Keywords
SARS-CoV-2, COVID-19, Coronavirus, Head and Neck Cancer, Treatment Delays, Wellness
Abstract
Introduction: The COVID-19 pandemic has raised controversies regarding safe and effective care of head and neck cancer patients. It is unknown how much the pandemic has changed surgeon practice.
Methods: A questionnaire was distributed to head and neck surgeons assessing opinions related to treatment and concerns for the safety of patients, self, family, and staff.
Results: A total of 67 head and neck surgeons responded during the study period. Surgeons continued to recommend primary surgical treatment for oral cavity cancers. Respondents were more likely to consider non-surgical therapy for patients with early glottic cancers and HPV-mediated oropharynx cancer. Surgeons were least likely to be concerned for their own health and safety and had the greatest concern for their resident trainees.
Conclusions: This study highlights differences in the willingness of head and neck surgeons to delay surgery or alter plans during times when hospital resources are scarce and risk is high.
Introduction
The coronavirus disease 19 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a pandemic by World Health Organization (WHO) on March 11, 2020.1This pandemic has placed increased stress on health care systems, both due to critical resource shortages and delays in care. Health care providers now must find new ways of safely providing cancer care without compromising patient outcomes, or overutilizing precious resources.2 The American Academy of Otolaryngology – Head & Neck Surgery has recommended surgeons delay elective cases to allow for improved safety of staff and patients, preservation of critical personal protective equipment (PPE), and to expand hospital capacity during the COVID-19 pandemic.3 Additionally, the American College of Surgeons (ACS) has provided guidance defining the acuity of cancer surgeries, with most mucosal cancers of the upper aerodigestive tract meeting the criteria for Tier 3a (high acuity surgery/healthy patient). Accordingly, delays in treatment should not occur.4 The ACS feels that “the risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay, including the expectation that a delay of 6-8 weeks or more may be required to emerge from an environment in which COVID-19 is less prevalent”.4
Head and neck cancer care poses a unique challenge during the COVID-19 pandemic because increasing evidence has emerged that Otolaryngologists are at significantly higher risk of infection due to exposure to the upper airway and respiratory droplets.5,6Additionally, reasonable alternative treatment options are lacking for many head and neck malignancies and treatment delay leads to increased morbidity and mortality.7,8 Head and neck cancer is unique in that oral cavity cancers, human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC), and advanced laryngeal cancers are considered aggressive malignancies and there is no widely-accepted neoadjuvant treatment option that can allow definitive surgery to be delayed. Other subtypes such as HPV-mediated OPSCC and early laryngeal squamous cell carcinoma can be treated either with radiation-based or surgical-based therapy, which offer equivalent oncologic outcomes.
Despite ACS recommendations that delays in cancer treatment be avoided during the COVID-19 pandemic, treatment delays are anticipated and are currently occurring. This can be expected to alter the management strategies as head and neck surgeons and radiation oncologists weigh the risks and benefits of viral exposure both to the patient and to operating room and clinic staff. Furthermore, patients who unknowingly have surgery during the incubation period of COVID-19 infection appear to be at extremely high risk of morbidity and may have approximately 20% risk of mortality8. There is also a high level of concern over the risk of immunosuppression with systemic chemotherapy during the ongoing pandemic. These risks must be balanced with the risk of cancer progression by delaying therapy as well as the psychological impact on patients of delayed or altered plans of care.10-12 It has been established in the literature that increases in the duration of time between diagnosis and definitive therapy is associated with decreased overall and disease-free survival.7,8 In addition, delays in surgery may result in increased morbidity due to disease progression necessitating more extensive tumor resection.
Because of the potential increase in morbidity and mortality, most head and neck surgeons including the authors advocate for initiation of treatment within one month of the patient’s presentation to clinic. However, in the COVID-19 era it is unclear what the appropriate length of time from evaluation to initiation of treatment should be given limited resources and new concern over potential morbidity and mortality from early initiation of treatment.
Therefore, the primary objective of this study was to assess head and neck surgeons’ priorities and the extent to which they would consider delaying surgery or changing treatment modality in the era of COVID-19. This knowledge may help guide the development of guidelines and support treatment decisions both now and during future pandemics. The secondary objective was to understand surgeons’ concerns regarding safety of treatment for their patients during the COVID-19 pandemic as well as the safety of their families, their staff, and themselves.
Methods
This descriptive study was performed after a waiver was obtained from internal review board at the University of Pennsylvania. A questionnaire assessing three separate domains was conducted. Demographics included surgeon age, academic versus private practice, and zipcode in which the surgeon practices. Utilizing zipcode data, participants were subsequently grouped into two categories: those practicing in an area with less than 25,000 confirmed cases of COVID-19 vand those practicing in an area with greater than or equal to 25,000 confirmed cases. These domains included surgeon preferences related to treatment delays and referral for nonsurgical therapies; concerns regarding various treatment-related complications secondary to COVID-19; and worry about the health and safety of self, family, staff, and trainees. Questions related to treatment delays and nonsurgical therapy specifically addressed management related to early tumor stage oral cavity cancer, locally advanced oral cavity cancer, HPV-associated oropharyngeal cancer, early tumor stage glottic cancer, locally advanced laryngeal cancer, and recurrent laryngeal cancer requiring salvage surgery.
The survey was administered through the Research Electronic Data Capture (REDCap)13 platform and was distributed amongst head and neck surgeons in different geographic regions across the United States and Canada using message boards and social media. Questions regarding respondents’ demographic information included age, zipcode in which they practice, and whether they practice in an academic or private hospital. The survey was completed by 67 respondents over a 5 day period (April 9 – April 14, 2020). Statistical analyses were performed using STATA/IC 15.0 software (Stata Corporation, College Station, TX).
Results
A total of 67 head and neck surgeons responded to the survey during the study period. Fifty-nine (88.1%) practiced in an academic setting while the remaining 8 (11.9%) worked in a private practice setting. The majority of respondents were between the ages of 30 and 39 (52.2%; Table 1). There were no differences in responses when stratifying by age or whether the participants were practicing in an area with a high prevalence of COVID-19.