Type of treatment
Several groups developed recommendations on the management of patients with head and neck cancer during the pandemic, including both general recommendations as well as specific surgical and non-surgical recommendations 16–20. Treatment of head and neck cancer has been restricted around the world due to capacity limitations and to the increased risk of infection for both staff and patients. In our centre, the intensive care unit (ICU) had only limited restrictions, therefore decision-making process for surgical treatment was not influenced by any ICU-related restrictions. With regard to non-surgical treatment, we observed some delays during the 12-month Covid-19 study period related to inpatient coronavirus infections during the course of radiotherapy, which perhaps explains why there were no significant differences between the two periods in the proportion of patients eligible for radical surgery (71% vs. 75.4%). Kiong and colleagues did not observe any differences in surgical vs. non-surgical treatment, although fewer patients were considered eligible for primary surgery than in our study (47.3% vs. 73.2%).
We also assessed the type of treatment in two specific anatomic locations (larynx and oropharynx), which were selected because oncological outcomes for this two sites are similar regardless of the treatment type in patients with early-stage disease21–25. We found no significant differences between the pre-Covid and Covid periods in terms of the proportion of laryngeal cancer patients treated surgically (80% vs. 74%, respectively), but we did find a significant difference in early-stage oropharyngeal cancer (47% vs. 86%), perhaps due to the use of minimally-invasive surgery (mainly robotic surgery) in these patients, where the risk of tracheostomy is low and the hospital stay is much shorter than in radical radiotherapy.
Our data shows that a significantly higher proportion of patients received palliative radiotherapy during the pandemic period (20.5% vs. 32.9%) and palliative care alone was indicated in a higher percentage of patients (1.8% vs. 6.2%). Both of these findings are likely directly related to the pandemic. Although disease severity (TNM staging) did not differ in the two periods, the limited access to basic medical care (with the consequent delays in diagnosis and treatment), resulted in an increase in the number of patients ineligible for radical treatment due to comorbidities and cancer-related malnutrition. Of the 21 patients in the Covid-19 period referred to best supportive care, six were offered palliative radiotherapy but declined due to pandemic-related fear. Given the importance of palliative care to ensure adequate pain management and nutritional and respiratory support, we believe that a symptom-based approach to these patients should be taken during the pandemic. In this regard, Singh and colleagues published recommendations on the management of palliative patients during the pandemic, emphasizing the need for better access to drugs, greater use of teleconsultation, and wider community support 26.