Endocrine surgery in the Coronavirus disease 2019 pandemic: Surgical Triage Guidelines

Impact of COVID-19 pandemic on thyroidectomy for malignant diseases in high-volume referral centers

INTRODUCTION

The COVID-19 pandemic has limited the availability of healthcare resources for non-COVID patients and decreased elective surgeries, including thyroidectomy. Despite the prioritization of surgical procedures, it has been reported that thyroidectomy for thyroid cancer (TCa) was adversely impacted. We assessed the impact of the pandemic on the surgical activities of two high-volume referral centers.

MATERIALS AND METHODS

Patients operated at two National Referral Centers for Thyroid Surgery between 03/01/2020 and 02/28/2021 (COVID-19 period) were included (P-Group). The cohort was compared with patients operated at the same Centers between 03/01/2019 and 02/29/2020 (pre-COVID-19 pandemic) (C-Group).

RESULTS

Overall, 7017 patients were included: 2782 in the P-Group and 4235 in the C-Group. The absolute number of patients with TCa was not significantly different between the two groups, while the rate of malignant disease was significantly higher in the P-Group (1103/2782 vs 1190/4235) (P < 0.0001). Significantly more patients in the P-Group had central (237/1103 vs 232/1190) and lateral (167/1103 vs 140/1190) neck node metastases (P = 0.001). Overall, the complications rate was significantly lower (11.9% vs 15.1%) and hospital stay was significantly shorter (1.7 ± 1.5 vs 1.9 ± 2.2 days) in the P-Group (P < 0.05).

CONCLUSION

The COVID-19 pandemic significantly decreased the overall number of thyroidectomies but did not affect the number of operations for TCa. Optimization of management protocols, due to limited resource availability for non-COVID patients, positively impacted the complication rate and hospital stay.

Impact of COVID-19 on operating assignments in residency training of endocrine surgery: A retrospective cohort study

PURPOSE

Airborne pandemics illustrate a significant problem in training grounds. From the endocrine surgery point of view, we scrutinized the impact of Covid-19 on general surgery residency training in our university hospital.

METHODS

The number of endocrine procedure curves was forecasted using the expert modeler in a time series model from March to September 2020 based on data from previous years. We then compared the estimation curves to actual numbers.

RESULTS

There were 1340 resident participants in thyroid procedures, 405 in parathyroid procedures, 65 in other neck procedures, and 304 in adrenal procedures. In 884 of the endocrine procedures, the operating surgeon was a resident. The median experience of operating residents in endocrine procedures was 3.2 years (interquartile range 2.7-3.6) before the impact and 3.8 years (interquartile range 3.1-4.1) after it (p = 0.023). The monthly number of actual procedures with at least one resident participation in the Covid-19 period was significantly lower (8.7 ± 7.5 vs. 19.9 ± 3.7, p = 0.012) than the forecasted numbers. There were no semi-autonomous operating chief residents, although we expected a moderate level (0 actual vs. 0.5 ± 0.2 predicted, p = 0.002).

CONCLUSION

This study clearly represents sustainability in surgical training and includes usual trends. Essential endocrine surgical procedures the pandemic disrupted the most were the treatment of thyroid and parathyroid diseases. Covid-19 reduced our surgical volume and resulted in delays in training. A full-scale disaster plan is necessary for possible crises threatening surgical education.

Delay in Surgery and Papillary Thyroid Cancer Survival in the United States: A SEER-Medicare Analysis

INTRODUCTION

Delays in surgery and their impact on survival in papillary thyroid cancer (PTC) is unclear. We sought to investigate the association between time to surgery and survival in patients with PTC.

METHODS

A total of 8170 Medicare beneficiaries with PTC who underwent thyroidectomy were identified within the Surveillance, Epidemiology, and End Results-Medicare linked data files between 1999 and 2018. Disease-specific survival (DSS) and overall survival (OS) were estimated using Kaplan-Meir analysis, and Cox proportional hazards models were specified to estimate the association between time to surgery and survival.

RESULTS

Among 8170 patients with PTC, mean age 69.3 (SD+/- 11.4), 89.8% had surgery within the first 90 days, 7.8% had surgery 91 to 180 days from diagnosis, and 2.4% had surgery after 180 days. Increasing time to surgery was associated with increased mortality for OS in the >180-day group [adjusted hazard ratio (aHR) 1.24; 95% CI, 1.01-1.53]. Moreover, on stratification by summary stage, those with localized disease in the 91- to 180-day group increased risk by 25% (aHR 1.25; 95%CI, 1.05-1.51), and delaying over 180 days increased risk by 61% (aHR 1.61; 95%CI, 1.19-2.18) in OS. Those with localized disease in the >180-day group had almost 4 times the estimated rate of DSS mortality (aHR3.51; 95%CI, 1.68-7.32). When stratified by T stage, those with T2 disease in the >180 days group had double the estimated rate of all-cause mortality (aHR 2.0; 95% CI, 1.1-3.3) and almost triple the estimated rate of disease-specific mortality (aHR 2.7; 95% CI, 1.05-6.8).

CONCLUSIONS

Delays in surgery for PTC may impact OS and DSS in localized disease, prior to nodal metastasis.

The effect of COVID-19 process on patients with endocrinological disease in a pandemic hospital: What happened to the others?

Objective

To evaluate the effects of the pandemic process on those with an endocrinological disease that will require close follow-up from the last visit before the pandemic.

Materials and Methods

Patients of 3,903 with thyroid, calcium-bone metabolism, adrenal gland, pituitary diseases, and neuroendocrine tumor (NET) were retrospectively scanned. The remaining 855 (656 females and 199 males) patients with active disease or who still needed multidisciplinary approaches were included. The number of patients who continued the disease-related medical procedures and could complete these procedures on time in the pandemic period was determined, and medical deprivation rate (MDR) was calculated.

Results

The prepandemic period of our patients with thyroid disease (n = 594), calcium-bone metabolism disorder (n = 130), adrenal disease (n = 85), pituitary disease, and NET (n = 46) had MDRs of 85%, 56%, 81%, and 89%, respectively. For each subgroup of patients, the lowest MDR (67%) was in medullary thyroid carcinoma, the highest MDR (89%) was in differentiated thyroid carcinoma; the lowest MDR (6%) was in osteoporosis, the highest MDR (100%) was in the active Paget's disease; the lowest MDR (0%) was in primary adrenocortical insufficiency, the highest MDR (100%) was in hyperfunctional adrenal adenomas; the lowest MDR (81%) was in pituitary nonfunctional adenomas, and the highest MDR (100%) was in Cushing's disease, active prolactinoma, TSHoma, and NET, respectively.

Conclusion

This study showed that not only those who had COVID-19 but also those who had medical deprivation due to their current endocrinological disease were not to be underestimated during the pandemic period.

Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19

BACKGROUND

The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans.

METHODS

American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon.

RESULTS

Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ² = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66).

CONCLUSION

Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.

Thyroid surgery during the COVID-19 pandemic: difficulties - how to improve

In December 2019, the new coronavirus infection (COVID-19) was declared a pandemic by the World Health Organization after rapidly spreading over the world in just a few months. All elective operations and nonemergency treatments have been postponed worldwide. However, some patients require surgical therapy as well, and the time spent waiting should not have a negative impact on the surgical outcome or disease course. Following the initial onset of the COVID-19 epidemic, instructions for proper and safe surgery for healthcare staff and patients should develop. Thyroid surgeries have decreased during the COVID-19 pandemic. Most of them can be postponed for a long time. Assessment of thyroid nodules recommends clinical examination, imaging studies, fine needle aspiration (FNA) and vocal cord examination. All these procedures are necessary, and sometimes they cannot be postponed. To determine the best timing, a thorough preoperative assessment should be undertaken, taking into account both oncological and anatomical features. Furthermore, COVID-19 status must be negative prior to any intervention, and hospital infrastructure must be ready to deal with the demanding situation.

Analysis of Delayed Surgery and Clinical Outcomes in Intermediate- and High-risk Papillary Thyroid Cancer

CONTEXT

The optimal timing to performing thyroid surgery following a diagnosis of papillary thyroid cancer (PTC) has yet to be fully defined.

OBJECTIVE

We aimed to examine if a delayed surgery may worsen the clinical outcome of PTC patients with intermediate- to high-risk of recurrence.

METHODS

All consecutive PTC patients with intermediate- to high-risk of recurrence who underwent total thyroidectomy and radioactive iodine (RAI) ablation at 3 tertiary hospitals in southwest China were retrospectively included. Excellent response at 1-year follow-up after initial therapy was defined as no clinical, imaging, or biochemical evidence of PTC. Association of the timing of surgery and excellent response rates.

RESULTS

The study included 871 patients. The median time interval between PTC diagnosis and surgery was 2 months (range, 1-87 months). Patients were divided according to the timing of surgery, < 6 months (group A, 624/871 [71.6%]), ≥ 6 to 11 months (group B, 123/871 [14.1%]), or ≥ 12 months (group C, 124/871 [14.2%]). One year after initial therapy, 64.7%, 71.5%, and 66.1% of patients in groups A, B, and C, respectively, achieved excellent response (P = 0.27). The lack of impact of surgery timing was observed across intermediate- to high-risk classifications and all T stage categories. These findings did not change when we separately analyzed the groups according to RAI dose (intermediate-dose group: ≤ 3.7 GBq [n = 654], and high-activity group: 5.5 GBq [n = 217]) further subdivided according to the timing of surgery.

CONCLUSION

Timing of surgery does not seem to affect short-term disease outcomes in intermediate- to high-risk PTC patients. Further research is necessary to assess the impact of delayed surgery on long-term prognosis.

Safe provision of elective endocrine surgery operations amid the COVID-19 crisis

INTRODUCTION

The aim of this study was to determine the impact of the COVID-19 pandemic on the provision of clinical services (perioperative clinical outcomes and productivity) of the department of endocrine and general surgery at a teaching hospital in the UK.

METHODS

A retrospective chart review was conducted of all patients who were operated in our department during two periods: 1 April to 31 October 2019 (pre-COVID-19 period) and 1 April to 31 October 2020 (COVID-19 period). The perioperative clinical outcomes and productivity of our department for the two time periods were compared.

RESULTS

In the pre-COVID-19 period, 130 operations were carried out, whereas in the COVID-19 group, this reduced to 89. The baseline characteristics between the two groups did not significantly differ. Parathyroid operations decreased significantly by 68% between the two study periods. Overall, during the COVID-19 phase, the department maintained 68% of its operating workload compared with the respective 2019 time period. The clinical outcomes for the patients who had a thyroid/parathyroid/adrenal operation were not statistically different for the two study periods. There were no COVID-19 related perioperative complications for any of the operated patients and no patient tested positive for COVID-19 while an inpatient. For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies.

CONCLUSIONS

The COVID-19 pandemic significantly reduced the clinical activity of our department. However, it is possible to continue providing clinical services for urgent/cancer cases with the appropriate safety measures in place.

Thyroid surgery during the COVID-19 pandemic: results from a systematic review

PURPOSE

During the COVID-19 pandemic, elective thyroid surgery is experiencing delays. The problem is that the COVID-19 pandemic is ongoing. The research purposes were to systematically collect the literature data on the characteristics of those thyroid operations performed and to assess the safety/risks associated with thyroid surgery during the COVID-19 pandemic.

METHODS

We used all the procedures consistent with the PRISMA guidelines. A comprehensive literature in MEDLINE (PubMed) and Scopus was made using ''Thyroid'' and "coronavirus" as search terms.

RESULTS

Of a total of 293 articles identified, 9 studies met the inclusion criteria. The total number of patients undergoing thyroid surgery was 2217. The indication for surgery was malignancy in 1347 cases (60.8%). Screening protocols varied depending on hospital protocol and maximum levels of personal protection equipment were adopted. The hospital length of stay was 2-3 days. Total thyroidectomy was chosen for 1557 patients (1557/1868, 83.4%), of which 596 procedures (596/1558, 38.3%) were combined with lymph node dissections. Cross-infections were registered in 14 cases (14/721, 1.9%), of which three (3/721, 0.4%) with severe pulmonary complications of COVID-19. 377 patients (377/1868, 20.2%) had complications after surgery, of which 285 (285/377, 75.6%) hypoparathyroidism and 71 (71/377, 18.8%) recurrent laryngeal nerve injury.

CONCLUSION

The risk of SARS-CoV-2 transmission after thyroid surgery is relatively low. Our study could promote the restart of planned thyroid surgery due to COVID-19. Future studies are warranted to obtain more solid data about the risk of complications after thyroid surgery during the COVID-19 era.

Impact of the Coronavirus Disease Pandemic on the Annual Thyroid, Parathyroid, and Adrenal Surgery Volume in a Tertiary Referral Endocrine Surgery Center in 2020

Objective:

The purpose of the study was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on endocrine surgical volumes.

Methods:

There were periodic surgical restriction sin our country in 2020 due to the pandemic. Endocrine surgery volumes at the Division of Endocrine Surgery, Istanbul Medical Faculty were compared between 2019 and 2020.

Results:

The surgical volume reduction in 2020 compared to 2019 was 20%, 54.5%, and 40% for thyroid, parathyroid, and adrenal surgery, respectively. Surgical volume for thyroidectomy for benign nodular goiter and parathyroidectomy significantly decreased, whereas adrenal surgery showed no significant difference in 2020 compared to 2019. No significant difference was found in the rates of thyroid cancer and adrenocortical cancer surgery in 2020compared to 2019.

Conclusion:

The COVID-19 outbreak led to a significant reduction in the annual rates of parathyroidectomy and thyroidectomy for benign goiter, whereas the volume of thyroid cancer and adrenal surgeries were similar to the previous year.

Thyroid cancer surgery during the coronavirus disease 2019 pandemic: perioperative management and oncological and anatomical considerations

The coronavirus disease 2019 (COVID-19) pandemic has changed many aspects of our everyday lives and medical practice, including oncology treatment; thyroid cancer surgery is not an exception. The reported number of fine-needle aspirations performed during the first semester of 2020 was significantly reduced. Poorly differentiated, medullary and anaplastic thyroid tumors are considered important indications for immediate surgical intervention. By contrast, most well-differentiated carcinomas present slow growth, and thus surgery can be deferred for a short period of time during which patients are under active surveillance. Thyroid surgeries have decreased during the COVID-19 pandemic. Furthermore, prior to any intervention, negative COVID-19 status - with the use of a nasopharyngeal swab and reverse transcription PCR assay as the gold standard and chest CT scan as a complementary modality in some cases - must be confirmed to achieve a COVID-free pathway. Thorough preoperative assessment regarding both oncological and anatomical aspects should be performed to identify optimal timing for safe management.

Endocrine Surgical Procedures During COVID-19: Patient Prioritization and Time to Surgery

BACKGROUND

We tracked endocrine surgery patients with treatment delays due to COVID-19 to investigate the relationship between physician assigned priority scoring (PAPS), the Medically Necessary, Time Sensitive (MeNTS) scoring system and delay to surgery.

MATERIAL & METHODS

Patients scheduled for endocrine surgery or clinically evaluated during COVID-19-related elective surgery hold at our institution (2/26/20-5/1/20) were prospectively enrolled. PAPS was assigned based on categories of high, moderate, or low risk, consistent with the American College of Surgeons' priority system. MeNTS scores were calculated. The primary outcome was delay to surgery. Descriptive statistics were performed, and receiver operator characteristic (ROC) curves and area under the curve (AUC) values were calculated for PAPS and MeNTS.

RESULTS

Of 146 patients included, 68% (n = 100) were female; the median age was 60 years (IQR:43,67). Mean delay to surgery was significantly shorter (P = 0.01) in patients with high PAPS (35 d), compared with moderate (61 d) and low (79 d) PAPS groups. MeNTS scores were provided for 105 patients and were analyzed by diagnosis. Patients with benign thyroid disease (n = 17) had a significantly higher MeNTS score than patients with thyroid disease which was malignant/suspicious for malignancy (n = 44) patients (51.5 versus 47.6, P = 0.034). Higher PAPS correlated well with a delay to surgery of <30 d (AUC: 0.72). MeNTS score did not correlate well with delay to surgery <30 d (AUC: 0.52).

CONCLUSION

PAPS better predicted delay to surgery than MeNTS scores. PAPS may incorporate more complex components of clinical decision-making which are not captured in the MeNTS score.

Osteoporosis care amidst the prolonged pandemic

As SARS-CoV-2 stunned and overtook everyone's lives, multiple daily briefings, protocols, policies and incident command committees were mobilized to provide frontline staff with the tools, supplies and infrastructure needed to address the COVID-19 pandemic. Medical resources were immediately shifted. In light of the necessity for self-isolation, telemedicine was expanded, although there has been concern than non-pandemic disorders were being ignored. Ambulatory care services such as bone densitometry and osteoporosis centered clinics came to a near halt. Progress with fracture prevention has been challenged. Despite the prolonged pandemic and the consequent sense of exhaustion, we must re-engage with chronic bone health concerns and fracture prevention. Creating triaging systems for bone mineral testing and in person visits, treating individuals designated as high risk of fracture using fracture risk assessment tools such as FRAX, maintaining telemedicine, leveraging other bone health care team members to monitor and care for osteoporotic patients, and re-engaging our primary care colleagues will remain paramount but challenging. The pandemic persists. Thus, we will summarize what we have learned about COVID-19 and bone health and provide a framework for osteoporosis diagnosis, treatment, and follow-up with the extended COVID-19 pandemic. The goal is to preserve bone health, with focused interventions to sustain osteoporosis screening and treatment initiation/maintenance rates.

COVID-19 and the Endocrine System: A Comprehensive Review on the Theme

Background and aim. The review aimed to summarize advances in the topic of endocrine diseases and coronavirus disease 2019 (COVID-19). Methods. Scientific and institutional websites and databases were searched and data were collected and organized, when plausible, to angle the discussion toward the following clinical issues. (1) Are patients with COVID-19 at higher risk of developing acute or late-onset endocrine diseases or dysfunction? (2) May the underlying endocrine diseases or dysfunctions be considered risk factors for poor prognosis once the infection has occurred? (3) Are there defined strategies to manage endocrine diseases despite pandemic-related constraints? Herein, the authors considered only relevant and more frequently observed endocrine diseases and disorders related to the hypothalamic-pituitary region, thyroid and parathyroid glands, calcium-phosphorus homeostasis and osteoporosis, adrenal glands, and gonads. Main. Data highlight the basis of some pathophysiological mechanisms and anatomical alterations of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)-induced endocrine dysfunctions. Some conditions, such as adrenal insufficiency and cortisol excess, may be risk factors of worse clinical progression once the infection has occurred. These at-risk populations may require adequate education to avoid the SARS-CoV-2 infection and adequately manage medical therapy during the pandemic, even in emergencies. Endocrine disease management underwent a palpable restraint, especially procedures requiring obligate access to healthcare facilities for diagnostic and therapeutic purposes. Strategies of clinical triage to prioritize medical consultations, laboratory, instrumental evaluations, and digital telehealth solutions should be implemented to better deal with this probably long-term situation.

Systematic review of international guidelines for head and neck oncology management in COVID-19 patients

Purpose

The coronavirus pandemic has redefined the practice of head and neck surgeons in the management of oncology patients. Several countries have issued practice recommendations in that context. This review is a collaboration of the YO-IFOS (Young Otolaryngologists of the International Federation of Otolaryngological Societies) group in order to summarize, in a systematic way, all available guidelines and provide clear guidelines for the management of head and neck cancer patients in the COVID-19 pandemic.

Methods

This systematic review was performed according to the PRISMA statements. Inclusion criteria for the systematic review were based on the population, intervention, comparison, and outcomes according to (PICO) framework. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to assess quality of all practice guidelines included in this review.

Results

Recommendations include adjustments regarding new patients’ referral such as performing a pre-appointment triage and working in telemedicine when possible. Surgical prioritization must be adjusted in order to respect pandemic requirements. High-grade malignancies should, howeve,r not be delayed, due to potential serious consequences. Many head and neck interventions being aerosol-generating procedures, COVID-19 testing prior to a surgery and adequate PPE precautions are essential in operating rooms.

Conclusion

These recommendations for head and neck oncology patients serve as a guide for physicians in the pandemic. Adjustments and updates are necessary as the pandemic evolves.

Multimorbidity patterns among COVID-19 deaths: proposal for the construction of etiological models

OBJECTIVES

To describe patterns of multimorbidity among fatal cases of COVID-19, and to propose a classification of patients based on age and multimorbidity patterns to begin the construction of etiological models.

METHODS

Data of Colombian confirmed deaths of COVID-19 until June 11, 2020, were included in this analysis (n=1488 deaths). Relationships between COVID-19, combinations of health conditions and age were explored using locally weighted polynomial regressions.

RESULTS

The most frequent health conditions were high blood pressure, respiratory disease, diabetes, cardiovascular disease, and kidney disease. Dyads more frequents were high blood pressure with diabetes, cardiovascular disease or respiratory disease. Some multimorbidity patterns increase probability of death among older individuals, whereas other patterns are not age-related, or decrease the probability of death among older people. Not all multimorbidity increases with age, as is commonly thought. Obesity, alone or with other diseases, was associated with a higher risk of severity among young people, while the risk of the high blood pressure/diabetes dyad tends to have an inverted U distribution in relation with age.

CONCLUSIONS

Classification of individuals according to multimorbidity in the medical management of COVID-19 patients is important to determine the possible etiological models and to define patient triage for hospitalization. Moreover, identification of non-infected individuals with high-risk ages and multimorbidity patterns serves to define possible interventions of selective confinement or special management.

What is the best treatment option for head and neck cancers in COVID-19 pandemic? A rapid review

With the onset of the COVID-19 crisis in late 2019, the health care systems of different countries are experiencing stressful conditions. Many patients need care in hospital wards and intensive care units (ICU). Head & neck cancers (HNC) are in a special condition in this pandemic. The main treatment in these patients is surgery. Most of these patients need care in the ICU, which is reduced in capacity in pandemic conditions. It's important to note that delays in the surgery of these patients make them non-operable and on the other hand increase mortality and morbidity. Numerous non-surgical alternative therapies have been proposed in these conditions, but there are fundamental questions about these suggestions. 1 How long should we look for alternative therapies? Because many countries are facing a second wave of the disease. 2 What's the effect of these alternative therapies and the delay in starting standard treatments in patients' survival?

Different countries have different financial resources; many countries, patients face restrictions on receiving alternative therapies to standard treatments, and in non-pandemic conditions, long queues are given for non-surgical treatments such as chemo-radiotherapy. There are numerous guidelines to guide head and neck surgeons to the best choice in this situation. It seems that different countries have to make individual decisions based on the prevalence of COVID-19 and the financial resources and facilities of the health care system.

In this review article, we have collected the opinions of world-renowned guidelines and institutions on how to treat HNCs during the pandemic.

The ongoing COVID-19 pandemic will create a disease surge among cancer patients

With major parts of the United States in lockdown, parts of Europe and the UK possibly going back on lockdown or expecting a second COVID-19 wave and rapidly rising rates elsewhere other than Asia, many people are forgoing regular cancer screenings and prevention services. More worrisome, some may be experiencing early signs or symptoms, yet they are not seeking evaluation, treatment or surveillance examinations. The long-term impact of this on patients, families and health care providers will be substantial. Not only will this strain sophisticated health systems in developed countries, but it will also overwhelm the health care infrastructure in developing countries.

Health-care executives, cancer center directors, oncologists and policy experts should focus now on serving this potential “third wave” of sick patients who have delayed treatment. Stopping COVID-19 is critical. However, it’s also essential to plan for the coming wave of patients who have delayed seeking care or don’t have access.

A Review of Clinical Practice Guidelines and Treatment Recommendations for Cancer Care in the COVID-19 Pandemic

The COVID-19 pandemic has inevitably caused those involved in cancer care to change clinical practice in order to minimize the risk of infection while maintaining cancer treatment as a priority. General advice during the pandemic suggests that most patients continue with ongoing therapies or planned surgeries, while follow-up visits may instead be delayed until the resolution of the outbreak. We conducted a literature search using PubMed to identify articles published in English language that reported on care recommendations for cancer patients during the COVID-19 pandemic from its inception up to 1st June 2020, using the terms "(cancer or tumor) AND (COVID 19)". Articles were selected for relevance and split into five categories: (1) personal recommendations of single or multiple authors, (2) recommendations of single authoritative centers, (3) recommendations of panels of experts or of multiple regional comprehensive centers, (4) recommendations of multicenter cooperative groups, (5) official guidelines or recommendations of health authorities. Of the 97 included studies, 10 were personal recommendations of single or multiple independent authors, 16 were practice recommendations of single authoritative cancer centers, 35 were recommendations provided by panel of experts or of multiple regional comprehensive centers, 19 were cooperative group position papers, and finally, 17 were official guidelines statements. The COVID-19 pandemic is a global emergency, and has rapidly modified our clinical practice. Delaying unnecessary treatment, minimizing toxicity, and identifying care priorities for surgery, radiotherapy, and systemic therapies must be viewed as basic priorities in the COVID-19 era.

Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

Head and neck surgical oncology in the time of a pandemic: Subsite-specific triage guidelines during the COVID-19 pandemic

BACKGROUND

COVID-19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of health care personnel.

METHODS

The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging head and neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular.

RECOMMENDATIONS

Each subsite is presented separately with disease-specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred.

CONCLUSION

These guidelines are intended to help clinicians caring for patients with HNC appropriately allocate resources during a health care crisis, such as the COVID-19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability.

Endocrine surgery in the Coronavirus disease 2019 pandemic: Surgical Triage Guidelines

Background

In the face of the COVID‐19 pandemic, cancer care has had to adapt rapidly given the Centers for Disease Control and Prevention and the American College of Surgeons (ACS) issuing recommendations to postpone nonurgent surgeries.

Methods

An institutional multidisciplinary group of Head and Neck Surgical Oncology, Surgical Endocrinology, and Medical Endocrinology devised Surgical Triaging Guidelines for Endocrine Surgery during COVID‐19, aligned with phases of care published by the ACS.

Results

Phases of care with examples of corresponding endocrine cases are outlined. Most cases can be safely postponed with active surveillance, including most differentiated and medullary thyroid cancers. During the most acute phase, all endocrine surgeries are deferred, except thyroid tumors requiring acute airway management.

Conclusions

These guidelines provide context for endocrine surgery within the spectrum of surgical oncology, with the goal of optimal individualized multidisciplinary patient care and the expectation of significant resource diversion to care for patients with COVID‐19.