Re: “Strategy for the practice of digestive and oncological surgery during the COVID-19 epidemic”

It was with considerable interest that I read the manuscript entitled “Strategy for the practice of digestive and oncological surgery during the COVID-19 epidemic” [1]. The objective of this letter is not to provide reasoned commentaries on the proposals put forward. Instead, I will offer some thoughts on methodology and an analysis of the resources proper to our health care system.

At present, the different “recommendations” on therapeutic adaptation of digestive cancer management are based on analysis of the work by Liang et al. [2].

The authors [2] reported a higher percentage of cancer patients in the COVID-19 cohort (n  = 18: 1%) than in the overall population (0.29%). Moreover, patients with past history of cancer had more severe forms of covid (7/18: 39%) than those without prior history of cancer (124/1572: 8%). Lastly, among the 4 patients having undergone surgery or chemotherapy during the month preceding COVID-19 infection, 3 patients (75%) had developed a severe form of the disease.

However, this series does not suffice to justify the conclusion that cancer patients ran a higher risk of contracting COVID-19. Incidence of this disease in cancer patients would be more contributory to evaluation if we knew whether or not these patients indeed ran a heightened risk of contracting COVID-19. For another type of coronavirus, this does not seem to be the case, with 9% (41/455) of coronavirus-related pneumopathy in patients having had cancer, and 9.6% (101/1048) in patients not having had cancer [3]. That said, coronavirus-related pneumopathy presented a higher risk of mortality in patients having had cancer. However, the new 2019-nCoV coronavirus possesses different epidemiological and biological characteristics [4], and its consequences cannot be extrapolated to those of other strains. Some Chinese authors [5] ascribe the increased risk not to the cancer itself, but rather to the patients’ having been unable, due to the epidemic, to receive necessary medical treatment.

In the work by Liang et al. [1], 50% (n  = 9) of the patients had been treated for cancer ≥ 4 years and 33% (n  = 6) had been treated ≥ 5 years and were consequently considered cured (extreme: 16 years). With these patients, it is a matter not of refining a therapeutic strategy but rather of taking all necessary precautions so as to avoid their contracting COVID-19, following the same recommendations as the overall populations and, in certain cases, limiting their hospitalizations.

The population in this series is very low, calling into question the power of the statistical tests mentioned, including a multivariate analysis by logistic regression with almost as many variables as events (6 variables for 7 patients with a severe form). Moreover, the “cancer patient” group and the “non-cancer patient” group were not significantly comparable, with two older patients, who were smokers, in the cancer group. Age and smoking status are two factors associated with occurrence of a severe form of COVID-19 [6], [7].

As regards the patients’ characteristics, 6 patients (out of 16, insofar as two patients’ treatment information remains unknown) are currently undergoing some form of treatment: 1 adrenalectomy at 3 weeks, 1 recurrent kidney cancer necessitating immunotherapy, 3 lung cancers [including 2 advanced cases) necessitating chemotherapy (including 2 occasioning targeted therapy) and 1 papillary thyroid cancer treated by TSH inhibitor. According to the text, during the month preceding covid-19 infection 4 out of the 16 patients had undergone chemotherapy or surgery, including 3 (75%) who developed more severe forms; there was consequently only 1 patient having had surgery (adrenalectomy), while there were 3 chemotherapy patients (kidney cancer and lung cancer).

Taken together, these elements do not justify treatment adjustment that would postpone surgery by privileging neoadjuvant chemotherapy, which would in no way prevent them from developing a severe form of COVID-19, quite the contrary. Moreover, this sub-group includes no cancer of the digestive system characterized by different biological behaviors of tumors or being treated by different therapies; that is why, at this stage, extrapolation to our discipline remains problematic.

I wish to finish by putting forth some general remarks on “proposals” that from my standpoint raise questions on how we are to envision the evolution of our health care system. In fact, the proposals seem to emanate from a service-centered or structure-centered vision. Before suspending or postponing all oncological activity, organization-wide adaptation mobilizing the different territorial treatment resources (private/public care offer) should be comprehensively explored.

The official opinion of the HSPC (Haut conseil de la Santé Publique: French public health council) put forward in its 14/03/2020 circular is that cancer patients undergoing treatment should be considered as being at risk of developing a severe form of the SARS-CoV-2 infection and ought to benefit, at best, from protective (“barrier”) measures, that is to say from measures aimed at preventing SARS-CoV-2 infection and, concurrently, from the adaptation of the organization of health care services in health care institutions. It is a question of adaptation not of therapeutic strategies, but rather, let me repeat, of the organization of health care services. In my opinion, the COVID-19 pandemic must not lead to the proposal of non-validated therapeutic strategies or sequences. To be clear, the HSPC recommends prioritizing the treatment, according to classical recommendations and in hospital if necessary, of cancer patients in curative treatment. Based on a Chinese publication [8] (clinical case versus the 3 cancer patients having contracted severe COVID-19 and mentioned in the paper by Liang et al.), colectomy for cancer patients can quite certainly take place in COVID+ patients.

During this COVID-19 pandemic outbreak, one may reasonably raise a question: Can medical or surgical cancer treatment be reasonably postponed, without loss of opportunity? In order to estimate the risks incurred by treatment delay or postponement, it matters above all to know exactly which time interval is being contemplated. More often than not, surgeons and oncologists are at the end of their therapeutic programs and it is necessary to take into account not only the time elapsed between consultation and treatment implementation, but also the therapeutic programs in their entirety [9] (15 different times are reported in this work, which analyzes their effects of the lapses and intervals on oncological outcomes).

Some complex or highly specialized surgical interventions entailing postoperative hospitalization in intensive care or reanimation facilities are usually carried out in specialized centers that are presently totally occupied in the fight against COVID-19, and there is little or no alternative to the postponement option, unless the patients are referred or transferred to other national centers located in areas where some non-pandemic activity is permitted. That said, some cancer surgeries do not justify a place taken in intensive care units and can be performed in virtually all relevant private and public establishments. The structuring of a care pathway under the aegis of the ARES (regional health agency) would permit the preservation in their functioning of a limited number of establishments capable of contributing to the collective effort not by setting up beds for intensive care under possibly highly suboptimal conditions, but rather by assuring a “vital minimum” level of health service in view of complying with a recent ministerial directive: “The deprogramming of all non-urgent chirurgical or medical activity, without prejudice or loss of opportunity for the patients” (patient referral, or reference to an interim agreement authorizing entrance of operators external to health care structures).

The suspension of virtually all cancer surgery [1] would be consequential, entailing losses of opportunity that are difficult to evaluate at this point in time. Nobody knows when the crisis will come to an end, and when it does, there will be waiting lists generated by the paralysis of the health care system; what is more, the ongoing crisis is likely to lead to physical and psychological exhaustion among health care professionals.

It will also be necessary to anticipate that the public sector, where some surgical activities are carried out as matters of priority, will be among the very last to get back in running order once the crisis situation shall have eased. The time lag will be due to (a) the need to manage an unusually sizable number of patients, entailing (b) a massive increase in number of ICU beds and (c) the predictable exigencies of post-ICU management, in hospitals where, prior to the present crisis, (d) social movements were staging protests.

While we were unfortunately not able to avoid the COVID-19 health care crisis, we cannot allow ourselves a 2nd health care crisis, which could be lessened and alleviated by collective intelligence and the pooling of resources before withholding treatment offer in digestive oncology. It is indeed our duty, for our patients’ sake, to go all out, and to draw up imaginative ways to avoid leaving sick individuals on the sidelines.

Disclosure of interest

The author declares that he has no competing interest.