Cancer COVID-19 (coronavirus) The Brief: Colorectal Cancer Blog

To patients awaiting cancer surgery: you are not alone

A patient and cancer care provider
Dr. Shady Ashamalla

Q: While everyone is struggling with the coronavirus global pandemic and all the social, financial and health consequences, I’m doing it with a cancer diagnosis — with no treatment yet. Now what?

A: There is so much uncertainty in all of our lives right now but I will start with this: you are not alone. You are not alone in your situation, and you are absolutely not alone in managing this unparalleled challenge. My response to your question will be in general terms because I do not know your specific clinical situation. But also, because I’ve spoken a lot to my cancer physician colleagues throughout this, I know I speak for many of them. So if you are facing cancer right now, wherever you are in Ontario, this response is for you.

A global pandemic

On March 12, everything changed. The World Health Organization officially declared COVID-19 a global pandemic, and life as we knew it closed and shuttered.

Even with weeks of lead up and preparation, this was a precise moment of pivot in Canada.

Sunnybrook launched its structured pandemic plan. The government asked that all hospitals drastically scale back their elective surgeries.

Of course this led to questions: What’s an elective surgery? Is cancer surgery really considered elective?

Elective surgery is any surgery that can safely be done at a later time. So the short answer is yes. Cancer surgeries were to be scaled back.

Here’s the long answer. Learning from the experiences of other countries around the world, it was obvious that a potential surge of COVID-19 patients was looming. With hospitals functioning at or near full occupancy (meaning there are people in every bed) at any given time, there was an urgency to create capacity in the system for what was coming. Without planned surgery, fewer people need to recuperate in the hospital, which means beds can be empty and available in case of an influx of COVID-19 patients.

Also, with any staff member with even the slightest cold-like symptoms not able to work, reducing activity helps make sure there’s enough healthy staff to take care of all the patients in hospital.

And lastly, and most importantly, it was clear that hospitals could become ground zero for this pandemic. So reducing hospital activity aims also to keep the public away from the epicentre of the disease, when at all possible.

So with all this in mind and to ensure the safety of patients and staff, all hospitals in Ontario began visitor restrictions, started allowing only essential staff to work on site, and immediately postponed many surgeries, including cancer surgeries.

Difficult conversations

As a surgical oncologist with a practice dedicated to colorectal cancer, the impact was immediately profound. I called every planned surgery patient and explained their surgery was no longer scheduled and that I would call them as soon as their operation could be completed based on a complex triage system. I will always remember these conversations as amongst the most difficult of my career. These were people that I had promised to help, patients I had asked to trust in me to remove their cancers and get them back to their lives. These therapeutic relationships of trust define what it means to be a cancer surgeon; now we were having discussions I had never rehearsed or imagined. I can only imagine the fear and horror of being on the receiving end of these phone calls. After first dealing with the fear and vulnerability of accepting surgery, now my patients faced fear of not having this same surgery as scheduled.

During these conversations, I tried my best to reiterate: these are difficult steps being taken across the province and country. We are in this together. You are not alone in managing this challenge. You are not forgotten.

Who does get cancer surgery during a global pandemic?

Guided by the Ontario Health-Cancer Care Ontario (OH-CCO) pandemic plan, every cancer surgeon sprang into action to review each one of their patients and place them into a defined category as outlined by OH-CCO.

At Sunnybrook, every delayed cancer patient was reviewed at a virtual ‘cancer conference’ that included surgeons, medical and radiation oncologists, radiologists, geneticists, nurses and pathologists. Together we discussed every patient’s situation to ensure the categories were as accurate as possible.

We know that not all cancers behave the same and not all tumour biology is identical. That means there is variability in the urgency of surgery that allows us to use this triage system. The surgical administrative leadership then worked through this triage plan to ensure that all ‘Priority A and B’ cancer surgeries would have surgery in a timely way and not be overly postponed. The definition of Priority A and B are patients who, if not operated on within 4 weeks, would suffer a significant change in their prognosis. Our entire oncology team used our expertise and knowledge to protect all cancer patients from a ‘significant change in prognosis’.

The team meets daily to review the patient lists to ensure no decision remains static; these decisions are fluid and can change. We determine each day’s surgical list 48 hours prior, and all cancer surgeons are prepared to go the operating room whenever their patients have been triaged to surgery. In doing so, we are working as a unified team to ensure that despite the delays, we do not allow cancer patients to suffer as we manage COVID-19 patients. Importantly, we are still operating, day and night; we are still removing cancers.

Monitoring all patients     

The next critical step is the monitoring of all patients that are awaiting surgery. Once again, this is a very personalized process. Every cancer surgeon has a list of patients, each one with unique characteristics, and each patient will require their own plan.

For my colorectal cancer patients, all patients who are delayed are assigned a ‘surveillance’ plan or an alternative treatment plan, which will include weekly phone calls to assess symptoms, as well as direct endoscopic visualization (like colonoscopy) and CT scans at set intervals to ensure that there is no cancer progression and to ensure that the patient should not be immediately recategorized as a Priority A or B. If there is one thing all cancer doctors know, it’s that cancer can sometimes act in unpredictable ways and therefore watching closely is always part of the plan.

We are in this together

So for you and all patients, who in the midst of their cancer journey find themselves in this holding pattern waiting for the turbulence to stop so they can continue on their journey, please know that we are doing everything possible to keep you safe. We want to navigate these troubled waters with you.

Humans are incredibly resilient beings when they can understand the plan and know its timing. But chaos and uncertainty are often the very worst aspects of any tribulation, including a cancer diagnosis.

Usually, I take great pride in meeting my patients and sitting down with them, face to face, and discussing all aspects of their care and their concerns until the chaos and uncertainty are gone. I look them in the eye and promise them that they will always know what I am thinking and how I am feeling about each situation.

Today, I can’t quite look you in the eye (as our visits have become virtual) and I don’t know how or when COVID-19 will be defeated, but I can still tell you exactly what I am thinking and feeling: I am scared and anxious and tense too. But I also know that no matter what happens, we will not back down to this enemy and we will not knowingly allow it to change the course or prognosis of our cancer patients.

In the meantime, every cancer patient deserves to know exactly what their individual situation and timeline is, so if you are unsure or have not heard from your physician, reach out to them, have a discussion and find out exactly where you stand in these triage systems. Our cancer care system is still functioning daily. Surgeries are continuing, chemotherapy and radiation are ongoing, follow-ups are happening (mostly virtually). We are cautiously navigating the fine balance required to keep everyone safe. Every patient still, despite a global pandemic, deserves to know their plan. Make sure you know yours and please know it could change.

And remember, you are not alone and you are absolutely not forgotten. Together we will get through this.

About the author

Dr. Shady Ashamalla

Dr. Shady Ashamalla

Dr. Ashamalla is a colorectal cancer surgeon at Sunnybrook’s Odette Cancer Centre specializing in minimally invasive surgical treatments. He’s also a teacher and researcher in surgical education and simulation, and he's a consultant surgeon to the Toronto Maple Leafs. Read more posts on his blog. Follow @ShadyAshamalla on Twitter.