What are the American College of Surgeons recommendations for COVID-19-related triage of patients with colorectal cancer?

Updated: Mar 18, 2021
  • Author: Elwyn C Cabebe, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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The American College of Surgeons has released a guideline on COVID-19–related triage of patients with colorectal cancer. [31]

As a general recommendation, the guidelines advise that determination of patients’ case status (ie, risk of death time frame) be made by a multidisciplinary team, ideally in a multi-clinician setting (breast tumor board conference).  This multidisciplinary discussion should be documented in the medical record.

Phase I – Semi-urgent Setting (Preparation Phase)

In this setting, the hospital has few COVID-19 patients, its resources are not exhausted, it still has intensive care unit ventilator capacity, and the COVID-19 trajectory is not in rapid escalation phase.

In phase I, the following cases need to be done as soon as feasible (recognizing that the status of each hospital is likely to evolve over the next week or two):

  • Nearly obstructing colon
  • Nearly obstructing rectal cancer
  • Cancers requiring frequent transfusions
  • Asymptomatic colon cancers
  • Rectal cancers that have shown no response to neoadjuvant chemoradiation therapy
  • Cancers with concern about local perforation and sepsis
  • Early-stage rectal cancers where adjuvant therapy is not appropriate

The following diagnoses could be deferred 3 months:

  • Malignant polyps, either with or without prior endoscopic resection
  • Prophylactic indications for hereditary conditions
  • Large, benign-appearing asymptomatic polyps
  • Small, asymptomatic colon carcinoids
  • Small, asymptomatic rectal carcinoids

The following alternative treatment approaches to delay surgery can be considered:

  • In locally advanced resectable colon cancer: Neoadjuvant chemotherapy for 2-3 months followed by surgery
  • In rectal cancer cases with clear and early evidence of downstaging from neoadjuvant chemoradiation: Where additional wait time is safe and where additional chemotherapy can be administered
  • In locally advanced rectal cancers or recurrent rectal cancers requiring exenterative surgery: Where additional chemotherapy can be administered
  • In oligometastatic disease: Where effective systemic therapy is available 

Phase II – Urgent Setting

In this setting, hospitals have many COVID-19 patients, ICU and ventilator capacity are limited, or supplies are limited or the COVID-19 trajectory within the hospital is in a rapidly escalating phase. Cases that need to be done as soon as feasible (recognizing that the hospital’s status is likely to progress over the next few days) include the following:

  • Nearly obstructing colon cancer where stenting is not an option
  • Nearly obstructing rectal cancer (should be diverted)
  • Cancers with high (inpatient) transfusion requirements
  • Cancers with pending evidence of local perforation and sepsis

All colorectal procedures typically scheduled as routine should be deferred.

Alternative treatment approaches include the following:

  • Transfer patients to a hospital with capacity
  • Consider neoadjuvant therapy for colon and rectal cancer
  • Consider more local endoluminal therapies for early colon and rectal cancers, when safe

 Phase III

In this setting, hospital resources are all routed to COVID-19 patients, there is no ventilator or ICU capacity, or supplies have been exhausted. The guidelines recommend restricting surgery to patients whose survival is likely to be compromised if their procedure is not performed within next few hours.

Cases that need to be done as soon as feasible (recognizing that the hospital’s status is likely to progress in hours) include the following:

Cases that need to be done as soon as feasible (status of hospital likely to progress in hours)

  • Perforated, obstructed, or actively bleeding (inpatient transfusion-dependent) cancers
  • Cases with sepsis

All other cases should be deferred.

Recommended alternative treatments include the following:

  • Transfer patients to hospital with capacity
  • Diverting stomas
  • Chemotherapy
  • Radiation

Society of Surgical Oncology

The Society of Surgical Oncology has released COVID-19–related recommendations for colorectal cancer surgery. The Society advises that the recommendations represent generalized opinions from experts in their fields, and that decisions must be made on a case-by-case basis. [32] The recommendations are as follows:

  •  Defer surgery for all cancers in polyps, or otherwise early-stage disease.
  • Operate if the patient has intestinal obstruction (divert only if rectal) or is acutely transfusion dependent.
  • Proceed with curative-intent surgery for colon cancer.
  • Consider all options for neoadjuvant therapy, including utilization of total neoadjuvant therapy (TNT) for rectal cancer and consider neoadjuvant chemotherapy for locally advanced colon cancer
  • Delay post-TNT rectal surgery for 12 to 16 weeks.
  • Utilize 5x5 Gy pelvic radiotherapy and defer further surgery for patients with locally advanced rectal cancer.

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