baso~the association for cancer surgery - bahno · baso ~the association for cancer surgery at the...

Company7225131,RegisteredOffice35-43Lincoln’sInnFields,London,WC2A3PELimitedbyGuaranteeandRegisteredasCharityNo1136067

BASO~TheAssociationforCancerSurgeryatTheRoyalCollegeofSurgeonsofEngland,35-43Lincoln’sInnFields,LondonWC2A3PETelephone02078696854Emailadmin@baso.org.ukwww.baso.org.uk

Dateissued/Modified:9thApril2020

BASOGuidance-StrategyforCancerSurgerysustainabilityandrecoveryintheCOVID19pandemic

TheCOVID-19Pandemichascreatedunprecedentedpressureonthehealthcaresystemcreatinga need to conserve critical resources (e.g. ventilators, ICU beds) and to provide the PPE(Personal Protection Equipment) that is essential for protecting both patients and staff fromintra-hospitaltransmissionandunnecessaryexposure.In the COVID-19 Pandemic cancer patients are at an increased risk of contracting the viralinfectionbothbecauseoftheirunderlyingdiseaseandtheimmunosuppressionassociatedwiththe treatment theyare receiving (e.g. surgeryor chemotherapy).There is thereforeaneed tominimise the risk of cancer patients contracting the infection and of avoiding surgicalcomplicationswhilstmakingbestuseofresources.ThisincludestheprotectionofHealthcareworkersinvolvedinthedeliveryoftheircare.Thisguidanceintendstosupportfrontlineclinicians,whoarewitnessinganincreasingburdenofCOVID-19patients,tocontinueprovidingessentialcancersurgery.Cancersurgerytreatslife-threatening diseases, and where practicable, it should go ahead within the SAFE practiceframework. This was highlighted in the “Advice onmaintaining cancer treatment during theCOVID-19Response”documentsent toNHStrustson30thMarch2020(Publicationsapprovalreference:001559).BASOhascontributedtotheNHSEnglanddocument“MaintenanceofEssentialCancersurgeryfor adults during the COVID-19 emergency”. However as we have members in the devolvednations,aswellasinternationally,BASOhasalsoprovidedamoredetailedrecommendationtoallcolleagues.TherecommendedBASOguidanceshouldalsoberead incombinationwith thelatest government advice regarding the practice of surgery (e.g. Clinical guide for themanagementofnon-coronaviruspatientsrequiringacutetreatment:Cancer23/3/2020).CancerServicesshouldcontinuetoinvestigate,treatanddelivercaretopatients.Thereshouldbeplanstoidentifywaysofdeliveringappropriatecaretocancerpatientswhilstbalancingtheresources for the coronavirus response. These plans should also include potential situationswhere cancer treatments may be compromised because of factors such as staff or supplyshortages.Itisvitalthatclinicianstaketheleadattimesofcancerservicesdisruptioninordertoprioritise treatment for those inmostneed, usingbestpractice.Thesedecisions shouldbetakenwithMDTinvolvementandclearlycommunicatedtopatients.ItisimportanttomaintainweeklyMDTmeetings;ideallytheseshouldbedoneremotely.Ifaface-to-faceMDTisfelttobenecessary, then aim tominimise the number ofstaff present at theMDT in person and haveother members others joining remotely. Consider a quorate membership of 1 surgeon, 1oncologist,1pathologist,1radiologistandonecancercarenurse.



Many tumour specific societies have provided guidance to theirmembers on prioritising thetreatmentoptionsinthecurrentclimateofthepandemic(seebelow).Theseshouldalsobereadin linewith this document.Whilstmost research has stopped, any initiatives that encouragequality improvement in the NHS and require data collection, observational, or potentiallyrandomised interventional trials using innovative pragmatic governance and currenttechnology,shouldbesupportedwherepracticable.Theseareunprecedented timesandweacknowledge the trauma thework force is facingandwillbe facing in the future. “Self-care”and“mentalwellbeing”support is imperative. Cancersurgeons and the cancer team members have dedicated their careers to improving canceroutcomesandwillnowbemakingdifferent typesofdifficultdecisions.Ensuringthatweseekhelpwhenneededandthatwesupportourcolleaguesindistresswillensureoursustainabilityandabilitytomoveintothesystemrecoveryphase.



1. Maintain capacity to under take SAFE surgery for urgent cancers at individual acute

hospitals.Thisshouldincludeasystemwhichallowssurgeonstopooltheatrecapacity,lists,andsurgicalteamstodelivercancersurgery.

2. Decisionmakingforsurgery,resourceconsiderationandprocess–teamconsistingofseniorclinicians to help guide the management regarding clinical cancer; emergency surgeryprioritisationandCOVID-19planning(e.g.MedicalDirector,CancerClinicallead(describedinNationalguidanceforcancer23/3/20)andaclinicalDirector(e.g.surgeon,anaesthetist,intensivist etc). These individuals need to meet daily/more frequently to agreeprioritisationof resources.Thisgroupwill requireoperational support frommanagementteams.

3. Cancer Clinical Lead – ideally they should have no clinical activity/on call; to coordinate

processes aroundmanaging patient lists, helping decide priorities for theatre access andansweringcancerrelatedqueriesfrommanagement/others.

4. Atriagesystemshouldbeimplementedtoidentifycancerpatientswhoshouldhavesurgical

intervention(balancingCOVIDriskandurgencyfrompathologyperspective)andthosewhomightbereasonablydeferredduringtheCOVID-19outbreak.

The “Clinical guide for the management of non-coronavirus patients requiring acutetreatment: Cancer” document dated 23/3/2020; has identified clinical priority scores forpatientshavingsystemicchemotherapy,asbelow.Howeverthesescorecanbeadaptedforcancersurgery:-Table1PrioritisingpatientsforsystemicanticancertreatmentPrioritylevel CategorisationbasedontreatmentintentandRisk:Benefitratiooftreatment

1 • Curativetreatmentwithahigh(>50%)chanceofsuccess• Adjuvant(orneo)therapywhichaddsatleast50%chanceofcuretosurgeryor

radiotherapyaloneortreatmentgivenatrelapse2 • Curativetreatmentwithanintermediate(20%to50%)chanceofsuccess

• Adjuvant(orneo)therapywhichadds20–50%chanceofcuretosurgeryorradiotherapyaloneortreatmentgivenatrelapse

3 • Curativetherapyofalowchance(10–20%)ofsuccess• Adjuvant(orneo)therapywhichadds10–20%chanceofcuretosurgeryor

radiotherapyaloneortreatmentgivenatrelapse• Non-curativetherapywithahigh(>50%)chanceof>1yearoflifeextension

4 • Curativetherapywithaverylow(0-10%)chanceofsuccess.• Adjuvant(orneo)therapywhichaddsalessthan10chanceofcuretosurgeryor

radiotherapyaloneortreatmentgivenatrelapse• Non-curativetherapywithanintermediate(15-50%)chanceof>1yearlifeextension.

5 • Non-curativetherapywithahigh(>50%)chanceofpalliation/temporarytumourcontrolbut<1yearlifeextension.

6 • Non-curativetherapywithanintermediate(15-50%)chanceofpalliationortemporarytumourcontroland<1yearlifeextension.

Tableadapted fromNHSEngland'sClinicalguide for themanagementofnon-coronaviruspatientsrequiringacutetreatment:Cancer23March2020Version2.

Phase1:SAFESurgeryforUrgentCancerCases



Cancer surgery on the whole falls into categories 1 and 2, but in special circumstancespatientsmaybeofferedsurgeryforcategories3and4.Inthecurrentpandemicwedonotrecommendsurgeryforpatientswithalowchanceofsuccessorlifeprolongation.

ClinicalprioritycanbescoredasfollowsusingtheCategorisationofpatientsintheabovedocument:

Table2:CategorisingpatientsforsurgicalcancertreatmentPrioritylevel

Categorisation

1a Emergency-operationneededwithin24hourstosavelife.Thisshouldbeundertakenontheacutesite,ascurrently.

1b Urgent-operationneededwith72hours.Thisshouldbeundertakenontheacutesite,ascurrently.

2 Electivesurgerywiththeexpectationofcure,prioritisedto:Surgerywithin4weekstosavelifeorpreventprogressionofdiseasebeyondoperability.Thisshouldbeprioritizedforphase2(below)

3 Elective surgery can be delayed for 10-12weekswith no predicted negative outcome.Thisshouldbeprioritizedforrecoveryphase,dependingonlengthofpandemic.

Table adapted from NHS England's Clinical guide for the management of non-coronavirus patientsrequiringacutetreatment:Cancer23March2020Version2.

Patientco-morbidityand frailtyshouldbeassessedand factored into thedecision-makingalgorithm.PatientswhoareathighestriskofCOVIDrelatedmorbidityormortalityshouldideallybemanagedata“COVID-19free”cleansite(seebelow).Allnewdatabeingpublishedshouldbe consideredwhenmakingdecisions, for example informationbeingpublished isindicatinga20%mortalityforpatientswhodeveloppost-operativeCOVID-19pneumonia.Using thisguidancecouldmake triageandresourceallocationsimplerandobjective.Thisfacilitates a way of summarising the variables of clinical treatment priority and post-operative patient risk based onpatient frailty, co-morbidity and risk of COVID-19 relatedadverseoutcome.UpfrontdiscussionsonescalationoftreatmentplansandDNARstatusinpatients embarking on cancer surgery will need to be considered inmany of our cancersites.

5. Thereneedstobeaconsultantledanddeliveredserviceinordertoreducethenumberofpeople in theatresand thereby todecreaseriskbyaerosoling. Thiswillalso freeupnon-consultant staff tohelpdealwith inpatientsbeing treated forCOVID-19 complications (inaccordancewithPHEletterdated28March2020onPPE-publicationapprovalreference:001559).

6. PPE isessential forreducingunnecessaryexposureandprotectingpatientsandstaff fromthe intra-hospital transmission. Whilst use of this should follow PHE/national guidance,new evidence is continually emerging and national guideless are undergoing regularupdates.



1. TheeffectsoftheCOVID-19pandemicwillbelonglasting;thereisaneedtodeliverawell-

coordinatedcancerserviceforthenext6monthsandprobablyforsometimeafterthat.Itislikely that therewillbeacontinuingneed forCOVID-19patients tooccupybeds inwardsandinoperatingtheatresinhospitalswhichhaveA&Edepartments.Clean“COVID-19free”sitesthereforeneedtobeidentifiedasapriority.

2. Clean(i.e.COVID-19free)sitesshouldbeidentifiedfordeliveryofSAFEcareforlessurgentcancer cases where non-surgical options are not feasible. Cancer Alliances and HealthBoardsneedtoidentifycold“clean”sites.Eachoftheseshouldideallybeahospitalwithoutanemergencydepartmente.g.aprivatehospitaloraregionalhospitalserving5-6hospitalsinthevicinitywithappropriatefacilities(e.g. includinghighdependency,radiology)whichcanactas“clean”site for theregion.Theremayalsobetheoptionof identifyinga“clean”isolated sitewithin a large acute hospital if other options are not possible. These “clean”sitescanhaveadualfunctionasanoncologyhubtodeliversystemicchemotherapy.

3. Staffing-Ideallythereisaneedforacleansitetohavepatientsandstaffthatarelesslikely

tobeexposedtotheinfectionrisk.COVID-19screeningofstaffshouldbeconsidered.ItisimportantthatthefightagainstCOVIDworkshandinglovewiththefightagainstcancer.Werecommend that each service/hospital identify 1-2, an agreed number of surgeons, toprovidea“hotblock”ofoperatingforthesecancerlistsovera4-6weekcycle.Theywouldbe expected to deliver and provide clinical continuity of care. Senior trainees will bevaluableinthedeliveryofpatientcare.Thissystemshouldlimittheresourceconstraintsontheoverallstaffingrequirementsforeachhospital.Similarworkforceplanningwillneedtobe undertaken for other teams e.g. anaesthetic staff, Macmillan, AHP and CNS who areimperativeincancerpatients’care.Itmaybepossibletocallonrecentlyretiredcolleaguestosupportthiseffort.

4. Screening and testing will need to be carried out on all patients being admitted to a

designatedcoldcleansite.Thisshould includeacareful travelandcontacthistoryusingahealthquestionnaireadministeredatpointofentry. Thisshould ideallybeundertakenatthepre-operativeassessmentclinic. Inaddition,patientsshouldself-isolate1weekbeforeadmission.

5. Assessment forCOVID-19symptomsshouldbe carriedoutonadailybasis for inpatients.

Patients who develop symptoms should be swabbed and moved to cohort wards forsuspected or confirmed cases. Contact tracing and isolation of COVID-19 patients or staffshouldbeprioritised.

6. Environment - theatreandwardspaceneedsdisinfectionaspernationalguidelines.Each

clinical area should have appropriate PPE as per latest national guidelines. No visitorsshouldbeallowedintocleanhospitalsexceptessentialcarers.

7. Aclinicalassessmentortriagesystem(SeePhase1Para4)shouldbeinstigated.Thetheatre

listsshouldbemanagedcentrallyusingtheadministrativesupportfromthecanceralliancesorhealthboards.

Phase2:CleanSites(“COVID-19free”)forlessurgentCancerCases(urgentandadvancedcancers)wherenon-surgicaloptionsarenotfeasible



8. Post-operativemajorcancersurgerypatientsshouldbeadvised to followshieldingadviceastheyfallinthishigh-riskcategory.

9. MitigateRisk forcancelledpatients- it isessential thatariskassessmentbeperformedon

patients who have their surgery cancelled or re-scheduled. Holding treatments such aschemotherapy or loco-regional therapies should be considered wherever possible. Thepotentialriskofprogressionneedstobeclearlydiscussedwiththepatientsandtheoptionofearlyreassessmentneedstobe factored intothetreatmentplan– includinggivinghighriskpatientspriorityonce‘businessasusual’isresumed.

10. Patientsneed tobe informedof theextrariskposedbyCOVID-19aspartof the informed

consentprocess.Thisrequiresdevelopmentofsuitableliterature.



1. When the system returns to normal we need to identify good practice and innovations

whichhavebeenintroducedduringthecrisis(e.g.telemedicineforMDTs,followupclinics,monitoringclinicsetc).

2. Extra resources will be needed to cover diagnostic services, theatre and critical carecapacity in order to allow delayed cancer treatments to be carried out without furtherunnecessarydelay.Withoutthisfurtherfundingtherewillbeagreatersecondarydeathratebecauseofdelayedorcancelledcancersurgery. Duringthistimenewcancercaseswillbepresentingwhichwillrequirediagnosis,investigation,assessmentandtreatment.

3. The key for system recovery depends onmaintaining a healthyworkforce (e.g. adequate

PPE),bedandoperativecapacity.TheCOVID-19Pandemichasput immensestrainonourhealthcaresystembuthasalso ledtoinnovation in a short period of time. It is important that surgery, as one of the few curativeoptions for patients with solid organ tumours, is maintained throughout this crisis. Therecommendations abovemayhelp commissionerswith the systemchange that is required torespondtothecurrentcrisis.Finally,pleaserefertotheBASOwebsiteforupdatedinformationregardingCOVID-19.DocumentIssuedon:9thApril2020DocumentApprovedby:BASONationalCouncilDocumentisEndorsedandSupportedby:

(AUGIS)AssociationofUpperGastrointestinalSurgeon (BAETS)BritishAssociationofEndocrineandThyroidSurgeons (BAHNO)BritishAssociationofHeadandNeckOncologists

(BGCS)BritishGynaecologicalCancerSociety(BOOS)BritishOrthopaedicOncologySociety(BSG)BritishSarcomaGroup(SCTS)SocietyforCardiothoracicSociety

Phase3:CancerSurgerySystemRecovery

Conclusions


BASO~TheAssociationforCancerSurgeryatTheRoyalCollegeofSurgeonsofEngland,35-43Lincoln’sInnFields,LondonWC2A3PETelephone02078696854Emailadmin@baso.org.ukwww.baso.org.ukSpecialityAssociationGuidelines/Statements:

UK

ABShttps://associationofbreastsurgery.org.uk/for-members/covid-19-resources/ASGBIhttps://www.asgbi.org.uk/ACPGBIhttps://www.acpgbi.org.uk/news/considerations-for-multidisciplinary-management-of-patients-with-colorectal-cancer-during-the-covid-19-pandemic/https://www.acpgbi.org.uk/news/acpgbi-guidance-for-colorectal-surgeons-and-trainees-on-rising-to-the-challenges-of-covid-19-as-citizens-doctors-and-surgeons/AUGIShttps://www.augis.org/wp-content/uploads/2020/03/Advice-for-Endoscopy-Teams-during-COVID-ver-2-3-published-17032020FINAL.pdfhttps://www.augis.org/wp-content/uploads/2020/03/Surgical-Priority-in-Oesophageal-and-Gastric-Cancer.pdfhttps://www.augis.org/wp-content/uploads/2020/03/Statement-from-AUGIS-re-Hepatobiliary-and-Pancreas-Cancer-Patients.pdfBAHNOhttps://www.bahno.org.uk/clinicians_area/default.aspxBASO* https://baso.org.uk/media/98159/covid_19_and_breast_cancer_march_2020.pdfBGCShttps://www.bgcs.org.uk/covid-19/BOAhttps://www.boa.ac.uk/resources/statement-for-boa-members-on-trauma-and-orthopaedic-care-in-the-uk-during-coronavirus-pandemic.htmlBAUShttps://www.baus.org.uk/about/coronavirus_covid-19.aspxSBNShttps://www.sbns.org.uk/index.php/about-us/news/SCTShttps://scts.org/guidance-for-surgical-support-during-covid-19/

InternationalSocietyofSurgicalOncologyhttps://www.surgonc.org/resources/covid-19-resources/



NHSEnglandGuidance:https://www.england.nhs.uk/coronavirus/OtherGuidance:

Macmillanhttps://www.macmillan.org.uk/coronavirus

*BASO‘srecommendations(inconsultationwithProfessorJeffreyTobias,ProfessorofClinicalOncology,andProfessorBobLeonard,ProfessorofMedicalOncology)tobeusedinconjunctionwiththeguidancealreadyissuedbyAssociationofBreastSurgery(ABS)forthemanagementofbreastcancerpatientsduringCovid-19.References:1. InterimprocessandmethodsfordevelopingrapidguidelinesonCOVID-19

https://www.nice.org.uk/process/pmg35/chapter/scoping2. https://cleanhospitals.com/2020/03/18/clean-hospitals-coronavirus-statement/3. https://www.england.nhs.uk/coronavirus/wp-

content/uploads/sites/52/2020/03/specialty-guide-acute-treatment-cancer-23-march-2020.pdf

4. https://www.thelancet.com/action/showPdf?pii=S2468-2667%2820%2930060-85. https://www.england.nhs.uk/coronavirus/wp-

content/uploads/sites/52/2020/03/specialty-guide-acute-treatment-cancer-23-march-2020.pdf

6. https://www.bgs.org.uk/sites/default/files/content/attachment/2018-07-05/rockwood_cfs.pdf

7. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty-guide-surgery-and-coronavirus-v1-16-march-2020.pdf

8. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0094-Letter-to-Cancer-Alliances-6-April.pdf

9. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0119-_Maintaining-cancer-services-_-letter-to-trusts.pdf

10. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/877728/T1_Recommended_PPE_for_healthcare_workers_by_secondary_care_clinical_context_poster.pdf

baso~the association for cancer surgery - bahno · baso ~the association for cancer surgery at the...

Documents