Beware of Time Delay and Differential Diagnosis when Screening for Symptoms of COVID-19 in Surgical Cancer Patients

We read with interest the original paper by Forrester and colleagues¹ and would like to congratulate the authors on producing an operational algorithm for operating room team members' protection. At the National Institute of Oncology of Rabat, we share the same guiding principles for team safety. However, we would like to draw attention to time-delay risk on screening symptoms for novel coronavirus (COVID-19), especially in cancer patients.

Indeed, we consider breast surgery a low-risk procedure. When surgical side effects occur, it becomes an urgent operation, which allows a delay of few hours, to admission to the operating rooms as an urgent low-risk procedure.

We report a case of a young woman in need of urgent operation for surgical site infection with negative screening symptoms at admission to the surgical ward. When she was admitted to the operating room, a fever was discovered and linked to the breast disease, and surgery was allowed with standard surgical attire and protective equipment for the operating room team. Afterwards, in the recovery room, there was a de novo worsening clinical respiratory condition, in addition to a thorough anamnestic investigation, at which time the patient revealed a contact situation and exposure to a COVID-19–positive patient in the family.

This case illustrates 2 problems. First, frequently in urgent surgery, a delay (sometimes of several hours) may occur between diagnosis and admission to the operating room. Second, many urgent surgical diagnoses can occur with fever or respiratory difficulty linked to infection, inflammation, or bowel distension.

In conclusion, in low-risk COVID-19 urgent surgical procedures with an initial negative symptom screen, we recommend carrying out a new symptom screening before each patient movement. Second, during phase 2 of the COVID-19 outbreak, we recommend considering COVID-19 as a differential diagnosis, especially within risky conditions like urgent surgical procedures in cancer patients.