Discussion
In this report we present two cases of immunocompromised patients
presenting with head and neck cancer with the goal of using their
management as illustrations that exemplify how therapeutic decisions
might be made in this extremely vulnerable population at a unique time
in the practice of medicine.
In Case 1, a patient developed another early oral tongue lesion on a
background of a very complicated history of prior oral cavity cancers
and chronic GVHD after allogeneic stem cell transplant for aplastic
anemia. In this case, we determined that the risk of potential COVID-19
exposure outweighed the risk of delaying his treatment for a few months.
A number of factors contributed to our decision. The location and size
of the lesion on the tongue was thought to not put the patient at risk
for airway obstruction. The lesion was easy visualized by the patient
and clinician through telemedicine visits, and the patient felt
comfortable sharing photographs regularly. Finally, the anticipated
delay in definitive therapy of a few months was thought unlikely to
significantly alter his functional outcome and overall survival.
In Case 2, we presented a recurrent early stage glottic lesion in a
patient on chronic immunosuppressive medications for Crohn’s disease.
The biologic agent used to treat her inflammatory bowel disease was
modified to use a less systemically immunosuppressive agent. The
benefits of proceeding with surgery immediately were felt to outweigh
the risk of possible COVID-19 exposure. The main reasons for this
decision were the implications of rapid cancer progression on her
overall outcome, the potential airway risk, and inability to monitor
with telemedicine. The decision to recommend surgery over definitive
radiotherapy was multifactorial but incorporated the heightened risk of
exposure to SARS-CoV-2 during a typical six-week course of radiotherapy,
which in her case would have corresponded to the predicted peak surge in
COVID-19 cases in our region.
During this pandemic, especially in situations where the benefits of
each modality are comparable, we should consider the degree of
immunosuppression caused by our therapies as well as the risks of viral
exposure to the immunocompromised patient. There is a period of
immunosuppression in the immediate post-operative period due to a
variety of metabolic and endocrine responses with studies showing
increases in glucocorticoids and decreases in the number and function of
critical leukocyte subpopulations for up to 30 days; the extent of the
change is related to the magnitude of surgical
insult.19 Additional studies also have shown that the
immunosuppressive effects of surgery can be minimized by adequate pain
control and the use of minimally invasive surgical techniques.
While surgery may put the patient at acute risk for exposure to
COVID-19, chemotherapy may result in further immunosuppression, and
radiotherapy typically requires daily visits to an outpatient clinic
over a period of five to seven weeks.20-25 The latter
will increase the potential exposure to SARS-CoV-2. The overall risk to
the immunocompromised patient of acquiring a COVID-19 infection is
probably greater with radiation therapy with or without chemotherapy
than after a single visit to the hospital for surgery, even if that one
visit requires tracheostomy and hospitalization. However, sufficient
data are not available to reach definitive conclusions about these
competing risks at this time.
A discussion with an Infectious Disease specialist about the potential
benefit of medications such as hydroxychloroquine, a drug with some
preliminary, but limited, evidence of inhibition of SARS-CoV-2 in vitro
and viral load reduction in COVID-19 patients, may be warranted for the
post-operative period, as was agreed upon in Case
2.26-29 The importance of home isolation should be
stressed with all of these patients.
The current rule of thumb in the face of this pandemic is cancellation
of elective appointments and surgeries; however, no cancer treatment is
truly elective.30-32 Decision-making for all patients
with operable cancers requires a nuanced approach, especially when there
is the added complication of co-morbid immunosuppression as in the two
cases we present. We favor operating when there is a concern for future
airway obstruction or life-threatening bleeding if treatment is delayed.
If the decision is made to operate, appropriate PPE, such as an N95 mask
with a face shield and eye protection, is of utmost importance to
protect the entire surgical team as well as the
patient.8,13-15 Telemedicine appointments and
photographic monitoring should be used whenever feasible in order to
allow home isolation. Most importantly, we recommend an honest
discussion of the situation with the patient, taking into account their
comfort and goals of care.