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.