Steven Lee Chang, MD, MS, discusses the impact of the COVID-19 pandemic on surgical practices, alternative options to surgery, and potential lessons to be learned from the pandemic.
Steven Lee Chang, MD, MS,
The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the surgical management of patients with genitourinary (GU) cancers, said Steven Lee Chang, MD, MS, who added that understanding how to prioritize patients for surgery has been one of the greatest challenges faced in the operating room.
“As a urological oncologist, I’ve always been trying to balance the risks and benefits for patients. It’s been taken up a notch now that we have the new variable of COVID-19,” said Chang. “It’s been hugely disruptive to the care of patients with urinary cancers. In the end, I hope we [will] become more efficient caregivers given the limited resources. We have a new normal; it’s even more of a balancing act than before, but I am hoping it ends up giving us more tools and a greater understanding of how to take care of our patients with cancer.”
In an interview with OncLive® during the Institutional Perspectives in Cancer webinar on Genitourinary Cancers, Chang, an assistant professor of surgery at Harvard Medical School, and an associate surgeon at Brigham and Women’s Hospital and Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center, discussed the impact of the COVID-19 pandemic on surgical practices, alternative options to surgery, and potential lessons to be learned from the pandemic.
OncLive: How has COVID-19 impacted cancer-related surgeries?
Chang: It has been an evolving situation. Right from the beginning, at least in the United States, a real effort was made to figure out how to postpone or even cancel cases. This was not just for cancer cases, but all surgical cases in order to free up resources for the incoming or anticipated surge of patients with COVID-19.
Certainly, cancer cases were a real point of contention because the general belief was that we needed to cancel non-elective cases. How do you define elective versus non-elective? Many people assume that any cancer-related case would be an urgent matter. However, there are a wide range of cancer presentations. As a surgical community, we had to figure out which cases were more urgent, and which could be postponed.
From late February to early March, there was a lot of discussion [regarding this]. By mid-March, when there was a sort of decree that non-urgent cases would not proceed, we had a plan in place.
In the world of GU cancers, many patients do not have an urgent surgical need. For example, many renal cell carcinoma (RCC) tumors that we see—which are bonafide cancers—are found at a very early stage and are very small. As such, they can be monitored or treated alternatively with non-surgical measures, such as ablation. Low-risk prostate cancer and low-risk bladder cancer can also be safely deferred.
We ended up creating certain protocols based on the urgency of cases. For example, we determined clinical stage III RCC to be very urgent, meaning if there was a delay, there could be a decrement in patient outcome. Similarly, patients with upper tract urothelial carcinomas that necessitated a nephroureterectomy were also deemed to be relatively urgent and remained on the schedule. Certainly, patients who had muscle-invasive bladder cancer were also placed into that group of surgeries that we kept on the schedule.
For very high-risk patients, such as those who had metastatic disease, we would collaborate with our colleagues in medical oncology so they could arrange nonsurgical management with a plan for potential surgery at a later date.
There was also the category of patients who had a lot of symptoms, such as pain or bleeding and required palliative surgery. It made sense to proceed with those cases.
After the major surge, at least in Boston, Massachusetts, things began gradually opening up in a relatively tiered fashion. We used many of the same criteria to prioritize our patients. I am pleased to say that at this point, most of my colleagues and I have cleared our backlog of cases. We have caught up in many ways with the patients who we could not take care of early during the surge period.
How long can surgery be delayed for patients with GU cancers?
That still remains to be seen. For many of our low-risk patients, we knew from the start that they would be fine [to postpone surgery]. It’s still unclear for the patients with more advanced disease. Unfortunately, it will require much more time to determine what the appropriate time of delay is. I suspect that we are going to find that many patients will be OK despite delaying their therapies, even if they’re not low risk.
A whole series of published reports by various institutions, as well as institutional guidelines, show a variety of different approaches in terms of prioritizing patients. There is a great deal of debate. It is going to take months, maybe even years to realize what the appropriate timing was. These data have never been available because nobody has been willing to defer patients who are not low risk. Hopefully, we will gain some information through this process, but I don’t think we have that information yet.
If surgery is delayed, what are some alternative approaches that can be implemented?
For patients who have RCC and smaller masses, it has been well established as a standard of care that thermal ablation is an excellent modality for treatment. It is perfect, particularly for tumors less than 4 cm in size. Some of my radiation colleagues say they can [perform thermal ablation] on much larger tumors.
Another option—which is also recognized as a standard of care—is active surveillance. That is an ideal option for patients who have tumors less than 2.5 cm in size. Monitoring those patients has been an established treatment, particularly for patients who have comorbidities and are [older].
We’re extrapolating from that, and we can employ these techniques for patients who are younger rather than patients who are in that older, classic population with a lot of health issues. Essentially, we performed active surveillance because that is what many patients elected to do. Many of the cases that were in my backlog are those that I didn’t operate on. We are scheduling those patients for repeat imaging in the fall or winter of 2020 at which point we will decide on the next step.
Another alternative in kidney cancer is stereotactic body radiation therapy (SBRT).
We usually monitor patients with low-risk bladder cancer using cystoscopy. Now, we are trying to push intravesical therapies rather than surgery for patients with low- or intermediate-risk disease. These are procedures that can be done in the office. Even though we are trying to be aggressive with intravesical therapy to avoid patients going to the operating room, we are also trying to limit patient’s time in the clinic.
For patients with low-risk upper tract urothelial carcinoma, we are also trying to monitor them periodically without taking them to the operating room.
Many of the considerations are not just whether we should perform surgery or not, but whether that surgery requires a long hospital stay. Is the surgery going to use a lot of hospital resources? That is dependent on the type of disease and the patient. Even though we have established these guidelines, nothing is written in stone. A lot of the decisions are shared between the patient, surgeon, anesthesiologist, nurses, hospital administrators, and even ethic committees to determine whether surgery should be offered.
How do you weigh the risk versus the benefit of a surgical procedure? Is there a particular scoring system that you use?
I raised the Medically Necessary, Time-Sensitive Procedures Scoring System [during my presentation] as an example of how people have tried to objectify this decision-making process. It’s not uniquely different than what I have described, trying to put together patient factors, surgical factors, and hospital factors. To be honest, I have not used this scoring system, but it’s important to people to know that it exists to help with the decision-making process.
In the end, we are trying to put together all the information to come up with a reasonable recommendation. There are going to be patients who are clearly in the do not proceed with surgery category, as well as patients in the definitely proceed with surgery category. However, there is also a big, gray area in the middle. Something like a scoring system may help to facilitate navigating that conversation.
In my experience, we have had very little pushback from our patients and hospital administrators. Most patients were agreeable to proceed or not proceed with surgery based on the understanding that we’re in a global pandemic. Our hospital administrators and operating room staff were accommodating when we needed them to be. I’m glad to say that we never had to rely on this scoring system to tease out debatable cases. It is important to know that it exists, but whether it is necessary will depend on the situation.
What risks did patients who were undergoing surgery during the COVID-19 surge face? How were these risks mitigated?
Of course, the major concern was the spread of COVID-19. There were early reports out of China and later through multi-national and multi-institutional studies that patients who had COVID-19 did worse with surgery versus those who did not. Patients could suffer pulmonary complications, and in some series, the mortality rate was alarmingly high. That was a big concern for patients, and we had to make an effort to protect our patients and staff from COVID-19 transmission.
In our hospital, patients were largely segregated. Those who had a concern for COVID-19 were all placed within a certain portion of the hospital. In terms of going to the operating room, patients had to be screened with 2 negative COVID-19 tests within 24 hours of each other. It was difficult to bring someone urgently to the operating room because we needed time to turnaround these tests.
The hope was to operate within a negative-pressure operating room. Even if not in a positive-pressure room, the operating staff, nurses, surgeons, and anesthesiologists were wearing the universal precautions, including N-95 masks, gowns, and eye protection.
The individuals who had a unique risk during this period of time were the anesthesiologists simply because intubation and excavation of patients for surgery was a hazardous procedure. Multiple studies have shown that respiratory aerosolization can occur during these events. The belief was that COVID-19 could be aerosolized during these procedures, so during intubation and excavation, all staff who were not anesthesiologists and could leave the room did so. Then there was roughly a 20- to 30-minute period of time for the air to circulate properly through the filter to clear the room.
[It was] challenging, but it is what we had to do during that time. Since then, things have scaled down, but there remains a concern for COVID-19 transmission and acquisition. Patients are still screened.
I am pleased to say that the availability of testing is more widespread, and our patients have been routinely screened beforehand. Ideally, everyone, including myself, who is relatively asymptomatic would also be screened, but we haven’t achieved that yet.
Are practices beginning to operate at full capacity now?
Over the past several weeks, we’ve seen a ramp up of cases in the operating room, but that doesn’t happen on its own. It has to occur in a coordinated fashion: seeing more patients in the clinic through either in-person or virtual visits and having our preoperative center staffed appropriately so that we can screen patients before surgery.
It’s a challenge because we are meeting patients [virtually]. The preoperative center is also evaluating patients by phone or video. This approach may not be quite the same as if we were seeing a patient in person to evaluate them for surgery. There is a bit of a risk in that regard.
We’ve had to open our clinics to a greater extent as well, while still maintaining social distancing. Of course, protective gear is still necessary, but we have had to open up the clinics to our patients who have to come in for say catheter removal or drain removal after surgery.
By seeing more patients in the operating room, it implies that there is a whole series of events progressing in concert with the idea of surgery, care before and after surgery, and all other parts of the hospital. Anesthesia, radiology, and physical therapy have to be ramped up similarly. Otherwise, we can’t take care of our patients.
Although many of us have been able to clear our backlog, this is still far from normal. We are constantly thinking about our patients and whether surgery is the best approach for them.