Page 38 - Swsthya Winter Edition Vol 1 Issu 3 DEC 2020 Circulation copy BP

SURGERY

benefits are marginal and different high risk procedures. significant challenges.
therapeutic options are available, and may
be safer. Decision-making should be patient-centred, Radiotherapy is a valid treatment however
taking into account the potential risk of radiation dosage and fractionation should
Further research is needed to expand our pursuing, delaying or omitting surgery, be optimised and adapted to the pandemic
knowledge on how best to manage cancer the most curative treatment strategy. It context. Hypofractionated regimens and
in older adults. The pandemic has produced has been repeatedly proven how ASA and shorter schedules may be preferable in the
barriers: efforts should be made to ensure ECOG-Karnofsky are unsatisfactory in curative setting.
prospective data is collected to elucidate predicting treatment outcomes.
the outcomes of COVID-19 in this age group. Conversely, a shorter course of adjuvant
Local and national health organizations Aside patients’ fitness and the number/ RT (26 Gy in 5 fractions) is also non-
attempted to minimize viral transmissions severity of comorbidities which may inferior to a standard regimen of 40 Gy in
and allocate resources for primary and influence the postoperative course, health- 15 fractions for patients with early-stage
[6]
secondary prevention, including home carers should consider tumour related breast cancer and could be considered as
confinement and social distancing of cancer factors as well as the presence of cancer- an alternative option in order to minimise
patients, limiting their hospital visits when related symptoms, besides risks associated the risk of exposing older patients to the
the risk of acquiring COVID-19 is high, and to the operation itself. viral infection. Modest hypofractionation
reducing iatrogenic immunosuppression could also be considered for early prostate
and treatment-related toxicities. Most elective surgical procedures can be cancer patients.
delayed safely, in view of reducing the
Several geriatric-focused issues have risk of COVID-19 infection. In the case of In the palliative setting, patients should be
been identified as a result of an imposed cancer surgery, the definition of “elective” offered the smallest number of fractions to
quarantine and social distancing; these is entirely dependent on the biology of the minimise the number of visits to hospital
(6)
include (a) feeling of estrangement, disease and the symptoms generated by and consequently the risk of exposure .
loneliness and neglect due to limited the tumour. There is no doubt that those
access to news or information, friends procedures aiming for a rapid relief of RT should be delayed in the absence of any
and family, particularly when access to symptoms (e.g. obstructions of the GI tube) significant impact on cancer outcomes. On
digital technology is lacking; (b) decline in or to minimize neurological complications the other hand, in case of curative intent
communication and comprehension not (e.g. spinal metastases and hip erosions or rapidly progressive disease, the risks
only due to isolation but also from wearing due to secondarisms) should be prioritised. of delaying RT will outweigh the risks of
masks and facial shield, more particularly On the other hand, surgical treatment of COVID-19 exposure and infection. Patients
so for hearing-impaired patients who rely non-invasive tumours (e.g. ductal in-situ already undergoing RT should be offered a
on lip reading and non-verbal cues; (c) loss carcinoma of the breast) can be delayed discussion about the risks and benefits of
of autonomy and ensuing dependency on since these are unlikely to impact on continuing it based on individual goals of
others to satisfy basic needs such as drugs survival. The risk of tumour progression care.
supplying, food and other home provisions with a delayed radical surgery should
due to travel restrictions or lack of access also be balanced against the availability of The potential tumour control offered by
to transportation. On the other hand, resources, including operating theatres that systemic treatment is unchanged during a
community support for seniors such as may been converted in Intensive Care Units pandemic, whereas risks may be increased,
cleaning, shopping and home maintenance (ICUs), the local ICU capacity, the number of especially for those regimens causing
to aid them cope with daily life have also been available anaesthetists, the risk of surgical myelosuppression or requiring frequent
disrupted. Therefore, several disabilities complications and the expected time to visits to hospital therefore increased
become a major handicap, which may lead recovery. There is evidence that operating infection exposure. The balance of harms
to an increased risk of institutionalisation. older patients with a confirmed COVID-19 and benefits remains uncertain as there
Institutionalised patients, such as those in infection exposes them to a higher 30-day is no evidence to suggest changing or
(5)
the nursing care facility are at higher risk risk of death . withholding it. Therefore, decision-making
of acquiring COVID-19 infection, increased should be individualised on the tumour
feeling of abandonment, as well as mental On the other hand, there is a window of biology, the type of therapy, the patients’
health problems [2,3] . opportunity which allows considering neo- general health status and his/her very own
adjuvant and less toxic treatments such preferences.
The impact of social isolation as a result of as endocrine therapy or radiotherapy, as
recommendations on physical distancing, a mean to delay surgery in selected cases: Geriatric Assessment has proven reliable
excessive risk of delirium with limitations under certain circumstances, the omission in predicting toxicity in older patients; its
in its management, and decisions regarding of surgery may be appropriate in case implementation is particularly appropriate
anticancer treatment, are important issues the impact on symptoms and survival in the context of the ongoing COVID-19
to assess and pro-actively address. is minimal, or when a safe and effective pandemic. The Cancer and Aging Research
The risk of delirium is high as well as alternative therapeutic option is available. Group (CARG) model takes into account age,
underestimated: when the current status This is the case of primary endocrine type of cancer, the proposed chemotherapy
of hospitals and other healthcare settings therapy for older patients with early-stage regimen, renal and hematologic function,
are becoming more “deliriogenic” and ER-positive, HER2-negative breast cancer. hearing, along with GA domains such as
visit times are restricted, staff members In a similar way, the use of radiation therapy ability to take medications, physical activity
(7)
are required to wear personal protective in older patients should be prioritised and social activity . The Chemotherapy
equipment (PPEs); patient interaction is according to the expected benefits and Risk Assessment Scale for High age (CRASH)
[4]
also minimized to avoid exposure . In the tumour biology, within the context is based on the specific chemotherapy
these times, it is paramount to evaluate of patients’ fitness and preference. In the regimen being considered as well as
and stratify the risk of delirium in patients older age group, travelling constraints, laboratory values (creatinine, albumin,
who are candidates for chemotherapy and daily hospital visits and patients’ concerns haemoglobin, lactate dehydrogenase,
surgery since both treatments can become regarding exposure may represent liver function tests) and assessments of

38 Volume: 1 I Issue: 3 I 2020