Cancer and COVID-19: surgeons speak of surgery reductions, patient fears and triaging

Cancer and COVID-19: surgeons speak of surgery reductions, patient fears and triaging

While many cancer patients are feeling heightened anxiety over postponed surgeries due to the COVID-19 pandemic, the chief of surgical oncology at the Princess Margaret Cancer Centre says he's encountered another sentiment as well — patients who are scared to come in for surgeries.

"I understand completely the anxiety that my patients are feeling," said Dr. Jonathan Irish, who is also the provincial head for the surgical oncology program at Cancer Care Ontario, which is now part of the provincial health-care agency called Ontario Health. "I have almost as many patients telling me that they’re actually scared to come into the hospital for their care."

"I’ve had patients say, 'I know you’re offering my surgery next week, but I want to not have my surgery as I am afraid of getting COVID-19. I live on a farm outside of Peterborough in the middle of nowhere and you’re asking me to come to the big city where there are lots of people, I’m afraid,'" Irish recounted during an interview with QP Briefing on Thursday morning. Later that day the province announced it would likely enter the first stage of reopening the economy on May 19, with scheduled surgeries and procedures listed among the services set to resume.

While Irish said he does't want to dismiss the anxiety patients are feeling over postponed surgeries, "there is another side to it as well" that sheds light on the importance of keeping hospitals safe — things like ensuring adequate personal protective equipment so that surgeons can try to give their patients some reassurance.

"More commonly, once we talk to the patient about the fact that we’ve created safe environments, it is extremely rare for a patient to say 'no thank you,'" said Irish, noting that amongst a team of six or so head and neck surgeons, he's aware of a few patients who have deferred their surgeries. "It is a small percentage, but it is out there."

Irish, who also leads the head and neck oncology and reconstructive surgery division at the University of Toronto, said two of the patients were elderly and from rural areas.

"First of all coming to the big city, coming to a place that is the centre of COVID-19 activity, I can understand," he said. "No one is penalizing a patient because of this anxiety, I think we would all appreciate the fact that this is a unique and an unprecedented set of circumstances and I think we can all appreciate that we’re dealing with patients, we’re dealing with humans, and we’re dealing with all of the human emotion that we’ve all experienced through this and I think we’re all respectful of that."

Irish said those few patients who defer their surgeries wouldn't "lose their spot" or be placed at the bottom of the wait list, but rather would still be considered "high priority" cases.

For those awaiting surgery, Irish said doctors are constantly monitoring them.

"When I check in with my patients, for example, I’m not just checking in on how their cancer symptoms are, I’m also reassuring them that we are monitoring them and where appropriate we are escalating them on our priority levels if their symptoms change or if there is evidence of progression of their cancer," he said. "A good part of time and energy that we are spending now unlike the pre-COVID era is monitoring patients much more aggressively."

Irish's experience offers a glimpse into some of the things surgeons and patients have experienced with surgeries having taken a major hit during the COVID-19 crisis. The provincial government ordered hospitals to ramp down scheduled surgeries and procedures in mid-March to create capacity for COVID-19 patients, and that directive is currently still in place. QP Briefing previously reported that 72,392 fewer surgeries were performed between March 16 and April 26 compared to the same period last year. According to the data from Ontario Health, there were 2,039 fewer adult cancer surgeries performed, or a 34-per-cent reduction, during the six-week period in 2020 compared to 2019.

Updated numbers from Ontario Health showed that from March 15 to May 10, a 57-day period, there were 2,670 fewer surgeries than a 57-day period last year from March 17 to May 12.

The data shows the largest reductions were in prostate and endocrine cancer surgeries — 61 per cent and 56 per cent respectively. The cancer surgeries that saw the smallest reduction in terms of volume between the two years include gastrointestinal, liver and pancreatic and breast cancers.

The numbers reflect the aggressiveness of different cancers and the decisions that multidisciplinary teams at hospitals have been making about the risks cancer patients face with potentially delayed surgeries, said Irish and Dr. Shaf Keshavjee, surgeon-in-chief at the University Health Network's Sprott Department of Surgery, and a professor of thoracic surgery at the University of Toronto.

Head and neck cancer, for example, is generally a more aggressive type of cancer, said Irish, though he stressed that there is variation between patients. There was a 30-per-cent reduction in surgeries of these cancers, compared to the 56-per-cent reduction in the endocrine category, which includes thyroid cancer.

"That’s a great demonstration of where a patient group which might have a...more aggressive type of cancer like a head, neck, mucosal cancer, a mouth cancer, or a throat cancer, which when it’s delayed would result in blockage of the airway or loss of weight because one can’t eat," said Irish. However, thyroid cancer is more common and has a "very different behaviour typically, is much slower growing, typically biologically lower grade and in fact in (some) cases can be observed rather than operated on," Irish said, adding that some patients would, however, require surgery.

"We know that when we look at prioritizing patients in an environment where there's reduced resources that our teams can make decisions based on the individual characteristics of the patient and the cancer," he said. "We know that some patients can wait more safely than others, and I think that’s what you're seeing here on this chart."

Compared to the generally slower growing prostate cancer, lung, pancreatic or brain cancers are typically fast-growing, said Keshavjee.

"Lung cancer, pancreatic cancer are very aggressive as soon as you diagnose them, you take them out," he said, also going on to note some variations in colon cancer, which falls into the gastrointestinal category.

"There’s colon cancers that (are) in a polyp that need to be taken out, and it’s basically made colon cancer completely curable when found in that stage; that could wait a few weeks," he said. "But a colon cancer that’s grown to the point where it’s nearly obstructing your colon, well that’s at risk of spreading and that’s a risk of obstructing the bowel and that’s urgent."

A brain cancer where someone suddenly starts to have headaches, seizures or increased pressure in their head would be "urgent," for example, Keshavjee explained.

Keshavjee said the difference in the numbers are indicative of the "medical judgement" that went into triaging surgeries.

"We didn’t cut across the board...we’ve cut back selectively in areas where we could more and less in ones where we couldn’t,"  he said.

Irish also noted that for some cancers, other treatments can be used that can defer surgery. This includes neoadjuvant chemotherapy that can be used before breast cancer surgery in an effort to shrink a tumor or hormonal therapy for prostate cancer.

Overall the numbers are worrisome "because everybody's got their story, everybody's patient's important," said Keshavjee. "We do 25,000 operations a year at UHN and we cut that down to 30 per cent of that and now we have to build back up."

"Cancers that are operable and curable with surgery are in danger of becoming incurable and inoperable," he said. "Surgery’s a way to cure a cancer, so I think from that point of view, anybody who knows they have the diagnosis wanted that yesterday."

Speaking to QP Briefing prior to the government's reopening announcement, Keshavjee said that with the flattening of the epidemiological curve, "it’s time to look after the surgical patients."

"It needs to be clear that we need to open now. I think it should happen tomorrow and it can and we have the capacity," he said, noting that surgeries are something that can be ramped down again if necessary.

But he said there are challenges to ramping up. One issue is the "huge backlog" combined with the "usual run rate."

"Just picking up where we left off at the usual rate of 100 per cent is not going to be adequate to deal with the backlog," Keshavjee said. Adding to this is the government requirement for hospitals to ensure that as they ramp up scheduled surgeries, they operate at a maximum capacity of 85 per cent to keep room for possible COVID-19 patients.

"How are you going to catch up with the excess if you’re using 85 per cent of what you usually use which usually wasn’t enough?" he said. "The math doesn’t add up."

He said in order to ramp up surgeries, hospitals would also need some of their staff back who were deployed to other care settings, such as long-term care homes.

"I think it’s time for all of society to step up to the plate; where they can help in these areas, they should," he said. "Because then we can keep the hospitals going and keep the operating rooms going."

Stuart Edmonds, executive vice-president of mission for the Canadian Cancer Society, said the data indicates "there have been a significant number of cancer surgeries postponed as a result of the COVID-19 pandemic."

He said while the "immediate impact of COVID-19 on cancer patients is easy to understand, the long-term effects will be equally devastating."

"CCS is concerned about the numbers of patients who are waiting to hear about a new date for their surgeries, while hoping that their cancer hasn’t spread," Edmonds said. "When the time comes to reschedule surgeries, we trust that the healthcare system will work through the backlog and appropriately prioritize procedures based on urgency, and CCS will continue to be a watchdog to ensure cancer patients in this situation are not forgotten."

Photo Courtesy of University Health Network

Sneh Duggal

Reporter, Queen's Park Briefing

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