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Journal of Clinical Oncology recognizes that readers do not always have time to review an article in depth, and yet they still wish to understand how the results will influence their clinical practice or research. To address this need, we offer podcasts that will enhance the readership experience by presenting the key results of high-profile publications in a convenient audio format. Our podcasts are designed to place selected articles into a clinically useful perspective that is easy to listen to in the office or while on the road.

Sep 29, 2020

In this study of cancer operations conducted during the COVID-19 pandemic, rates of pulmonary complications and SARS-COV-2 nosocomial infections were compared between patients operated on in COVID-19-free facilities and those operated on in non-segregated facilities. Because lower rates of pulmonary complications and nosocomial SARS-COV-2 infection were observed in COVID-free facilities, the authors propose a restructuring of surgical facilities and pathways for cancer patients during the COVID-19 pandemic.

This JCO podcast provides observations and commentary on the JCO article “Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International Multicenter Comparative Cohort Study, “ by Bhangu et al.  My name is Ken Tanabe, and I serve as Chief of Surgical Oncology at Massachusetts General Hospital, Professor of Surgery at Harvard Medical School, and Deputy Clinical Director of the Massachusetts General Hospital Cancer Center in Boston, Massachusetts.  My oncologic specialty is surgical oncology.

 

The devastation and destruction brought about by the SARS-CoV-2 pandemic is difficult to fully comprehend.  At time of this podcast there are more than 28 million infections worldwide and nearly 200,000 deaths in the United States alone. Hospitals and healthcare networks have been uniformly challenged to provide care and safety for patients and providers. In response to this initial wave, elective operations were cancelled as a strategy to increase critical care resources, preserve Personal Protective Equipment – or PPE, and re-deploy surgical team members to support care for COVID-19 patients.  On a worldwide basis, this amounted to cancelation of a substantial number of operations.  And a significant fraction of these backlogged operations was for cancer. Once hospitals recognized they could handle the size and peak of the initial wave, they resumed elective cancer operations.  Some hospitals had the capacity to create COVID-19 free surgical units for these operations, as a strategy to reduce the risk of cross-infection of patients.  Subsets of cancer patients are known to be at higher risk from COVID-19 morbidity and mortality, including those with lung cancer.  However, creation of parallel pathways for COVID and non-COVID cancer patients diverts resources and is associated with significant costs.  The relative value of this maneuver is not known, but is of critical importance, particularly in light of catastrophic hospital finances created by the pandemic.

 

In the article that accompanies this podcast, the authors studied the impact of creation of COVID-19-free surgical facilities.  Specifically, they gathered data from 445 hospitals in which patients underwent operation either in a COVID-19-free surgical pathway, or alternatively underwent operation in a hospital that did not have separate, COVID-free surgical units. The study included over 9,000 patients that underwent cancer operations during the pandemic.  Hospitals in 54 countries are included, though the United Kingdom, Italy, Spain and United States accounted collectively for over 60% of the patients.  A surgical facility was defined COVID-19 free if it had a policy of segregation of COVID-19 patients in three specific areas of the hospital: the operating rooms, the ICUs, and the inpatient units.  Conversely, a surgical facility was not considered COVID-19 free if this segregation was absent in any of these three areas.

 

There are several key findings. 

  • First and foremost, patients who underwent surgery within COVID-free units were younger and had fewer comorbidities compared to patients operated on in non-segregated surgical units.
  • After adjustment for these differences, pulmonary complication rates were lower amongst patients operated on in COVID-free units compared to those operated on in non-segregated surgical units.
  • The post-operative SARS-COV-2 infection rate was lower in COVID-free surgical units – 2.1% compared to the 3.6% observed in non-segregated units.
  • The preoperative COVID testing rate was higher in the COVID-19-free surgical units.  Specifically, the testing rate was 39% in the COVID-19-free surgical units and only 23% in the non-segregated facilities.  However, in a sensitivity analysis for patients with a negative preoperative swab test, the benefit of COVID-19 free pathways remained apparent.
  • The authors conclude it is likely that differences in SARS-CoV2 transmission rates are responsible for the lower pulmonary complication rates in those operated on in COVID-19-free surgical units.

 

The authors cite these observations as the basis for their recommendation for, quote, “major international redesign of surgical services -- based on local available resources -- to provide elective cancer surgery in COVID-19-free surgical pathways.”  End quote.  Of note, there are many hospitals and healthcare networks in the U.S., let alone worldwide, that don’t have the resources required to create COVID-19-free operating rooms, ICUs and in-patient wards amidst a devastating pandemic.  And thus, it’s imperative to understand if that is really the lesson learned here.

 

It is relevant to point out that COVID-19-free surgical units – whether they cause a lower rate of post-operative complications or are merely associated with these outcomes – are sought out by patients.  In my own surgical practice, once we resumed operations after the initial COVID-19 wave, some patients declined or further delayed vital cancer operations for fear of SARS-COV-2 at the hospital, despite my assurances of the strict infection control policies in place. 

 

There are certainly limitations to this study.  The first is that selection bias was present: patients that underwent operation in COVID-19-free surgical facilities were significantly younger and healthier.  Although statisticians have developed strategies to adjust risk in scenarios like this, these approaches do not always completely remove bias.  The second limitation is that this study took place at a time during which relatively few patients were COVID-19 tested prior to operation.  Some of the observed effect in this study may be related to unknown SARS-COV-2 infection in asymptomatic patients.  Only 27% of patients underwent preoperative SARS-CoV-2 testing in this study.  Going forward, all patients are tested prior to surgical procedures.  The current study suggests an effect even when the analysis is limited to patients that were tested preoperatively, but a more robust analysis of post-operative transmission of infection in non-segregated facilities can be performed when all patients are tested preoperatively. 

 

Another important limitation of the study is that the definition of COVID-19 free surgical pathway was arbitrary in the degree of completeness.  In the context of this retrospective, multi-institutional international study, the definition was relatively broad for purposes of inclusion, but simultaneously lacks some common sense, requiring only complete segregation of operating rooms, surgical ICUs, and inpatient wards to separate COVID-19 infected patients from those without infection. 

 

To be designated as a COVID-19 free facility for purposes of this study, it was not required to have segregated facilities for preoperative check-in, separate recovery rooms, separate emergency rooms for patients presenting with post-operative complications, or even separate equipment and staff.  What is the impact of sharing with COVID-19 areas patient transporters, EKG and X-Ray machines, food service racks, language translators, or use of common elevators and corridors, or even common pneumatic tube cannisters in a pneumatic tube system that runs throughout the facility?  If the best performing hospitals that don’t have COVID-19 free pathways perform better than the worst performing hospitals that do have COVID-19 free pathways, what is it that these hospitals are doing that makes the difference? 

 

In short, it seems more than just plausible that establishing infection control Standard Operating Procedures – or SOPs, staff training, and staff adherence to these SOPs are key to controlling spread of infection.  These are likely as important as segregation of just three parts of perioperative care.  In other words, this study demonstrates an association between having separate peri-operative facilities and a reduction in pulmonary complications.  But this type of study is unable to address whether a causal link exists.  Perhaps hospitals with the capability of achieving this segregation through duplicate facilities simply have more resources.  Perhaps they have more capable hospital administration and support that can more quickly implement the newest infection control policies.   Perhaps they have more PPE for hospital staff.  Given that many hospitals and health care networks do not have sufficient resources to create parallel, segregated COVID-19-free facilities for operations, drilling down on these important operational aspects for control of disease transmission is key.

 

The time period involved in the current report was one during which hospitals were struggling to cope with several challenges.  Of note, between May 14 and July 14 CDC data reveal that an average of 120 patients a day became infected with SARS-COV-2 inside U.S. hospitals.  During this time hospitals were managing gaps in testing – as were evident in the current report – and shortages of PPE required to protect staff and patients.  CDC data suggests hospitals have improved at controlling nosocomial SARS-COV-2 infections since then, with the risk dropping from 2% in mid-May to 1.2% as of mid-July.   These promising results are likely the result of better infection-control methods employed over time.  The impact of this downward trend was exemplified in a study from Brigham and Women’s Hospital that demonstrated only 1 case of nosocomial SARS-COV2 transmission over 12 weeks of the pandemic in which 9,149 patients were hospitalized and 8,656 days of COVID-19-related care were provided.  The infection-control strategies they implemented were thorough, improved over time, and did not involve a COVID-19-free surgical pathway.  The most recent changes implemented in the Brigham and Women's study included enhanced eye protection for employees, universal testing on admission, daily nursing screening for COVID-19 symptoms, and a hospital-wide shift to N95 masks for routine COVID-19 care. 

 

The current study focused on cancer operations, but does control of SARS-COV-2 transmission inside hospital surgical units have as much impact on other kinds of operations? Yes, the observations are relevant more broadly.  Cancer patients are at greater risk for developing severe complications from COVID-19.  But a large segment of the adult population has at least one underlying risk factor for increased susceptibility to infection, as well as increased likelihood of severe complication or mortality.    Razzaghi et all have determined that the prevalence of any of five underlying, non-cancer conditions associated with increased risk for severe COVID-19–associated illness among U.S. adults is 47.2%.  Moreover, particular races have significant higher risk of infection and higher risk of severe complications. 

 

Some health care systems have the resources to create separate surgical units to control nosocomial transmission.  But going forward, it appears that reducing in-hospital transmission of SARS-COV-2 to cancer surgery patients will rely primarily on rigorous implementation of aggressive and widely accepted infection control policies.

 

This concludes this JCO Podcast. Thank you for listening.