The COVID-19 Pandemic Impact on Cancer in Latin America

surgery in the middle of the severe limitations imposed by pandemics.


Introduction
As we write, there are recent publications that convey, hopes for a vaccine and policies on how to return to the new normal in all aspects of life [1,2]. Cancer treatments must be based on multidisciplinary planning, ideally with Tumor Boards committees. It is the intention of this manuscript to describe the manner of facing some types of cancers in the Latin American pandemic context, particularly the surgical approach. We all agree on the need to make treatment decisions in a "case by case and stratified way".

Materials and Methods
We employed a stratification method with the objective of systemizing surgical priority in the middle of the coronavirus pandemic.

Terminology
Stratification: In relation to stratification, we will use a terminology we use in Panama.
CIDURG= (Urgent Cancer Surgery). P = PRIORITY, 3-6 months. The priority, for the surgical treatment of cancer patients, in multimodal and neoadjuvant therapy, and therefore, we will break down both the type of cancer and the role of surgery. NOUR = not urgent. Due to the multiple factors during the pandemic, we will proceed "on a scheduled basis" to perform the surgery within 6-12 months. It is very important to emphasize that a greater use of the Tumor Boards Committees should be made. The tumor board discussion allows the best "case by case" decisions.

Breast Cancer
Only Lung cancer kills more women than breast cancer. The chance that a woman will die from breast cancer is about 1 in 38 about 2.6% [3]. Stratification of Patients with Breast Cancer during COVID-19. CIDURG. Urgent Breast Cancer Surgery. Priority of Breast Cancer Surgery, the schedule may go from days to a maximum of 3-6 months. NOUR = not urgent. It can be deferred for up to 6-12 months. Priority. Starting with an incipient disease, and carcinoma in situ. Specifically, Defer surgery. (for at least 3 months in cases of high-grade atypia, prophylactic / risk-reducing surgery, reconstruction, and benign breast disease.); Ductal carcinoma in situ Postpone for 3 to 6 months.). Delay post-chemotherapy surgery for as long as possible (1 to 2 months) in those patients for whom adjuvant systemic therapy is unclear / not indicated. CIDURG: if the patient does not need to undergo chemotherapy, the tumor is small and the information obtained by surgery will facilitate further decisions. Patients with a good postneoadjuvant response, patients with progressive disease in systemic therapy, angiosarcoma, and "malignant phyllodes" tumors (Table 1).

Gastric Cancer
Gastric Cancer. Third cause of death due to cancer, in the world, just after Lung and Colorectal cancer; it has a high incidence in several Latin American countries, in Panama (in the provinces of Chiriquí, Veraguas). CIDURG (E = Emergency, immediate. U = Urgency, hours). Early lesions without the metastatic disease, in bleeding and obstruction. P = Priority, days, or a maximum of 3-6 months. May involved chemotherapy or combine chemo-radiation therapies. NOUR = not urgent. 6-12 months or more. Evolving in situ, with atypia. Patients who complete neoadjuvant chemotherapy may continue chemotherapy, if they have responded, and are tolerating it (Table 3). Early lesions without metastatic disease. < 1mo.
Post completion neo Adjuvant. May continue if (+) response.

Melanoma
Skin melanoma is increasing its incidence in all countries. However, in some countries there is insufficient registration. Panama has the particularity of being a mixture of races. This multiracial population is constituted by the first inhabitants, European groups, during the discovery of the new land, by the Spanish, then groups of West Indians; to build a road between the Atlantic and Pacific oceans and a railroad; during the "California gold rush" The construction of the Panama Canal, started by the French and then by the US contributed to the populations build up. In Panama we have some of the highest incidence of albinism in the world, in the original indigenous people. They live mainly in the Caribbean in the northeast, on the islands, near the Colombian border with Panama [5]. They develop cutaneous melanomas of the amelanotic variety. Current recommendations to reduce the incidence of any type of cancer include prevention. In these remote islands, the population is not in the best conditions to follow the recommendations.
Regarding the approach, we follow the wide local excision options "WLE", based on thickness (Charles Balch. MD), the concepts of the Sentinel Lymph Node "SLN" (Donald Morton, Charles Balch, Jeffrey Greenwald, kelly McMaster; and Stanley Leon) and the American Society for Clinical Oncology Consensus (ASCO) [6][7][8][9][10][11][12][13]. To facilitate our communication, the term "TROPICALIZATION" was developed, with that, we include local and regional consideration for our countries, and especially for our primary inhabitants. The terminology regarding stratification and urgency is the same. CIDURG (situations of E = Emergency, immediate. U = Urgency, hours). P = Priority, days, or a maximum of 3-6 months. NOUR = not urgent. 6-12 months or more. Patients who complete Priority. Delay wide local excision of the disease in situ for 3 months and, as resources become scarce, all lesions with negative margins on the initial biopsy.
Efforts should be made to perform procedures in an outpatient setting to limit the use of the operating room (OR) resources. If a significant delay in definitive excision is anticipated, the precise location of the biopsy site should be carefully documented (vg, photograph, site marking by the patient or caregiver) to facilitate identification at a later time. Neoadjuvant chemotherapy may continue chemotherapy, if they have responded, and are tolerating it. CIDURG. Surgical treatment of T3 / T4 melanomas (>2.0-4.0 mm thick) should take precedence over T1 / T2 melanomas (< 2 mm thick). "Any melanoma" that undergoes partial or incomplete biopsy leaving a large residual clinical lesion. Complete resection is recommended in this case. Priority. Manage stage III disease with neoadjuvant systemic therapy. If resources allow and the patient is not suitable for systemic therapy, consider resection of the clinical disease in an outpatient setting. Priority. Sentinel lymph node biopsy (SLN), is reserved for patients with lesions > 1 mm and, as resources become scarce, it would be expected up to 3 months (Table 4).

Thyroid Surgery for Cancer and Non-Malignant Conditions
Thyroid Surgery in times of COVID will refer to situations of CIDURG (E = Emergency, immediate. U = Urgency, hours.). P = PRIORITY a maximum of 3-6 months. NOUR = not urgent. 6-12 months or more. CIDURG: Thyroid cancer that is a current or imminent threat to life, those that threaten morbidity with local invasion (for example, trachea, recurrent laryngeal nerve), aggressive biology (rapidly growing tumor or recurrence, rapidly progressive local-regional disease, including lymph nodes). Adding severely symptomatic Graves' Disease that has not responded to medical therapy and highly symptomatic Goiter or at risk of impending airway obstruction. NOUR: Biopsy, for diagnosis of lymphoma or other not specify Cancer (Anaplastic) ( Table 5).

Soft Tissue Sarcoma
Soft Tissue Sarcoma (STS). Surgery under COVID will refer to CIDURG (E = Emergency situations, immediately. U = Urgency, hours.). P = PRIORITY days, or a maximum of 3-6 months. NOUR = not urgent. 6-12 months or more. CIDURG: A primary soft tissue sarcoma without metastatic disease in staging requiring surgery will take precedence in the operating room. PRIORITY: Resection of newly diagnosed atypical lipomatous trunk/limb tumors (ALT), classic dermatofibrosarcoma protuberans without fibrosarcoma degeneration, and desmoid tumors can be deferred for 3 months or more. Resection of other low-grade sarcomas with known indolent behaviour (vg., well differentiated retroperitoneal Liposarcoma and low metastatic risk (vg, myxoid Liposarcoma, low-grade (Fibromyxoid) tumor) may differ by short intervals depending on available resources and absence of symptoms Consider deferral of new excision for R1 margins in limbs/trunk lesions if operating room (OR) resources are limited and there is no evidence of residual disease in the evaluation of unplanned excision.
If there is an indication for radiation therapy, plan to do it before the operation. This can be administered in a low-risk outpatient setting and will delay the time of surgery by approximately 3 to 4 months. Also, consider using preoperative radiation therapy as a bridge therapy to postpone surgery when appropriate, even if treatment is not standard but there is evidence that it will not harm (i.e., preoperative radiation therapy in retroperitoneal Liposarcoma CIDURG: Defer surgery for less biologically aggressive cancers, such as gastrointestinal stromal tumors (GIST), unless they are symptomatic or bleeding. There are two realities: the increasing incidence, as well as the formation of complex decisions for cancer patients and the COVID-19 pandemic progression curve. Local adaptations must be made (Table  6). Retroperitoneal-consider neoadjuvant therapy. Or -------<1mo.

Results
This project depends on multiple factors, including local and international policies; will have good or better results if all the factors required are considered and reviewed by the team of experts, the patient and relatives, the hospital administrators for supplies and regulations. Also, it is very important to maintain a good record of the patients and treatments. Most of us, are overwhelmed by the current situation. We either never experienced anything like this before, or we did not learn enough from previous similar situations. Anyway, we have to overcome our own condition in order to help others.

Conclusion
A systematic approach to the delay-pathology timetable under a stressed hospital environment may help decision making without increasing risk for patients, or at least minimizing the risk. This type of approach also requires a clear explanation to patients in order to avoid the psychological burden of delayed surgery. We would have to recruit a significant or representative amount of cases from different countries.