Coronavirus Disease (COVID-19) and Peritoneal Malignancies

Abstract

To the Editor, As the number of coronavirus disease 2019 (COVID-19) cases are rapidly increasing, hospitals are finding it progressively difficult to accommodate an increased patient load and provide services, both emergent and elective in nature. During this pandemic, it has become essential to ensure adequate allocation of resources for the management of both COVID19 patients and non-COVID-19 patients, and in particular, patients with cancer. Delayed cancer treatment may lead to an increased risk of disease progression and subsequent, worsening prognosis [1]. The Lancet reported an estimated 59.7% cancer surgeries being postponed in India during the peak 12 weeks of disruption due to the COVID-19 pandemic and lockdown, translating to about 51,100 cancer patients being denied of treatment. This delay in treatment could have led to disastrous consequences, such as increase in the tumor load leading to increased morbidity, inoperability, and eventual palliative intent of treatment [2]. Early studies have demonstrated that cancer patients are more likely to develop a severe form of COVID-19 [3, 4] with a fatality rate up to eight times as high as compared to noncancer patients [3]. Peri-operative infection with SARS-CoV2 has been associated with high mortality with more than half patients developing post-operative pulmonary complications in the form of pneumonia, requirement of post-operative mechanical ventilation, and acute respiratory distress syndrome [5]. However, no association has been found between chemotherapy and mortality related to COVID-19 [4]. Peritoneal malignancies, both of primary and metastatic origin, benefit greatly from cytoreductive surgeries (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) [6]. The performance of these potential life-saving surgeries in the current health crisis poses a significant dilemma to treating physicians. Another treatment offered for these malignancies is pressurized intraperitoneal aerosolized chemotherapy (PIPAC). Though its efficacy has not yet been proven, it is hypothesized to increase patient lifespan [3, 7]. Benefits of CRS-HIPEC are well established in peritoneal malignancieswith amedian disease-free survival of 98months being achieved in high volume centers for pseudomyxoma peritonei and median survival of more than 50 months after CRS-HIPEC for peritoneal mesotheliomas. On the other hand, median survival of 1 year has been achieved with isolated systemic chemotherapy in peritoneal mesotheliomas [3]. Thus, despite higher complication risks, improved survival benefits with surgery can justify the need to target curative intent with surgical procedures and thus improve the overall outcome of the patients. These procedures can, however, lead to exhaustion of resources, such as intensive care unit (ICU) beds and ventilators in the post-operative period along with the increased need for blood and blood products in the perioperative period besides being labor exhaustive with requirement of large teams for peri-operative management [8]. This puts both the healthcare professionals and the patients, at an increased risk of infection with the SARS-CoV2 virus. The decision to proceed with surgery must be made keeping in mind both risks and benefits associated with a major definitive surgery versus the risks of a lesser aggressive treatment modality with a higher chance of recurrence and progression. Also, the risk of death due The manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work.