Commentary: Thoracic surgery during the COVID-19 pandemic: Recommendations from China

Abstract

Central MessageThe article by Chen and colleagues highlights lessons learned and recommendations from China regarding thoracic surgery during the COVID-19 pandemic.See Article page 597dnp in the August 2020 issue. The article by Chen and colleagues highlights lessons learned and recommendations from China regarding thoracic surgery during the COVID-19 pandemic. See Article page 597dnp in the August 2020 issue. At the time of this writing, COVID-19 continues to surge in the United States, with more than 5.1 million cases and 165,000 deaths nationwide.1Johns Hopkins UniversityCOVID-19 Dashboard by the Center for Systems Science and Engineering (CSEE) at Johns Hopkins University (JHU).https://coronavirus.jhu.edu/map.htmlDate: 2020Google Scholar Guidelines from the United States and Europe have been published to aid treatment decision making for thoracic cancers during the pandemic.2Thoracic Surgery Outcomes Research NetworkCOVID-19 guidance for triage of operations for thoracic malignancies: a consensus statement from thoracic surgery outcomes research network, the Society of Thoracic Surgeons and the American Association for Thoracic Surgery.J Thorac Cardiovasc Surg. 2020; ([Epub ahead of print])Google Scholar, 3Mazzone P.J. Gould M.K. Arenberg D.A. Chen A.C. Choi H.K. 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Teo L.L. et al.Treatment guidance for patients with lung cancer during the coronavirus 2019 pandemic.J Thorac Oncol. 2020; 15: 1119-1136Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 15American College of Surgeons COVID 19: Elective case triage guidelines for surgical care: thoracic cancer surgery.https://www.facs.org/-/media/files/covid19/guidance_for_triage_of_nonemergent_surgical_procedures_thoracic_cancer.ashxDate accessed: June 10, 2020Google Scholar Most of these guidelines have been written for hospitals and clinicians who still have the capacity to take care of cancer patients and have not been completely overwhelmed by COVID-19. These guidelines have generally recommended delaying surgery for select instances of early-stage disease and, for more advanced disease, proceeding with traditional curative-intent treatment consistent with pre-COVID standard-of-care recommendations. Consideration of other nonoperative treatments (eg, stereotactic ablative radiotherapy for lung cancer, endoscopic therapy for esophageal cancer) has been proposed as well. In “peak” stages of the epidemic, when hospital resources are severely strained, thoracic surgery is recommended only for patients with emergent clinical conditions, such as perforated esophageal cancers, which if left untreated would result in death within hours or days.2Thoracic Surgery Outcomes Research NetworkCOVID-19 guidance for triage of operations for thoracic malignancies: a consensus statement from thoracic surgery outcomes research network, the Society of Thoracic Surgeons and the American Association for Thoracic Surgery.J Thorac Cardiovasc Surg. 2020; ([Epub ahead of print])Google Scholar,15American College of Surgeons COVID 19: Elective case triage guidelines for surgical care: thoracic cancer surgery.https://www.facs.org/-/media/files/covid19/guidance_for_triage_of_nonemergent_surgical_procedures_thoracic_cancer.ashxDate accessed: June 10, 2020Google Scholar Although these guidelines are useful, they have been written largely by American and European authors and speak to the American and European experience. To date, there have been very few recommendations from Asia.16Xu Y. Liu H. Hu K. Wang M. Clinical recommendations on lung cancer management during the COVID-19 pandemic.Thorac Cancer. 2020; 11: 2067-2074Crossref PubMed Scopus (7) Google Scholar, 17Li X. Liu M. Zhao Q. Liu R. Zhang H. Dong M. et al.Preliminary recommendations for lung surgery during COVID-19 epidemic period.Thorac Cancer. 2020; 11: 1372-1374Crossref PubMed Scopus (7) Google Scholar, 18Guo H. Chen X. Su C. Liu Y. Wang H. Sun C. et al.Challenges and countermeasures of thoracic oncology in the epidemic of COVID-19.Transl Lung Cancer Res. 2020; 9: 337-347Crossref PubMed Scopus (5) Google Scholar In the August issue of the Journal, Chen and colleagues,19Chen K.N. Gao S. Lunxu L. He J. Jiang G. He J. Insights from China: improving thoracic surgery outcomes during the COVID-19 pandemic.J Thorac Cardiovasc Surg. 2020; 160: 597-600Abstract Full Text Full Text PDF Scopus (2) Google Scholar all expert thoracic surgeons from high-volume thoracic surgery centers across China, make several recommendations for the treatment of thoracic surgical disease during the COVID-19 pandemic, in light of their experiences in China. The editorial is an important one, and the authors should be commended for their efforts. Several of the author's recommendations are similar to those made by American and European authors. For example, the authors call for “the cessation of all thoracic surgeries for GGO-like lung adenocarcinoma with a diameter of <30 mm during the COVID-19.” No specification of time interval accompanies this recommendation, but other American and European groups have similarly commented on postponing surgery for nodules with ground-glass opacities or lepidic adenocarcinomas for at least 3 to 6 months.2Thoracic Surgery Outcomes Research NetworkCOVID-19 guidance for triage of operations for thoracic malignancies: a consensus statement from thoracic surgery outcomes research network, the Society of Thoracic Surgeons and the American Association for Thoracic Surgery.J Thorac Cardiovasc Surg. 2020; ([Epub ahead of print])Google Scholar,4National Comprehensive Cancer Network (NCCN)Short-term recommendations for non–small cell lung cancer management during the COVID-19 pandemic.https://www.nccn.org/covid-19/pdf/COVID_NSCLC.pdfDate accessed: June 10, 2020Google Scholar,15American College of Surgeons COVID 19: Elective case triage guidelines for surgical care: thoracic cancer surgery.https://www.facs.org/-/media/files/covid19/guidance_for_triage_of_nonemergent_surgical_procedures_thoracic_cancer.ashxDate accessed: June 10, 2020Google Scholar The authors also call for “enhancing preoperative induction treatment” in a manner similar to that proposed in the United States and Europe. The authors recommend that patients with operable stage IIIA N2 disease undergo induction therapy first, as opposed to surgery. This would allow patients to avoid an operation during potential COVID-19 hospitalization peaks. The standard of care in the United States and Europe is to give induction therapy first, followed by surgery for operable stage IIIA-N2 NSCLC.20Vansteenkiste J. De Ruysscher D. Eberhardt W.E. Lim E. Senan S. Felip E. et al.Early and locally advanced non–small-cell lung cancer (NSCLC): ESMO clinical practice guidelines for diagnosis, treatment and follow-up.Ann Oncol. 2013; 24: vi89-vi98Abstract Full Text Full Text PDF PubMed Scopus (431) Google Scholar,21National Comprehensive Cancer Network (NCCN)Clinical Practice Guidelines in oncology: Non–small cell lung cancer (Version 3.2020).https://www.nccn.org/professionals/physician_gls/default.aspxGoogle Scholar In China, it can be common in centers to perform surgery first, followed by adjuvant chemotherapy for stage IIIA-N2 disease.22Zheng D. Ye T. Hu H. Zhang Y. Sun Y. Xiang J. et al.Upfront surgery as first-line therapy in selected patients with stage IIIA non–small cell lung cancer.J Thorac Cardiovasc Surg. 2018; 155: 1814-1822.e4Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,23Zhong W.Z. Wang Q. Mao W.M. Xu S.T. Wu L. Shen Y. et al.Gefitinib versus vinorelbine plus cisplatin as adjuvant treatment for stage II-IIIA (N1-N2) EGFR-mutant NSCLC (ADJUVANT/CTONG1104): a randomised, open-label, phase 3 study.Lancet Oncol. 2018; 19: 139-148Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar The authors' recommendation to proceed with induction therapy first, followed by surgery, is likely aimed at a Chinese audience, to urge more Chinese thoracic surgeons to consider the use of induction therapy during the pandemic. Other practices in China differ from those at many US hospitals. Through correspondence with Dr Chen, I learned that most COVID patients are cared for in separate “COVID” or “infectious disease hospitals” as soon as the diagnosis is made. As Dr Chen wrote, “if tracheostomies and chest tubes are needed, ENT (tracheostomies) and thoracic surgeons (chest tubes) from other hospitals will be temporarily transferred to that hospital. And some infectious disease hospitals also have their own surgeons to take care of patients, such as at Ditan Hospital in Beijing.” Another key difference between China and the United States is the degree of testing and observation each patient receives before undergoing thoracic surgery. For patients who need surgery, presumably for more advanced disease, the authors recommend that “patients should be observed in a transitional ward for 2 weeks.” The authors note that during this observational period, patients should be tested for COVID-19 by nasal swab 2 weeks before surgery and that within 1 week of surgery, patients should have a “chest CT for COVID-19 screening…C-reactive protein, procalcitonin, and influenza A and B examination.” There is some variation as to how these recommendations are implemented. In correspondence, I learned from Dr Chen that at his institution, the practice is that “all patients from other parts of the country will be isolated in designated places [eg, hotels] for 2 weeks before they can visit our outpatient clinic. And before their admission [to the hospital for surgery], they will have throat swab test, antibody and blood test, as well as CT examination, to confirm they are COVID-19–negative.” High-volume centers in China also generally seem to be better-equipped and/or prioritize wearing protective personal equipment to a greater degree than their US counterparts. For example, Dr Chen noted that at his outpatient clinic, every provider wears an N95 respirator, isolation gown, gloves, and a face shield when interacting with patients, regardless of whether the patient is suspected to have COVID. In my own experience, and anecdotally from speaking with colleagues, this is not common practice in the United States. This past week in clinic, at my own institution, I was required to only wear a surgical mask. The editorial by Chen and colleagues raises a number of points that are important for thoracic surgeons and oncologists treating lung and esophageal cancer patients to consider. There are additional questions that need to be discussed as well. For example, what if the pandemic continues with no abatement for another 1 to 2 years, how would practices change in that situation? How do we think about care for mesothelioma patients? Does definitive chemoradiation, which requires multiple outpatient visits, lead to less risk of exposure to COVID-19 to both patients and healthcare workers compared with surgery, which requires no outpatient visit (with telemedicine) and typically a single inpatient hospital stay? In addition, it is worth noting that recommendations made by both the authors and by American and European groups are based principally on clinical expertise and opinion. More actual data to drive policy and practice are needed as well. To date, only a few studies have reported outcomes of patients with lung cancer and COVID-19, including 8 from China,24Tian S. Hu W. Niu L. Liu H. Xu H. Xiao S.Y. Pulmonary pathology of early-phase 2019 novel coronavirus (COVID-19) pneumonia in two patients with lung cancer.J Thorac Oncol. 2020; 15: 700-704Abstract Full Text Full Text PDF PubMed Scopus (916) Google Scholar, 25Peng S. Huang L. Zhao B. Zhou S. Braithwaite I. Zhang N. et al.Clinical course of coronavirus disease 2019 in 11 patients after thoracic surgery and challenges in diagnosis.J Thorac Cardiovasc Surg. 2020; 160: 585-592.e2Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 26Huang J. Wang A. Kang G. Li D. Hu W. 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Acuna-Villaorduna A. et al.Case fatality rate of cancer patients with COVID-19 in a New York hospital system.Cancer Discov. 2020; 10: 935-941Crossref PubMed Scopus (509) Google Scholar,39Luo J. Rizvi H. Egger J.V. Preeshagul I.R. Wolchok J.D. Hellmann M.D. Impact of PD-1 blockade on severity of COVID-19 in patients with lung cancers.Cancer Discov. 2020; ([Epub ahead of print])Crossref Scopus (162) Google Scholar Most of these studies had only a few patients, and the largest involved only 22 patients.27Dai M. Liu D. Liu M. Zhou F. Li G. Chen Z. et al.Patients with cancer appear more vulnerable to SARS-CoV-2: a multicenter study during the COVID-19 outbreak.Cancer Discov. 2020; 10: 783-791Crossref PubMed Scopus (934) Google Scholar It will be critical for thoracic surgeons worldwide to actively report their experiences with COVID-19 patients and engage in dialogue and collaboration. Case reports are helpful, but more analyses of institutional data, national registries, and COVID-19 open-access data40National Institutes of Health Open-access data and computational resources to address COVID-19.https://datascience.nih.gov/covid-19-open-access-resourcesDate accessed: June 10, 2020Google Scholar are needed. Meaningful multi-institutional collaborations enable studies with sufficient statistical power to facilitate such analyses. These analyses in turn can provide the groundwork for meaningful, guideline-changing recommendations. Such recommendations are desperately needed during this first COVID-19 wave, as well as for future pandemic waves. Thoracic surgeons' insights: Improving thoracic surgery outcomes during the Coronavirus Disease 2019 pandemicThe Journal of Thoracic and Cardiovascular SurgeryVol. 160Issue 2PreviewAt present, Coronavirus Disease 2019 (COVID-19) is raging worldwide, and almost all thoracic surgeons are facing unprecedented challenges. In this special period, how can we treat patients with thoracic disease safely and, particularly, how can we perform thoracic surgery safely? In addition, how do we prevent COVID-19 infection in the hospital and protect medical personnel? Other questions we must answer are whether patients are more susceptible to COVID-19 after thoracic surgery and what are the clinical manifestations and outcomes of infected postoperative patients. Full-Text PDF Open Archive