Surgical cancer care in the COVID-19 era: front line views and consensus

Objective: to suggest a script for surgical oncology assistance in COVID-19 pandemic in Brazil. Method: a narrative review and a “brainstorming” consensus were carried out after discussion with more than 350 Brazilian specialists and renowned surgeons from Portugal, France, Italy and United States of America. Results: consensus on testing for COVID-19: 1All patients to be operated should be tested between 24 and 48 before the procedure; 2The team that has contact with sick or symptomatic patients should be tested; 3 Chest tomography was suggested to investigate pulmonary changes. Consensus on protection of care teams: 1 Use of surgical masks inside the hospitals. Use of N95 masks for all professionals in the operating room; 2 Selection of cases for minimally invasive surgery and maximum pneumoperitoneal aspiration before removal of the surgical specimen; 2 Optimization of the number of people in teams, with a minimum number of professionals, reducing their occupational exposure, the consumption of protective equipment and the circulation of people in the hospital environment; 3 Isolation of contaminated patients. Priority consensus: 1Construction of service priorities; 2 Interdisciplinary discussion on minimally invasive or conventional pathways. Conclusion: the Brazilian Society of Surgical Oncology (BSSO) suggests a script for coping with oncological treatment, remembering that the impoundment in the assistance of these cases, can configure a new wave of overload in health systems.


INTRODUCTION
T he estimate in Brazil for each year of the 2020-2022 triennium points out that there will be 625 thousand new cases of cancer (450 thousand when excluding cases of non-melanoma skin cancer). Non-melanoma skin cancer will be the most incident (177 thousand), followed by breast and prostate cancer (66 thousand each), colon and rectum (41 thousand), lung (30 thousand) and stomach (21 thousand). These data corroborate the magnitude of the problem 1,2 .
A few and limited studies address the risk of COVID-19 in cancer patients undergoing treatment. The association of these diseases and its relations with our population are still poorly understood 2 . The operational overload of health systems in the affected countries makes the situation even more worrisome [2][3][4][5] , especially in areas of scarce resources. However, data are lacking to understand the dynamics of the disease and its spread in a country with peculiar characteristics like Brazil 2 .
From the current information, we know that cancer patients may have a higher risk of manifestations of COVID-19 disease when compared with individuals without cancer 2,6-8 . In addition, cancer patients have  These routes must be agreed upon by local managers, both in public and private health, and must be prepared to meet the repressed demand of other units that specialize in caring for COVID-19 patients. Exceptional situations are highlighted, in which, due to an extreme emergency in public health, for a certain period the direct combat against the epidemic is required, abandoning the COVID-19 free condition. With the restoration of normality, these hospitals should also be the first to resume normal activities in view of the priority of the cases they provide care for.
Aiming also to produce knowledge, the SBCO Dr. Sepúlveda pointed out that until then, patients were not tested before surgery, and that this routine would have started that same week, 24 to 48 hours before the procedures. He remembered that false negatives are around 30%, and therefore, all surgical patients also undergo chest Computerized Tomography (CT) scans.
Pancreatic and liver cancer cases with few comorbidities and after neoadjuvancy are priority, and all are discussed in an interdisciplinary meeting. About liver transplants in that institution, they will be performed only in cases where the risk of death in this waiting period is greater than 50%. Another problem is the lack of donors.
The cases for laparoscopy are discussed individually, always taking care to deflate the entire pneumoperitonium before removing the surgical specimen, avoiding the spray of viral particles. The use of suitable masks is mandatory.
Then, Dr. Joaquim Abreu de Sousa, from IPO, Porto, Portugal, started his testimony. He explained that Portugal is still going through a different phase, but so far the case curve is similar to the French one.
He stressed that in his institution there is an attempt to maintain a COVID-free route to protect cancer patients, but the lack of tests makes effective diagnosis difficult. In their operating room, most elective surgeries take place, but they are already decreasing, as in the case of cytoreductive surgery with HIPEC and breast surgery.
He reported that many surgeries were postponed to increase availability for priority cases, delaying procedures that could be submitted to other treatment strategies, until the end of the crisis.
Laparoscopic surgeries were suspended. There is also an attempt to reduce the duration of the procedures, since this may be related to a higher risk of team contamination. The use of telemedicine, started about three weeks before, became a reality, since it was an instrument that had not been used before.   using the colors green, yellow and red, as follows: • Green: can wait > 2 months; • Yellow: can wait from 2 weeks to 2 months; • Red: can wait < 2 weeks.

DISCUSSION
It is a fact that surgical procedures that can wait should thus be treated. This cited difficulty refers to another need, that of developing a standardized informed consent form (ICF), with the help of legal advice, which legally protects the assistance team and ensures the understanding and the protagonism of the patient in therapeutic decision-making. The SBCO, through the crisis-response group, whose existence is 2. Discussion in meetings (preferably virtual) to assess priorities and the use of minimally invasive or conventional access routes 10,12 .