What are the American College of Surgeons guidelines on COVID-19-related triage of patients with lung cancer?

Updated: Jul 15, 2021
  • Author: Winston W Tan, MD, FACP; Chief Editor: Nagla Abdel Karim, MD, PhD  more...
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The American College of Surgeons has released a guideline on COVID-19–related triage of patients with thoracic cancer. [232]   As a general recommendation, the guideline recommends that determination of case status (ie, risk of death time frame) be made by Division, ideally in a multi-clinician setting (case review conference).

Suggested consent language: You are being offered surgery now, because at this time we feel that your risk of being harmed by infections, including coronavirus, within the hospital is low, and that delaying surgery could reduce your chances of being cured of cancer.  It is not possible to know either the risk of delaying surgery or the chance of getting an infection with perfect accuracy, but I did consult my colleagues and it is our group’s opinion that surgery is a reasonable thing to do.

Specific guideline recommendations are divided into three phases, depending on the COVID-19 status at a given hospital.

Phase I  – Semi-urgent Setting (Preparation Phase)

Features of this phase are as follows:

  • The hospital has few COVID-19 patients
  • Resources are not exhausted
  • ICU ventilator capacity exists
  • The COVID-19 trajectory is not in rapid escalation phase

In phase I, surgery should be restricted to patients whose survival is likely to be compromised if surgery not performed within next 3 months. The following cases need to be done as soon as feasible (recognizing that the status of each hospital is likely to evolve over next week or two):

  • Solid or predominantly solid (> 50%) lung cancer or presumed lung cancer > 2 cm, clinical node negative 
  • Node-positive lung cancer
  • Post–induction therapy cancer
  • Chest wall tumors of high malignant potential not manageable by alternative therapy
  • Staging to start treatment (mediastinoscopy, diagnostic VATS for pleural dissemination)
  • Symptomatic mediastinal tumors – diagnosis not amenable to needle biopsy
  • Patients enrolled in therapeutic clinical trials

Cases that should be deferred include the following:

  • Predominantly ground glass (< 50% solid) nodules or cancers
  • Solid nodule or lung cancer < 2 cm
  • Indolent histology (eg, carcinoid, slowly enlarging nodule)
  • Pulmonary oligometastases - unless clinically necessary for pressing therapeutic or diagnostic indications (ie, surgery will impact treatment)
  • Patients unlikely to separate from mechanical ventilation or likely to have prolonged ICU needs (ie, particularly high-risk patients)
  • Tracheal resection (unless aggressive histology)
  • Bronchoscopy
  • Upper endoscopy
  • Tracheostomy

The following alternative treatment approaches can be considered (assuming resources permit):

  • If the patient is eligible for adjuvant therapy, neoadjuvant therapy (eg, chemotherapy for 5-cm lung cancer)
  • Stereotactic ablative radiotherapy (SABR)
  • Ablation (eg, cryotherapy, radiofrequency ablation)
  • Stent for obstructing cancers, then treat with chemoradiation
  • Debulking (endobronchial tumor) only in circumstance where alternative therapy is not an option due to increased risk of aerosolization (eg, stridor, post-obstructive pneumonia not responsive to antibiotics)
  • Nonsurgical staging (endobronchial ultrasound, imaging, interventional radiology biopsy)
  • Follow patients after their neoadjuvant for “local only failure” (ie, salvage surgery)
  • Extending chemotherapy (additional cycles) for patients completing a planned neoadjuvant course

Phase II  –   Urgent Setting

Features of this phase are as follows:

  • Many COVID 19 patients
  • ICU and ventilator capacity limited
  • OR supplies limited  or
  • COVID trajectory within hospital in rapidly escalating phase

Surgery should be restricted to patients whose survival is likely to be compromised if surgery is not performed within the next few days. Cases that need to be done as soon as feasible (recognizing that the hospital’s status is likely to progress over next few days):

  • Tumor-associated infection – compromising, but not septic (eg, debulking for post obstructive pneumonia)
  • Management of surgical complications (hemothorax, empyema, infected mesh) – in a hemodynamically stable patient

All thoracic procedures typically scheduled as routine/elective (ie, not add-ons) should be deferred.

Alternative treatment approaches that are recommended, assuming resources permit, are as follows:

  • Transfer patient to a hospital that is in Phase I
  • If the patient is eligible for adjuvant therapy, give neoadjuvant therapy
  • SABR
  • Ablation (eg, cryotherapy, radiofrequency ablation)
  • Reconsider neoadjuvant therapy as definitive chemoradiation therapy, and follow patients for “local only failure” (ie, salvage surgery)

Phase III

In this phase, hospital resources are all routed to COVID-19 patients, the hospital has no ventilator or ICU capacity, and OR supplies are exhausted. Surgery should be restricted to patients whose survival is likely to be compromised if surgery is not performed within next few hours.

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

  • Threatened airway
  • Tumor-associated sepsis
  • Management of surgical complications – unstable patient (active bleeding not amenable to nonsurgical management, dehiscence of airway, anastomotic leak with sepsis)

All other cases should be deferred. Recommended alternative treatments are the same as for Phase II.

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