Article

Elective lung cancer surgery in the COVID-19 era: how do we do it?

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Abstract

The coronavirus 2019 (COVID-19) pandemic has caused significant mortality around the world and the focus has been on reducing the number of infections. In order not to compromise treatment of oncology patients, reducing the number of patients with COVID-19 undergoing treatment is mandatory. We reviewed the experience of the National Institute of Cancer in Milan and compared it with our experience.

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... All hospital strategies aimed at containing the infection by introducing isolation protocols (1)(2)(3). Many elective procedures and operations were postponed despite other diseases such as non-small cell lung cancer (NSCLC) continued to be an important cause of death (4)(5)(6)(7)(8)(9). ...
... The reduction in the availability of hospital beds has led to a delay in medical and surgical care for patients with lung cancer (10). Screening programs were temporarily interrupted and patients did not feel confident about going through regular visits and follow-ups (4,6,11,12). ...
... Currently, the most used screening method is the RT-PCR nasopharyngeal swab. In some centers it is followed (4,11,16) or preceded (17) by a chest CT scan to look for images suggestive of Covid-19 infection. ...
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The novel coronavirus (Covid-19), as of January 2021, infected more than 85 million people worldwide, causing the death of about 1,840 million. Italy had more than 2 million infected and about 75,000 deaths. Many hospitals reduced their ordinary activity by up to 80%, to leave healthcare staff, wards, and intensive care unit (ICU) beds available for the significant number of Covid-19 patients. All this resulted in a prolonged wait for hospitalization of all other patients, including those with non-small cell lung cancer (NSCLC) eligible for surgery. The majority of thoracic surgery departments changed the clinical-therapeutic path of patients, re-adapting procedures based on the needs dictated by the pandemic while not delaying the necessary treatment. The establishment of Covid-19-free hub centers allowed some elective surgery in NSCLC patients but most of the operations were delayed. The technology has partly facilitated patients' visits through telemedicine when security protocols have prevented face-to-face assessments. Multidisciplinary consultations had to deal also with the priority of the NSCLC cases discussed. Interpretation of radiologic exams had to take into account the differential diagnosis with Covid-19 infection. All the knowledge and experience of the past months reveal that the Covid-19 pandemic has not substantially changed the indications and type of surgical treatment in NSCLC. However, the diagnostic process has become more complex, requiring rigorous planning, thus changing the approach with the patients.
... Where possible, surgery and treatment for urgent conditions has continued. We have previously reported on our experience in management of lung cancer patients requiring surgery during the COVID-19 pandemic (7). During this period, we also continued to offer surgery to those with mediastinal tumours and indeed, patients with recurrent thymoma who have been shown to benefit from surgical resection. ...
... Although our series is of a relatively small number of patients, we have demonstrated that the risks of perioperative COVID-19 infection are low, when patients are admitted through a managed pathway. We have previously reported our experience of the surgical treatment of lung cancer during the COVID-19 pandemic (7). We believe that ensuring strict protocols in identifying those with COVID-19 are adhered to results in reduced risk of transmission to and from patients being admitted for elective surgery for cancer. ...
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Patients who have undergone surgical resection of thymoma may present later with recurrence of disease. This is most commonly in the pleural cavity. Surgery for recurrent thymoma has been shown to have a survival advantage. During the COVID-19 pandemic, there has been a reduction in capacity for routine healthcare provision. We present the outcomes of patients undergoing surgery for recurrent thymoma during the COVID-19 pandemic and our protocols to allow surgery to be performed during this time. Retrospective review of patients undergoing surgery for recurrent thymoma between March 2020 and the March 2021 at a single centre was performed. Preoperative demographic data, postoperative outcomes and the incidence of complications or postoperative COVID-19 infection were assessed. Over a 4-year period, and under the care of a single surgeon, 7 operations were performed for recurrent thymoma. Of these, three patients were operated during the COVID-19 pandemic. All patients had a history of myasthenia gravis (MG) and all patients presented with disease recurrence in the pleural cavity. No patients had post-operative complications and no patients tested positive for COVID-19 in the pre or postoperative period. Complete macroscopic resection was achieved in all patients. Surgery for recurrent thymoma can be performed safely and complete macroscopic resection can be achieved. It is possible to offer surgery with low risk of perioperative COVID infection and related morbidity and mortality. Given the benefits seen in survival and disease-free survival, we believe surgery for recurrent thymoma should continue to be advocated even during the current viral pandemic.
... Because there is no treatment for COVID-19 [1], the only way to reduce perioperative morbidity and mortality related to COVID-19 in patients undergoing surgery for NSCLC is to identify symptomatic COVID-19 patients before surgery and postpone surgery accordingly. In addition, to hasten time to operation, Bilkhu R et al. advised considering performing all elective non-oncologic surgeries in private hospitals, while continuing to operate on patients with cancer in non-private institutions [12]. Kapetanakis El et al. recommended postponing surgery in stage Ia-IIa NSCLC patients for 8 weeks, with new imaging obtained every 6 weeks [13]. ...
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Background: The highly contagious COVID-19 has created unprecedented challenges in providing care to patients with resectable non-small cell lung carcinoma (NSCLC). Surgical management now needs to consider the risks of malignant disease progression by delaying surgery, and those of COVID-19 transmission to patients and operating room staff. The goal of our study was to describe our experience in providing both emergent and elective surgical procedures for patients with NSCLC during the COVID-19 pandemic in Israel, and to present our point of view regarding the safety of performing lung cancer surgery. Methods: This observational cross-sectional study included all consecutive patients with NSCLC who operated at Tel Aviv Medical Center, a large university-affiliated hospital, from February 2020 through December 2020, during the COVID-19 pandemic in Israel. The patients' demographics, COVID-19 preoperative screening results, type and side of surgery, pathology results, morbidity and mortality rates, postoperative complications, including pulmonary complications management, and hospital stay were evaluated. Results: Included in the study were 113 patients, 68 males (60.2%) and 45 females (39.8%), with a median age of 68.2 years (range, 41-89). Of these 113 patients, 83 (73.5%) underwent video-assisted thoracic surgeries (VATS), and 30 (26.5%) underwent thoracotomies. Fifty-five patients (48.7%) were preoperatively screened for COVID-19 and received negative results. Fifty-six postoperative complications were reported in 35 patients (30.9%). A prolonged air leak was detected in 11 patients (9.7%), atrial fibrillation in 11 patients (9.7%), empyema in 5 patients (4.4%), pneumonia in 9 patients (7.9%) and lobar atelectasis in 7 patients (6.2%). Three patients (2.7%) with postoperative pulmonary complications required mechanical ventilation, and two of them (1.6%) underwent tracheostomy. Two patients (1.6%) were postoperatively diagnosed as positive for COVID-19. Conclusions: Our data demonstrate the feasibility and efficacy of implementing precautionary strategies to ensure the safety of lung cancer patients undergoing pulmonary resection during the COVID-19 pandemic. The strategy was equally effective in protecting the surgical staff and healthcare providers, and we recommend performing lung cancer surgery during the pandemic era.
... Many medical centers aim to control its spread by implementing isolation protocols (1)(2)(3). While non-small cell lung cancer (NSCLC) remains a major cause of death, many elective procedures and operations for the treatment of diseases have been delayed (4)(5)(6)(7)(8)(9). During the COVID-19 pandemic, some factors have led to changes in the management of patients with lung cancer. ...
Article
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Background: During the COVID-19 pandemic, some factors have led to changes in the management of patients with lung cancer. In our study, we aimed to present our surgical treatment approach to patients with NSCLC during the COVID-19 pandemic. Methods: Patients who underwent surgery for NSCLC in our thoracic surgery clinic between March 2020 and March 2021 were evaluated retrospectively. The patients operated on were retrospectively evaluated in terms of sex, age, tumor staging, lung resection type, histopathological type, COVID-19 status, length of stay, complications, and mortality. Results: Thirty-five patients, 27 men and 8 women, underwent surgery for lung cancer. The 2 most common types of surgery were lobectomy (in 32 patients) and pneumonectomy (in 3 patients). According to cancer staging based on 8th TNM, 14 patients were stage 2B, 12 patients were stage 2A, and 9 patients were stage 3A. The morbidity rate was 14 %. No postoperative mortality was observed. Nine patients had a history of COVID- 19 before surgery. No significant difference was found in terms of complications in patients with a preoperative history of COVID-19. In the postoperative period, COVID-19 was observed in no patient in our clinic. Conclusion: We think that surgical treatments should not be postponed for diseases such as lung cancer, where the mortality rate is high and early diagnosis and treatment are very important. There will be no delay or inadequacy in the treatment of patients if the rules determined during the COVID-19 pandemic and other types of pandemic possibly occurring in the future are followed (Tab. 1, Ref. 23).
... In response to the pandemic, unprecedented measures were introduced to reduce exposure to the virus 5 . Semiurgent and elective surgery, as well as endoscopy, were discontinued in many centres after relevant recommendations from professional bodies [6][7][8][9][10][11][12] . Educational courses 13,14 , examinations, conferences, and training rotations were cancelled 15 . ...
Article
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Background The SARS-CoV-2 pandemic had a profound impact on surgical services, potentially having a detrimental impact on training opportunities. The aim of this global survey was to assess the impact of the COVID-19 crisis on surgical training and to develop a framework for recovery. Methods A cross-sectional, web-based survey was conducted. This was designed by a steering committee of medical educationalists and validated by a group of trainees before dissemination. Results A total of 608 responses were obtained from 34 countries and 15 specialties. The results demonstrated major disruption in all aspects of training. The impact was greatest for conferences (525 of 608) and hands-on courses (517 of 608), but less for inpatient care-related training (268 of 608). European trainees were significantly more likely to experience direct training disruption than trainees in Asia (odds ratio 0.15) or Australia (OR 0.10) (χ2 = 87.162, P < 0.001). Alternative training resources (webinars, 359 of 608; educational videos, 234 of 608) have emerged, although trainees expressed some dissatisfaction with them. The collective responses generated a four-pillar framework for training recovery that involved: guidance from training stakeholders with the involvement of trainees; prioritization of training, especially the roles of senior surgeons/trainers; provision of access to alternative/new teaching methods; and measures to address trainee anxiety. Conclusion Training has been greatly affected by the COVID-19 pandemic. The introduction of new teaching methods and a focus on training after the pandemic are imperative.
... In response to the pandemic, unprecedented measures were introduced to reduce exposure to the virus 5 . Semiurgent and elective surgery, as well as endoscopy, were discontinued in many centres after relevant recommendations from professional bodies [6][7][8][9][10][11][12] . Educational courses 13,14 , examinations, conferences, and training rotations were cancelled 15 . ...
Article
Full-text available
Background: The SARS-CoV-2 pandemic had a profound impact on surgical services, potentially having a detrimental impact on training opportunities. The aim of this global survey was to assess the impact of the COVID-19 crisis on surgical training and to develop a framework for recovery. Methods: A cross-sectional, web-based survey was conducted. This was designed by a steering committee of medical educationalists and validated by a group of trainees before dissemination. Results: A total of 608 responses were obtained from 34 countries and 15 specialties. The results demonstrated major disruption in all aspects of training. The impact was greatest for conferences (525 of 608) and hands-on courses (517 of 608), but less for inpatient care-related training (268 of 608). European trainees were significantly more likely to experience direct training disruption than trainees in Asia (odds ratio 0.15) or Australia (OR 0.10) (χ2 = 87.162, P < 0.001). Alternative training resources (webinars, 359 of 608; educational videos, 234 of 608) have emerged, although trainees expressed some dissatisfaction with them. The collective responses generated a four-pillar framework for training recovery that involved: guidance from training stakeholders with the involvement of trainees; prioritization of training, especially the roles of senior surgeons/trainers; provision of access to alternative/new teaching methods; and measures to address trainee anxiety. Conclusion: Training has been greatly affected by the COVID-19 pandemic. The introduction of new teaching methods and a focus on training after the pandemic are imperative.
... 1 Guidelines from the U.S. and Europe have been published to aid treatment decision-making for thoracic cancers during the pandemic. [2][3][4][5][6][7][8][9][10][11][12][13][14][15] Most of these guidelines have been written for hospitals and clinicians who still have capacity to take care of cancer patients and have not been completely overwhelmed by COVID-19. These guidelines have generally recommended delaying surgery for select instances of early-stage disease, and, for more advanced disease, proceeding with traditional curative-intent treatment consistent with pre-COVID standard-of-care recommendations. ...
Article
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Background The rapid spread of coronavirus disease (COVID-19) is affecting many countries. While healthcare systems need to cope with the need to treat a large number of people with different degrees of respiratory failure, actions to preserve aliquots of the healthcare system to guarantee treatment to patients are mandatory. Methods In order to protect the Fondazione IRCCS–Istituto Nazionale dei Tumori di Milano from the spread of COVID-19, a number of to-hospital and within-hospital filters were applied. Among others, a triage process to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity in patients with cancer was developed consisting of high-resolution low-dose computed tomography (CT) scan followed by reverse transcription polymerase chain reaction (RT-PCR) detection of SARS-CoV-2 in nose–throat swabs whenever CT was suggestive of lung infection. To serve symptomatic patients who were already admitted to the hospital or in need of hospitalization while waiting for RT-PCR laboratory confirmation of infection, a COVID-19 surveillance zone was set up. Results A total of 301 patients were screened between March 6 and April 3, 2020. Of these, 47 were hospitalized, 53 needed a differential diagnosis to continue with their cancer treatment, and 201 were about to undergo surgery. RT-PCR was positive in 13 of 40 hospitalized patients (32%), 14 of 52 day hospital patients (27%), and 6 of 201 surgical patients (3%). Conclusion Applying filters to protect our comprehensive cancer center from COVID-19 spread contributed to guaranteeing cancer care during the COVID-19 crisis in Milan. A surveillance area and surgical triage allowed us to protect the hospital from as many as 33 patients infected with SARS-CoV-2.
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The paper presents data on the coronavirus diseaseCOVID-2019 caused by the SARS-CoV-2 coronavirus, which was temporarily named 2019-nCoV (2019 novel coronavirus) until 11 February 2020. An outbreak of pneumonia of unknown etiology in Wuhan (Hubei province of China) which was first described in an official publication of the Chinese Office of the World Health Organization on December 31, 2019, attracted attention of both dedicated experts and the entire international community. On January 30, 2019 it was recognised as a public health emergency of international concern. The first cases were reported on December 12, 2019 in China, and on January 31, 2020 Russia reported its first two cases of the infection in two Chinese citizens staying in Russia. The causative agent is the new SARS-CoV-2 coronavirus. It had not been detected before, and was first identified by Chinese researchers on January 7, 2020 under the temporary name 2019-nCoV. The aim of the study was to summarise information about coronavirus diseaseCOVID-2019 beginning from the onset of the epidemic until early March 2020. The paper provides general information about coronaviruses, developments of the COVID-2019 epidemic caused by the SARS-CoV-2 coronavirus, and gives an assessment of the global epidemiological situation. It cites the recommendations of national regulatory authorities and the World Health Organization on the treatment of various forms of coronavirus infection and septic shock caused by SARS-CoV-2, including target values of systemic hemodynamics, a list of recommended medicines, methods of their use, and limitations of pharmacotherapy.
Article
Importance The pandemic of coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents an unprecedented challenge to identify effective drugs for prevention and treatment. Given the rapid pace of scientific discovery and clinical data generated by the large number of people rapidly infected by SARS-CoV-2, clinicians need accurate evidence regarding effective medical treatments for this infection. Observations No proven effective therapies for this virus currently exist. The rapidly expanding knowledge regarding SARS-CoV-2 virology provides a significant number of potential drug targets. The most promising therapy is remdesivir. Remdesivir has potent in vitro activity against SARS-CoV-2, but it is not US Food and Drug Administration approved and currently is being tested in ongoing randomized trials. Oseltamivir has not been shown to have efficacy, and corticosteroids are currently not recommended. Current clinical evidence does not support stopping angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in patients with COVID-19. Conclusions and Relevance The COVID-19 pandemic represents the greatest global public health crisis of this generation and, potentially, since the pandemic influenza outbreak of 1918. The speed and volume of clinical trials launched to investigate potential therapies for COVID-19 highlight both the need and capability to produce high-quality evidence even in the middle of a pandemic. No therapies have been shown effective to date.
Article
To date, 1 million confirmed cases of SARS-CoV-2 virus have been reported worldwide with a death toll of over 50,000.1 Particular concern has been raised regarding the exposure of healthcare professionals. Early reports from the Wuhan province in China described up to 29% infection rates among healthcare professionals before the use of Personal Protection Equipment (PPE) was fully established.2 Several measures are being established with regard the correct use of PPE and reduction in aerosol generating procedures. However to our knowledge, no specific guidance is available regarding the potential risk of aerosolization of SARS-Cov-2 virus via chest drains in patients with active air leak. Viral Spread and Air Leak The SARS-CoV-2 virus, which leads to COVID-19, has been demonstrated to remain viable in aerosol form and is transmitted by droplets.3 Despite the current coronavirus pandemic, we are still faced with patients requiring chest tube drainage for pneumothorax on cardiothoracic and respiratory wards, as well as in critical care units. Whilst drains may be inserted with lower risk of viral spread for simple pleural effusions, we fear there may be a high risk of aerosolization in cases of pneumothorax with active air leak, whether that be primary, secondary or indeed iatrogenic in mechanically ventilated patients requiring high PEEP ventilation such as in patients with COVID-19. Citing a recent example of a postoperative thoracic surgical patient in our unit who had a prolonged air leak and who later was found to be positive for SARS-CoV-2, we have considered the implications of aerosolization from the chest drain and in particular the chest drain bottle. This may represent an under-recognised means of viral spread which may put patients and health care professionals at risk of infection. Chest Drains and risk of Aerosolization Traditional under water seal chest drain bottles have a port which allows attachment to low pressure wall suction. Most modern drain system also have a safety valve which opens to air should the suction be accidentally turned off in the presence of an air leak, to avoid a creating a closed system effect which could lead to a tension pneumothorax. If the drain bottle is not attached to suction, then the port is open to the atmosphere. When air leaks into a chest drain bottle, it causes the fluid inside to bubble. Given the aerosolization that is likely to occur inside the drain bottle, which then escapes through the suction port or safety valve, this may be a potentially important mode of viral transmission. Alternatives to a traditional chest drain bottle include a number of different digital chest drainage systems. Whilst these do not have a port open to room air, they are not closed systems and the air escapes from the system into the air without any specific viral filter. A number of patients on our unit’s thoracic ward have since tested positive for COVID-19. Whilst the patient with the air leak may not have been the source of infection, we feel this should be considered. In our patient, a digital chest drainage system was being used. In light of this, and until further robust evidence regarding the volume of aerosolization from a chest drain bottle emerges, we would recommend the use of closed drainage systems, i.e. connecting the standard drain bottle to wall suction to avoid the spread of viral load via aerosolization. However in order to obtain this, the safety valve will have to be occluded with potential risk of increasing intrathoracic pressure and cause tension, should the suction system be switched off whilst still connected to the bottle. Furthermore, keeping the bottle attached to wall suction will significantly limit the mobilization of patients, which is a significant risk factor for postoperative complications in the surgical patient. A bespoke Chest Drain System In order to overcome this, a possible consideration would be to attach an antimicrobial filter, such as those used in ventilator circuits, to the chest drain suction port leaving the drain off suction and occluding the safety valve. Connecting the filter directly to the chest drain should be discouraged as fluid and moisture directly from the chest cavity are likely to interfere with the functioning of the filter. Therefore, we designed a bespoke drainage system using the Filta-Guard™ ventilator filter from Intersurgical Ltd© 2020 and a segment of endotracheal tube to use in our unit (Figures 1&2). The filter guarantees a Filtration Efficiency of >99.999% as tested on Hepatitis C and Mycobacterium tuberculosis in addition to standard test micro-organisms 4. SARS-Cov-2 diameter varies from 60 to 140 nm, therefore larger than hepatitis C virus, which has an average diameter of about 55 nm only. We postulated that given the larger size compared to Hep C virus, this filter should be effective in preventing flow of SARS-Cov-2 across the filter, however to our knowledge, this has not been clinically tested. Regarding the possible resistance to the system added by the filter and related risk of building up pressure in the chest cavity, we believe this should be marginal. Published data suggest the above filter would generate a resistance against the passage of 30L/min of 1.0cm H2O and 2.3cm H2O at 60L/min.4 Conclusions The efficacy of our chest drain modification clearly needs to be further investigated, however, given the current pandemic, any method of reducing viral spread should be considered. Acknowledgements: We would like to acknowledge Mr Panagiotis Theodoropoulos and Mr Duncan Steele, Specialist Registrars in Thoracic Surgery at Hammersmith Hospital, London. Conflict of Interest Disclosures: None of the authors have any disclosures. REFERENCES 1. Johns Hopkins University & Medicine. COVID-19 Map. https://coronavirus.jhu.edu/map.html. Published 2020. Accessed April 2, 2020. 2. Chen W, Huang Y. To Protect Healthcare Workers Better, To Save More Lives. Anesth Analg. 2020:1-15. doi:10.1213/ANE.0000000000004834 3. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020. doi:10.1056/NEJMc2004973 4. Systems ICR. Filta-GuardTM range - high efficiency. https://www.intersurgical.com/products/airway-management/filtaguard-range-high-efficiency#1944000. Published 2020. Accessed April 2, 2020.
Article
Background: A cluster of patients with coronavirus disease 2019 (COVID-19) pneumonia caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were successively reported in Wuhan, China. We aimed to describe the CT findings across different timepoints throughout the disease course. Methods: Patients with COVID-19 pneumonia (confirmed by next-generation sequencing or RT-PCR) who were admitted to one of two hospitals in Wuhan and who underwent serial chest CT scans were retrospectively enrolled. Patients were grouped on the basis of the interval between symptom onset and the first CT scan: group 1 (subclinical patients; scans done before symptom onset), group 2 (scans done ≤1 week after symptom onset), group 3 (>1 week to 2 weeks), and group 4 (>2 weeks to 3 weeks). Imaging features and their distribution were analysed and compared across the four groups. Findings: 81 patients admitted to hospital between Dec 20, 2019, and Jan 23, 2020, were retrospectively enrolled. The cohort included 42 (52%) men and 39 (48%) women, and the mean age was 49·5 years (SD 11·0). The mean number of involved lung segments was 10·5 (SD 6·4) overall, 2·8 (3·3) in group 1, 11·1 (5·4) in group 2, 13·0 (5·7) in group 3, and 12·1 (5·9) in group 4. The predominant pattern of abnormality observed was bilateral (64 [79%] patients), peripheral (44 [54%]), ill-defined (66 [81%]), and ground-glass opacification (53 [65%]), mainly involving the right lower lobes (225 [27%] of 849 affected segments). In group 1 (n=15), the predominant pattern was unilateral (nine [60%]) and multifocal (eight [53%]) ground-glass opacities (14 [93%]). Lesions quickly evolved to bilateral (19 [90%]), diffuse (11 [52%]) ground-glass opacity predominance (17 [81%]) in group 2 (n=21). Thereafter, the prevalence of ground-glass opacities continued to decrease (17 [57%] of 30 patients in group 3, and five [33%] of 15 in group 4), and consolidation and mixed patterns became more frequent (12 [40%] in group 3, eight [53%] in group 4). Interpretation: COVID-19 pneumonia manifests with chest CT imaging abnormalities, even in asymptomatic patients, with rapid evolution from focal unilateral to diffuse bilateral ground-glass opacities that progressed to or co-existed with consolidations within 1-3 weeks. Combining assessment of imaging features with clinical and laboratory findings could facilitate early diagnosis of COVID-19 pneumonia. Funding: None.
Article
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data were collected by the National Center for Health Statistics. In 2017, 1,688,780 new cancer cases and 600,920 cancer deaths are projected to occur in the United States. For all sites combined, the cancer incidence rate is 20% higher in men than in women, while the cancer death rate is 40% higher. However, sex disparities vary by cancer type. For example, thyroid cancer incidence rates are 3-fold higher in women than in men (21 vs 7 per 100,000 population), despite equivalent death rates (0.5 per 100,000 population), largely reflecting sex differences in the "epidemic of diagnosis." Over the past decade of available data, the overall cancer incidence rate (2004-2013) was stable in women and declined by approximately 2% annually in men, while the cancer death rate (2005-2014) declined by about 1.5% annually in both men and women. From 1991 to 2014, the overall cancer death rate dropped 25%, translating to approximately 2,143,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the cancer death rate was 15% higher in blacks than in whites in 2014, increasing access to care as a result of the Patient Protection and Affordable Care Act may expedite the narrowing racial gap; from 2010 to 2015, the proportion of blacks who were uninsured halved, from 21% to 11%, as it did for Hispanics (31% to 16%). Gains in coverage for traditionally underserved Americans will facilitate the broader application of existing cancer control knowledge across every segment of the population. CA Cancer J Clin 2017. © 2017 American Cancer Society.
Response of a comprehensive cancer center to the COVID-19 pandemic: the experience of the Fondazione IRCCS–Istituto Nazionale dei Tumori di Milano
  • Valenza F.
  • Papagni G.
  • Marchiano A.
  • Daidone M.G.
  • De'Braud F.
  • Colombo M.P.
  • Frignani A.
  • Apolone G.