It is expected that the United States would experience around 60,000 deaths from the COVID-19 pandemic. As the country braces for its worst week, the capacity of the health system is already strained. While taking care of COVID-19 patients is a priority, there is another group of patients who could experience worse outcomes as a result of this pandemic: cancer patients. Recent policy recommendations have led major hospitals to cancel their elective surgeries. Even at our hospital, surgical teams have been reassigned to manage other types of critically ill patients.
While the intentions behind this policy are timely, the absence of evidence-based and data-driven clinical guidelines on how to manage cancer patients until this pandemic subsides can lead to more harm than good. There are several reasons for this.
COVID-19 does not change the fact that this year alone, over 1.8 million Americans would receive a diagnosis of cancer. Even with standard treatment, there are predicted to be over 600,000 cancer deaths in the United States alone. We cannot avoid the reality of these cancers because there is a pandemic.
Postponing surgery for cancer is only the metaphorical “tip of the iceberg.” It is likely that downstream effects — on clinical outcomes for cancer — will burden the U.S. health system for years to come.
To be diagnosed and treated for cancer, one typically needs to see a primary care physician; discuss the pros and cons of screening; get a blood test which requires phlebotomy and laboratory services. Then there are specialty referrals and procedures, such as colonoscopies for colon cancer, mammograms for breast cancer, and prostate biopsies for prostate cancer. Every step requires dedicated professionals, equipment and precious hospital space. Every one of these steps has already been impacted by the COVID-19.
The challenge doctors will face while triaging cancer care relates to the concept of “elective” surgery. The categorization of surgeries into “elective” and “non-elective” oversimplifies the nuance that goes into when and how to treat cancer. A week’s wait from diagnosis to cancer surgery seems fast. A year may be too long. Where do we draw the line?
Current clinical evidence that can guide surgeons and patients through such decision-making processes is incomplete and worrying. In JAMA, researchers from Fox Chase Cancer Center in Philadelphia found a 9 percent increase in odds of death for each 60-day delay in breast cancer surgery.
Projecting U.S.-wide estimates, a 60-day nationwide pause on all breast cancer procedures could amount over a thousand lives lost. While this calculation is a rough estimate and doesn’t account for lives lost to COVID-19 because of appropriation of hospital resources, or due to patients and personnel developing a fatal COVID-19 infection, such high numbers should deeply concern us all.
The surgeon general and the American College of Surgeons have already directed to stop performing elective surgeries. The chair of surgery at our hospital has also recommended stopping performing these procedures. But no one really tells us where we should draw the line. Our group and other researchers have shown that surgeons vary in many aspects of care including when they operate, how aggressively, and in their use of resources. It is likely that similar variations in surgical practice will also be seen in the COVID-19 era.
These sudden changes can have an impact on patient care as well. Patients understandably don’t want to wait on the sidelines with the knowledge that they may harbor lethal cancer. Some surgeons may honestly believe the concrete risk from known cancer should outweigh the theoretical risk of potential viral infection.
And there is a financial aspect to this issue as well — surgeons are still paid by the volume of operations that they do. Some doctors in communities less affected by the virus have been accused of opportunism as they target scared patients who would normally receive care at large urban medical centers. While upper Manhattan may be swamped with COVID-19 patients, those who can make the trip to a private suburban hospital on Long Island may well find a surgeon more than willing to spare the time and resources to remove a cancerous prostate.
To be sure, most surgeons have stepped up to the challenge and are doing their best to triage elective surgeries. Some professional societies, including the Society of Surgical Oncology and the American College of Surgeons, have attempted to provide preliminary guidelines about what kind of cancer surgeries can be safely postponed. And researchers across the country are working on complex analyses to better understand the risk, but in the absence of comprehensive data, questions on tradeoffs of cancer care delay remain.
While it is true that for a patient in their early seventies, serious viral pneumonia may cause more harm than delaying the cancer surgery, the policy guidance required to make such a critical determination is not readily available. Such difficult conversations about the timing of cancer with patients and their families are already becoming more common in our hospital.
We believe that the approach to the dilemma of cancer care in this pandemic must be principled and should emphasize fairness, uniformity, and data-driven approaches to allocate cancer care to the patients who stand to benefit the most. But we must act now.
Quoc-Dien Trinh is an associate professor of surgery at Harvard Medical School, co-director of the Dana-Farber/Brigham and Women's Prostate Cancer Program, and director of Clinical Operations at the Division of Urological Surgery at Brigham and Women’s Hospital. Follow him on Twitter: @qdtrinh.
Alexander P. Cole is the chief resident in Urology at Brigham and Women’s Hospital. Follow him on Twitter: @Putnam_Cole.
Junaid Nabi is a public health researcher at Brigham and Women’s Hospital and Harvard Medical School, Boston. He is also a senior fellow at The Aspen Institute, Washington, D.C. Follow him on Twitter: @JunaidNabiMD
The opinions expressed in this article are solely our own and do not reflect the views and opinions of Brigham and Women’s Hospital.