Concerns related to the well-being of self, staff, trainees, and family during the COVID-19 pandemic
Notably, head and neck surgeons were the least likely to be concerned for their own health and safety as compared to that of their residents, family, or staff. Surgeons had the greatest concern for the wellbeing of their resident trainees during the COVID-19 pandemic. The majority of respondents expressed moderate concern for the staff and their family during the COVID-19 pandemic (Figure 4).
Discussion
As the COVID-19 pandemic has forced head and neck surgeons to triage which patients should be operated urgently versus which can be delayed indefinitely, this study helps to provide granular data regarding the opinions of 67 head and neck surgeons across multiple geographic locations within the United States and Canada.
Our respondents still feel it is necessary to operate on patients with cancers of the larynx, oropharynx, and oral cavity in setting of the COVID-19 pandemic, however there are notable differences between sites and stages. As oral cavity squamous cell carcinoma is regarded as a primarily surgical disease due to higher treatment related complications and poorer outcomes with primary radiotherapy, our respondents were unwilling to refer patients for nonsurgical therapy. This trend is similarly noted in the setting of a recurrent laryngeal cancer as no other curative treatment is available. It was interesting to note that a minority of respondents were willing to refer a locally advanced T4a laryngeal cancer for primary nonsurgical treatment. While this is not standard of care, it may reflect the hope that a patient may respond to radiation therapy and undergo salvage at a later date if there is only a partial response or if the patient has a nonfunctional larynx.
Most respondents were willing to deviate from their standard practice and recommend primary (chemo)radiotherapy for early laryngeal cancers and HPV-mediated oropharynx cancers. While nonsurgical therapy is a standard of care for these cancers, the fact that surgeons are more willing to recommend them during the COVID-19 pandemic as compared to their normal practice indicates that our respondents felt that it might be safer for the patient and for the healthcare team if surgical treatment was deferred.
Although surgeons may wish to shunt patients towards radiation oncology in the hopes of limiting resource utilization and exposure in the peri-operative setting, the burden placed on radiation oncologists must also be considered. With 6 to 7 weeks of treatment, there is a substantial amount of travel and exposure to health care staff during treatment. The risk of treatment delays or breaks must also be taken into account if the patient becomes infected or if enough staff are quarantined resulting in a reduced capacity to treat patients.
Most surgeons were not willing to delay treatment beyond 4-6 weeks during the COVID-19 pandemic. This is likely related to the known risk morbidity and mortality among patients with head and neck cancer that results from treatment delays.7,8 In a systematic review of 51 studies, Schutte et al found that treatment delays led to reduced overall survival and disease specific survival, as well worsened functional and psychosocial outcomes. They recommended timely treatment to improve outcomes in HNSCC.7 Similarly, in 956 patients, Liao et al found that delays in treatment led to lower overall survival and higher risk of recurrence.8 This highlights the importance of timely intervention, even in the era of COVID-19, to maintain a high level of care. The need for timely intervention must be weighed with opposing concerns that necessitate delays or alterations in treatment paradigms to protect health care workers due to a lack of PPE or availability of preoperative COVID-19 testing.6
Additionally, there are significant concerns related to complications from COVID-19 during treatment that need to be taken into consideration. If patients are at high risk of mortality with SARS-CoV-2 infection due to age or comorbidities, then it is prudent to delay surgery, especially at the height of the pandemic. As demonstrated by the data presented above, surgeons’ willingness to delay surgery may vary. Increased risk of complications in the setting of SARS-CoV-2 infection may result from respiratory compromise due to aspiration pneumonia, atelectasis, or pneumonitis after airway surgery. Patients undergoing radiation may also have a theoretical risk of developing a more severe form of COVID-19 in the setting of concurrent mucositis, aspiration pneumonitis, or weight loss during radiation. Lastly, the immunocompromised state induced by chemotherapy may also increase the risks of respiratory compromise and failure in the setting of a COVID-19 infection.
Lastly, our respondents’ answers regarding their own health as well as the health of their family, staff, and trainees are heartening. The head and neck surgeons responding to this survey must limit exposure to their families while continuing to function as essential workers for their patients on the front lines of this pandemic. Our respondents greatest concern is related to the risk that is placed upon their staff and more so on their residents. Although resident duty hours have been substantially decreased amidst the COVID-19 pandemic to limit exposure, otolaryngology residents in academic centers still perform invaluable emergency services and provide assistance in complex cases that require more than a single surgeon. Shielding our residents from harm during this pandemic is of great concern as demonstrated by the findings of this study. Lastly, head and neck surgeons seem to have the least concern for their own health and safety during the pandemic. While this is laudable, it is important to stress physical and mental safety amongst our colleagues during this health care crisis.