The novel COVID-19 pandemic has generated substantial upheaval worldwide and has impaired the ability of the hospitals to diagnose and treat cancer patients. Faced with these challenges, we enacted a series of measures, which have yielded positive results. Given cancer patients’ increased susceptibility to viral infections (6,7), thorough epidemiological screening before outpatient admission ensured the safety of our patients. Beyond the outpatient clinic rational, selection of patients and proper allocation of resources helped us maintain most treatments involving surgery and chemotherapy for CRC patients, while focusing on routine clinical care practices and observing patient responses prevented complication rates in surgeries from increasing. On March 24, the Shanghai Municipal Government downgraded its major public health emergency first-level response to a second-level response (13). Since then, clinical work has gradually resumed to its original state, and some of the delayed treatments were performed in April.
Since the pandemic, public transport has been restricted, and nonlocal patients have been unable to enter Shanghai for treatment. Among local patients, elderly patients are at a greater risk of infection, and consequently, many have also been unwilling to undergo treatment. This inability for these two groups of cancer patients to receive outpatient treatment is evident in the significant reduction in outpatient volume after the pandemic began, as shown in this study’s results. In response, as previously discussed, we established a telemedicine networking platform to provide outpatient care and medical advice online, and only recommended online patients experiencing serious adverse events to be treated at our center. Through such online medical counseling, we effectively maintained treatment and patient follow-ups, thereby reducing mortality, while ensuring the safety of patients.
Adjuvant chemotherapy and palliative chemotherapy have had a great impact on the long-term prognosis of CRC patients. However, the immunosuppressive effects of chemotherapy have made their use controversial (6). At our center, despite restricting the number of patients who received chemotherapy during the pandemic, administration of oral chemotherapy and intravenous immunotherapies were maintained at normal levels. We believe that during the epidemic, adjuvant chemotherapy should not be discontinued, given its importance for ensuring survival of CRC patients. However, intravenous chemotherapy can be discontinued and replaced with oral chemotherapy in elderly patients (14). In addition, we believe that chemotherapy and immunotherapy must be maintained for advanced patients if the patient is confirmed to be free of infection. Otherwise, tumor-related mortality in these patients would increase.
As coronavirus is capable of fecal–oral transmission (4,5), endoscopy might serve as a vector for viral transmission. Consequently, our center discontinued nonurgent endoscopies and endoscopic treatments from February to March, as evident in the 76.1% reduction in the number of patients that underwent endoscopic treatment after the pandemic began. This number has gradually recovered after coronavirus infection rates were significantly reduced in April. Although we believe that endoscopy can be performed selectively during the outbreak, patients must be strictly screened, and only infection-free patients should undergo endoscopy. Moreover, all medical equipment should be strictly disinfected to ensure patient safety. Finally, we suggest that routine endoscopy should only be performed in patients with newly diagnosed colorectal tumors or polyps who are waiting for pathological confirmation. Endoscopies for patients who are routinely monitored through follow-ups can be delayed and replaced by other imaging modalities, such as CT or MRI. If a recurrence or metastasis is found, endoscopies should be resumed. In newly diagnosed patients, endoscopic polypectomy can be postponed if polyps are small or pathologically benign.
During the pandemic, colorectal surgery experienced many problems, including a lack of available blood for transfusions. We further debated the ethical merits of treating elderly patients who may be at a greater risk for viral infection if surgically treated (15-21). Consequently, while more than 700 curative enterectomies were performed during the pandemic, this represented a significant decrease from the number of surgeries performed during the same period in 2019. To ensure the safety of inpatients and medical staff, “infection-free” wards were established. In addition to a proof of admission, only patients and their accompanying guests who presented a proof of stay in Shanghai for 14 days were admitted to the wards.
Through the reasonable triaging of surgical procedures, selection of patients, deployment of medical resources, and careful pre-operation and post-operation observations, we maintained a large volume of surgeries as well as surgical safety. First, we agree that elective surgeries, such as apothesis after an enterostomy, can be delayed (15). Second, palliative surgeries can also be postponed unless the patient experiences serious tumor-related complications that require urgent enterostomy for decompression. Third, owing to the lack of available blood resources, multidisciplinary surgery for CRC with peripheral invasion or liver metastasis is not recommended. In particular, massive bleeding may occur during hepatic surgery. Staged resection combined with chemotherapy is suggested as an alternative. Fourth, curative surgeries should be performed for resectable CRC patients during the pandemic. Close observation and surveillance should be performed both in pre- and post- operation periods, and prolonged hospital stay ensures surgical safety. It is also important to generate a quick workflow to distinguish suggested infected patients from those with postoperative infection and tumor fevers, which has allowed us to identify and treat oncological complications. Last, elderly patients (aged >70 years) are at a greater risk of infection owing to both their cancer and age (17). However, we believe that elderly patients are not a surgical taboo, and regular curative surgery should be performed for those who meet the indications of surgery when strict infection prevention measures are met.
There are no compelling data supporting the notion that respiratory or blood-borne infectious viruses can be transmitted through surgical plumes or aerosolized laparoscopic gas. Laparoscopy is less traumatic compared with laparotomy, which may expedite recovery when compared with an open procedure. Laparoscopy allows for a self-contained operative field, which reduces the spillage of fluids and tissues, thereby decreasing the risk of operative staff to infection. Thus, we recommend the use of laparoscopy during the pandemic.
We recommend prophylactic enterostomy for patients who are at high risk for complications to improve surgical safety in the perioperative period. We also recommend neoadjuvant radiotherapy treatment, in accordance with the European guidelines (22), particularly for elderly patients. Neoadjuvant radiotherapy can contribute to tumor progression control (23) and allow for resource re-allocation, given staffing shortages. Once the pandemic is completed, we will perform curative resection for these patients.
There are some limitations in our research. First, this is a retrospective single-center study. Second, the results of our efforts during the pandemic have yet to be confirmed with longer follow-up times.