Effect of the COVID‐19 pandemic on surgical oncology practice—Results of an SSO survey

Abstract Background and Objectives The COVID‐19 pandemic significantly affected healthcare delivery, shifting focus away from nonurgent care. The aim of this study was to examine the impact of the pandemic on the practice of surgical oncology. Methods A web‐based survey of questions about changes in practice during the COVID‐19 pandemic was approved by the Society of Surgical Oncology (SSO) Research and Executive Committees and sent by SSO to its members. Results A total of 121 SSO members completed the survey, 77.7% (94/121) of whom were based in the United States. Breast surgeons were more likely than their peers to refer patients to neoadjuvant therapy (p = 0.000171). Head and neck surgeons were more likely to refer patients to definitive nonoperative treatment (p = 0.044), while melanoma surgeons were less likely to do so (p = 0.029). In all, 79.2% (95/120) of respondents are currently using telemedicine. US surgeons were more likely to use telemedicine (p = 0.004). Surgeons believed telemedicine is useful for long‐term/surveillance visits (70.2%, 80/114) but inappropriate (50.4%, 57/113) for new patient visits. Conclusion COVID‐19 pandemic resulted in increased use of neoadjuvant therapy, delays in operative procedures, and increased use of telemedicine. Telemedicine is perceived to be most efficacious for long‐term/surveillance visits or postoperative visits.

cancer patients were also categorized as elective and subjected to delays and cancellations. Many surgical oncologists were forced to alter their practices to comply with the restrictions. 2,4,5 The demotion of cancer management to "nonurgent," combined with global stay-athome recommendations, resulted in lower screening rates of melanoma, breast, colorectal, and lung cancers, fewer cancer diagnoses of all types, and a decrease in all cancer-related patient encounters. [6][7][8][9] Additionally, while institution-specific increased use of neoadjuvant therapy has been documented in breast, melanoma, and gastrointestinal (GI) cancers, the prevalence of increased neoadjuvant use across the field of surgical oncology has not yet been quantified. 4,5,10 As the pandemic continued to burden the healthcare system, many needs in surgical oncologic care were met with the increased use of telemedicine. Telemedicine, which improves access to care and decreases healthcare costs for patients, has been shown effective and safe in a substantial portion of visits for patients with cancer specifically. 11 However, the management of surgical oncologic patients differs from medical oncology in its surgical component, and from other surgical specialties in that cancer patients are more likely to require longitudinal, collaborative care. While many surgical specialties, such as dermatologic and endocrine surgery, found that telemedicine is appropriate in outpatient and postoperative patient management, the use of telemedicine in surgical oncology has not been analyzed. 12,13 As the first systemic survey of SSO members, this study aims to examine the effects of the COVID-19 pandemic on the practice of surgical oncology, including current telemedicine practices for surgical oncology patients.

Following approval by the Rutgers Cancer Institute of New Jersey
Institutional Review Board, a voluntary web-based survey was administered by the Society of Surgical Oncology to its active members via email yielding 121 responses. The survey collected demographic data from respondents, such as age, gender, country and state of practice, academic practice environment, current role, primary area of surgical oncologic practice, and years in practice. Members were also surveyed on the influence of COVID-19 on their outpatient clinical and surgical practices, specifically clinic hours, operative schedules, office support staff, and use of telemedicine. Case volumes, effect of telemedicine on compensation, opinions on the appropriate use for and barriers to the use of telemedicine were queried. Information on changes in clinical practices, such as increased use of neoadjuvant therapy or use of nonoperative therapy was also gathered. Finally, respondents were asked if their institution had a virtual telemedicine platform before the pandemic and asked about pre-pandemic or current telemedicine use. Estimates of patient volumes seen virtually were gathered during three distinct time periods-March to July 2020, August to December 2020, and January to May 2021. The participants were asked to rate the effectiveness of telemedicine using a 3-point scale (more effective, less effective, about the same) and identify which type of visits they found to be appropriate for telemedicine (initial or new patient visit, postoperative visit, longterm follow-up surveillance visit).
Study data were collected and managed using REDCap electronic data tool provided by the Rutgers Cancer Institute of New Jersey.
Participants were surveyed via email between May 6, 2021, and September 8, 2021, with an initial email followed by two reminder emails. Data collection occurred over 6 months with the final download in November 2021.
The data were analyzed using descriptive statistics. Two-tailed Pearson's χ 2 tests and odds ratio (OR) were used to assess the relationship between surgical oncologic specialty or practice type and the use of neoadjuvant therapy, definitive nonoperative treatment, and deferment of operative procedures, as well as the relationship between practice type and decreased clinic hours, decreased operative procedures, covering nonspecialty shifts and COVID- 19

| Telemedicine
One of the significant impacts of the COVID-19 pandemic on the delivery of health care has been a dramatic shift to telemedicine. Against Cancer suggests that delaying cancer surgery by more than 6 weeks is likely to be detrimental to the survival of the patient. 21 As the pandemic continues to threaten the scheduling of operations, surgical oncologists should continue to assess their patients individually, while aiming to not delay surgery by longer than absolutely necessary.

Rampant SARS CoV-2 infections among patients and physicians
alike, reduced support staff, and stay-at-home orders precipitated an unprecedented increase in the use of telemedicine. 22 However, the efficacy of telemedicine as a comprehensive tool in surgical oncology is yet to be examined. One of the aims of this study was to assess current telemedicine practices for surgical oncology patients and Cancer can be a longer and a more emotionally arduous diagnosis than many other surgical conditions, therefore patients can benefit from a dependable relationship with their physician. This study found that many surgical oncologists feel that telemedicine does not allow them to build an adequate rapport with their patients. Congruently, a study in medical oncology found that some cancer patients felt reluctant to communicate with their doctors via a video platform due to feelings of self-consciousness, and the absence of a physical examination. 24,25 As the perceived empathy of the provider and the patient's anxiety about their cancer can significantly impact the quality of life and oncologic outcome, the lack of rapport could prove to be a great barrier for telemedicine in surgical oncology. 26 30 Additionally, HIPAA regulations surrounding telehealth were relaxed and penalties for noncompliance with regulatory guidelines were disposed of, resulting in less scrutiny for physicians caring for out-of-state patients. 31 The new legislation also allowed for the use of any remote communication product, provided it is not public-facing, for medical communication, thereby attenuating the problem of patient access to technology as telemedicine can now be conducted via smartphone, which 85% of Americans own. 32,33 There remains a significant concern among physicians that when the temporary COVID-19 expansions lapse, the lack of parity in reimbursement will end with them. Although private insurance providers and CMS have expressed intentions to continue equal reimbursement, concern for rising costs and fraud may prevent this action. 30 There are currently several bills for the expansion of telehealth reimbursement under consideration in various state legislatures and in Congress. 34,35 Although the decisions on these legislative measures have not been made, telehealth continues to be a juggernaut in healthcare so parity in reimbursement must be achieved.
The COVID-19 pandemic has also altered the educational fra- The study had a small sample size and low response rate indicating that it might not be representative of surgical oncology practice across the board. Additionally, most respondents were academic physicians and located in urban areas, therefore not reflective of telemedicine practices in rural and nonacademic settings. Most respondents were in the US, limiting the applicability of this study internationally.

| CONCLUSIONS
In conclusion, this survey of SSO members aimed to assess the impact of the COVID-19 pandemic on clinical practice. Surgeons reported an increase in delayed operations and in the use of neoadjuvant therapy. Additionally, surgeons noted an increased use of telemedicine, which may be appropriate for long-term follow-up visits and postoperative visits, but not for first-time patients. Challenges regarding reimbursement, patient access to technology, and performing an adequate physical examination remain. Future studies will examine the long-term impact of changed practices on surgical oncology patients and reevaluate the place of telemedicine in surgical oncology.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
Data are available from the corresponding author upon reasonable request.