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.