Table 1.

Guidance for the triage of patients with thoracic malignancies

Phase I •Few COVID 19 patients in hospital •Hospital resources intact (eg, ICU beds, ventilators, clinicians, PPE) •COVID-19 trajectory not in rapid escalation phase Compass Statement: Surgery restricted to patients whose survivorship is likely to be compromised by surgical delay of 3 months
Surgery performed as soon as feasible	Surgery deferred (estimate 3 months)∗	Alternative treatment considered†
•Solid or predominantly solid (>50%) lung cancer or presumed lung cancer ≥2 cm, clinical node negative •Node-positive lung cancer •Postinduction therapy cancer •Esophageal cancer T1b or greater •Chest wall tumors of high malignant potential •Stenting for obstructing esophageal tumor •Staging to start treatment (EBUS, mediastinoscopy, diagnostic VATS for pleural dissemination)§ •Symptomatic mediastinal tumors—diagnosis not amenable to needle biopsy •Patients enrolled in therapeutic clinical trials	•Predominantly ground glass (<50% solid) nodules or cancers •Solid nodule or lung cancer <2 cm •Indolent histology (eg, carcinoid, slowly enlarging nodule) •Thymoma (nonbulky, asymptomatic) •Pulmonary oligometastases, unless clinically necessary for pressing therapeutic or diagnostic indications (ie, surgery will impact treatment) •Patients likely to require prolonged ICU needs (ie, particularly high-risk patients) •Tracheal resection (unless aggressive histology) •Bronchoscopy‖ •Upper endoscopy‖ •Tracheostomy‖	•Endoscopic therapy for early-stage esophageal cancer (stage T1a/b superficial) •If eligible for adjuvant therapy, then consider neoadjuvant therapy (eg, chemotherapy for 5-cm lung cancer)† , ‡ •Stereotactic ablative radiotherapy¶ •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 postobstructive pneumonia not responsive to antibiotics) •Nonsurgical staging (EBUS, imaging, interventional radiology biopsy)‖ •Monitor patients after their neoadjuvant for “local only failure” (ie, salvage surgery)#
Phase II •Many COVID 19 patients •Resources limited (eg, ICU beds, ventilators, clinicians, PPE) •COVID trajectory within hospital in rapidly escalating phase Compass Statement: Surgery restricted to patients likely to have survivorship compromised if surgery not performed within the next few days
Surgery performed as soon as feasible	Surgery deferred (estimate 3 months)	Alternative treatment recommended∗∗
•Perforated cancer of esophagus—not septic •Tumor-associated infection—compromising, but not septic (eg, debulking for postobstructive pneumonia) •Tumor associated with hemorrhage, not amenable to nonsurgical treatment •Management of surgical complications (hemothorax, empyema, infected mesh) in a hemodynamically stable patient	•All thoracic procedures typically scheduled as routine/elective	•Transfer patient to hospital that is in Phase I •If eligible for adjuvant therapy, then give neoadjuvant therapy •Stereotactic ablative radiotherapy for •Ablation (eg, cryotherapy, radiofrequency ablation) •Reconsider neoadjuvant as definitive chemoradiation, and monitor patients for “local only failure” (ie, salvage surgery)
Phase III •Hospital resources are predominately routed to COVID 19 patients •Resources critically limited/exhausted Compass Statement: Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next few hours
Surgery performed as soon as feasible	Surgery deferred (estimate 3 months)	Alternative treatment at alternate facility
•Perforated cancer of esophagus—septic patient •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 nonemergent operations	•See above

Table 1 defines 3 phases of hospital status based on (A) the prevalence of COVID-19 patients within the hospital, (B) availability of hospital resources, and (C) the rate of change (in terms of increasing prevalence of infections and resource depletion). Because there are unique considerations for individual patients, each phase is accompanied by a “compass statement” that is meant to give additional direction to navigate volume restriction based on perceived risk to patients and hospital staff. For each phase, surgeons should operate for recommended scenarios (first column) but also for recommended scenarios from all higher phases (ie, appropriate operations during Phase II, include first column under both Phase II or Phase III). There are very limited data to inform many key decisions. The data and references in this section are meant to serve as an estimate of effect size, using the largest data sets available. They are not complete and, therefore, should not be used as definitive data but are only suggestive of the magnitude of effect. ICU, Intensive care unit; PPE, personal protective equipment; EBUS, endobronchial ultrasound; VATS, video-assisted thoracoscopic surgery.

^∗A study from the National Cancer Database suggests that the interval between diagnosis and surgery (ie, time-to-treat) for stage I lung greater than 8 weeks is associated a reduction in 5-year survival (54.8% vs 48.7%, P > .001).¹ For stage III lung cancer patients, a delay of greater than 3 months between neoadjuvant therapy and surgery was associated with shorter median survival (33.2 months vs 39.8 months, P = .03).² Smaller institutional studies have not revealed a clear association between the diagnosis-to-treatment interval and long-term outcomes in patients with esophageal cancer.³ A delay of greater than 8 weeks between neoadjuvant therapy and surgery for esophageal cancer is not associated with decrement in long-term survival.⁴

^†Availability of alternative treatments may vary across health systems and over time. The decision to pursue alternative treatment must balance risk of deferring alternative treatment (chemotherapy and radiotherapy) with risk of exposure of both patients and staff to COVID-19 infection. In Phase I, alternative treatments predominately considered in patients felt to be harmed by delay are listed (ie, the first column of table).

^‡At the time of writing, the risk of death with COVID-19 infection is felt to be higher among patients receiving chemotherapy, but the data are incredibly limited (18 cancer patients in China).⁵

^§Although the accuracy of the clinical staging examination may be enhanced by invasive staging procedures, the magnitude of survival benefit from superior staging may be considered by some to be modest. In the setting of strained resources and potential exposure risk to clinical staff from staging procedures (bronchoscopy and mediastinoscopy), treating a patient based exclusively on a noninvasive staging evaluation (ie, imaging alone) is reasonable.

^‖These procedures are currently felt to be associated with a particularly high potential to disseminate COVID-19. They should be done selectively and ideally in patients who have been screened for active COVID-19 infection.

^¶There are incomplete data comparing surgery to stereotactic ablative radiotherapy for early-stage lung cancer in patients eligible for surgery. Observational data, which is likely biased with patients who were not surgical candidates, suggests a modest survival advantage of surgery (5%-15% higher 5-year survival).6, 7, 8

^#Among presumably highly selected patients, salvage resection has been associated with reasonable survivorship after definitive nonsurgical therapy for esophageal cancer, particularly if the patient has had a good response by imaging.^9,10

^∗∗Recommended for patients in whom a delay would likely compromise survival (ie, first column from Phase I section).