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.