Cancer surgery in Canada during the COVID-19 pandemic: qualitative analysis of cancer surgeons’ perspectives

Dear Editor The coronavirus disease 2019 (COVID-19) pandemic has presented unprecedented challenges to healthcare systems worldwide. In Canada, provinces and jurisdictions implemented directives to preserve and redirect resources, including reducing or cancelling non-emergency surgical procedures, which affected cancer treatments1–3. How these changes were enacted at the practitioner level by cancer surgeons directly engaged with patients has received little attention. The authors undertook a qualitative study to assess cancer surgeons’ perspectives on cancer treatment and the challenges they faced during the COVID-19 pandemic. Semistructured telephone interviews were conducted with 11 colorectal and gastric cancer surgeons from across Canada during the first wave of the pandemic (June 2020) (Fig. S1 and Table S1). Two researchers analysed the data for emergent themes using a grounded theory approach4,5. The data were organized using NVivo™ 12 software (QSR International, Melbourne, Victoria, Australia). Four major themes emerged from this analysis of surgeons’ perspectives on cancer surgery during the pandemic: surgical processes, surgeon stress, infection control, and cancer outcomes. The surgical processes and surgeon stress themes are discussed below (Table 1). The infection control and cancer outcomes themes are outlined in Tables S2 and S3. Summary of surgical processes and surgeon stress themes and subthemes with exemplar quotations OR, operating room. Summary of surgical processes and surgeon stress themes and subthemes with exemplar quotations OR, operating room. The surgical processes theme described the factors involved in performing cancer surgery during the pandemic. It was organized into the following subthemes: referral volumes, prioritization process, operative cases, treatment alterations, communication with leadership, unpredictable schedules, and surgical backlog. Participants reported receiving fewer cancer referrals, which they attributed to patients’ reluctance to seek healthcare services, difficulties in accessing care from primary or specialty physicians owing to reduced office capacity or pandemic-related office closures, and reductions in screening activities and diagnostic services (such as CT and endoscopy). They further described decreased operating room (OR) access because of institutionally or regionally mandated OR slate reductions or closures, although the degree of reductions varied by region and course of the pandemic. Many institutions set up prioritization processes to prioritize operative cases for the limited number of OR slates available, but the organization and transparency of these processes were variable. Most participants perceived delays in cancer operations because of OR reductions, especially for less urgent or earlier-stage cancers. Finally, participants were concerned about a potential surgical backlog of patients awaiting diagnosis and treatment of cancer, and their institutions’ preparedness to manage patient volumes once the pandemic had slowed down. Participants expressed heightened stress levels during the pandemic related to their role as surgeons and in their personal lives. The two major professional stressors were increased workloads and dealing with the uncertainty of whether OR requests would be approved. The process of seeking approval for surgery required increased administrative work. Surgeons were also unable to plan their schedules ahead of time and instead were constantly on standby, waiting to find out whether cases were approved and then needing to clear their schedules when OR time became available. Uncertainty in participants’ ability to provide timely care for their patients also caused stress. Participants also experienced pandemic-related stress in their personal lives, including concerns about their own health, managing childcare with schools closed, and financial concerns in the event of a prolonged OR shutdown. This study has highlighted areas requiring urgent attention to minimize negative and ongoing effects on patients with cancer, including diagnostic delays, developing reasonable and manageable prioritization processes a priori, dealing with backlogs of patients needing cancer treatments, and ongoing physician stress and burnout. Such studies need to be performed on an ongoing basis to mitigate negative unintended impacts on non-pandemic-related care and plan for future waves/pandemics. The authors have no funding to declare. Disclosure. The authors declare no conflict of interest. Supplementary material is available at BJS online.

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