of Texas MD Anderson Cancer Center has established multidisciplinary endocrine surgery guidelines and initiated specific conferences to determine case urgency. As a multidisciplinary group consisting of Head and Neck Surgical Oncology, Surgical Endocrinology, and Medical Endocrinology, we have devised the following Surgical Triaging Guidelines for Endocrine Surgery at the time of a pandemic such as COVID-19. These guidelines apply specifically to surgical procedures. Other adjuvant therapies, particularly postoperative radioactive iodine ablation, may also be safely deferred in the context of this pandemic.
We have aligned the case priorities to the phases of care outlined by the ACS and have triaged case acuity based on the American College of Surgeons Elective Surgery Acuity Scale11. Phases of care with added examples of corresponding endocrine cases have been provided. According to the listed acuity descriptions, most cases (including the majority of differentiated thyroid carcinoma) can be safely postponed with active surveillance. These guidelines provide a context for endocrine surgery within the entire spectrum of surgical oncology, especially when overall priorities may focus on ensuring available Personal Protective Equipment (PPE), ICU resources, and adequate protection of medical personnel during the COVID-19 pandemic. While these recommendations are intended to serve as general principles, and we continue to advocate that where possible surgeries be considered individually in a multidisciplinary setting based on the unique patient and environment circumstances.