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Table of Contents
MUSINGS
Year : 2020  |  Volume : 3  |  Issue : 5  |  Page : 123-126

Experience of treating head and neck cancers in government and private health-care systems during the COVID-19 pandemic: A viewpoint with summary of existing guidelines


Department of Head and Neck Surgery, Narayana Superspeciality Hospital; Department of Otorhinolaryngology Head-Neck Surgery, Institute of Post Graduate Medical Education and Research and SSKM Hospital, Kolkata, West Bengal, India

Date of Submission08-Apr-2020
Date of Decision09-Apr-2020
Date of Acceptance09-Apr-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Sourav Datta
Room No. 7, Ground Floor, Narayana Superspeciality Hospital, 120/1 Andul Road (Near Nabanna), Howrah - 711 103, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_143_20

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How to cite this article:
Dhar H, Datta S. Experience of treating head and neck cancers in government and private health-care systems during the COVID-19 pandemic: A viewpoint with summary of existing guidelines. Cancer Res Stat Treat 2020;3, Suppl S1:123-6

How to cite this URL:
Dhar H, Datta S. Experience of treating head and neck cancers in government and private health-care systems during the COVID-19 pandemic: A viewpoint with summary of existing guidelines. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jun 3];3, Suppl S1:123-6. Available from: http://www.crstonline.com/text.asp?2020/3/5/123/283306




  Introduction Top


The world today is grappling to stand its ground in the wake of the coronavirus disease 2019 (COVID-19) pandemic caused by the highly contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As we write this viewpoint today on April 6, 2020, the seriousness of the pandemic is evident, as it has affected 1,287,095 people globally, 70,523 of whom have succumbed to the disease already.[1] It is expected that the numbers will increase significantly in the next few weeks. Although it has the ability to affect all age groups, it has a propensity to affect the elderly and those with comorbidities.

Countries all across the globe have imposed travel and work restrictions/lockdowns in an attempt to flatten the curve, which has severely impacted the health-care systems with patients bearing the brunt of the limited access to treatment facilities. Patients with cancer have been impacted in more ways than one, given the fact that they are at a greater risk of acquiring the infection because of the immunocompromised state induced by the tumor and the related treatment.[2] In addition, they are facing delays in receiving care, as oncologists are having to triage patients for treatment, and a significant number of patients who might benefit from early treatment are unable to reach the hospitals because of the lockdown.[3]

Head and neck cancers account for a significant majority of cancer patients in our country, with oral cancer being the second most common solid tumor and the leading cause of cancer-related mortality in males. In addition, majority (almost 70%) of our patients present in a locally advanced state. The high burden of these cancers in our country places a huge load on our health-care systems, which is evident from the long waiting lists for surgery and radio/chemotherapy in most tertiary cancer centers.

We have reviewed several publications from the various oncology societies to aid in the decision making for the head and neck oncology patients. The general recommendation is to limit the outpatient clinic visits to only those who are symptomatic, and defer major surgeries, especially those that warrant tracheostomy and complex microvascular free flap reconstruction. We believe that the impact of the existing circumstances created by the COVID-19 pandemic on the treatment of patients with head and neck cancers, both from the patients' as well as oncologists' perspective merits discussion. Through this communication, we aim to throw light on two important aspects:First, the lack of clear guidelines from the clinicians' perspective, and second, the impact of the lockdown on patients seeking treatment.

As both authors have had the privilege to work simultaneously in a government hospital as well as a private setup, we shall discuss the above concerns in light of both these health-care scenarios.


  Review of Guidelines-Clinician's Perspective Top


Numerous guidelines and recommendations have been proposed in the past few weeks for the management of oncology patients, not only with respect to cancer in general, but also for the specific cancer types. Most of these recommendations have been made based on communications with clinicians who have faced the first phase of the pandemic and from the limited literature available on the subject. Hence, they may not be watertight. Few of the most widely read and followed guidelines among these are from the American Society of Clinical Oncology (ASCO),[4] American Head Neck Society (AHNS),[5] Journal of American Medical Association (JAMA) Otolaryngology-Head Neck Surgery,[6] British Association of Head Neck Oncologists,[7] and our national Foundation of Head Neck Oncology.[8]

The common aspects covered by these guidelines pertain to: (1) policies of outpatient consultation; (2) categorization of procedures that may be performed and those that may be deferred; (3) management of patients who test positive for SARS-CoV-2 infection; and (4) precautions for health-care workers.

A summary of recommendations on these aspects is detailed below.

Policies of outpatient consultation

All guidelines uniformly mention that outpatient clinics should be limited as much as possible. Only those who are acutely symptomatic or on active treatment should be given appointments, while routine follow-ups should be deferred. Teleconsultation should be provided to those who need medical advice, and the patients should be called to the hospital only if the symptoms are worrisome. Although a general clinical examination of patients is recommended as long as appropriate protective gear is used, all guidelines uniformly advise against performing endoscopies of the mucosa of the upper aerodigestive tract, as these are definite aerosol-generating procedures, which may expose the clinician and other personnel in the room to a high viral load.

Categorization of procedures

Emergency procedures such as tracheostomy for stridor and control of bleeding (carotid artery ligation) are recommended in all situations. Major surgeries for advanced cases, especially those that warrant a tracheostomy and postoperative intensive care unit (ICU) care with ventilation and microvascular free flap surgeries have been advised to be deferred. Daycare procedures or short procedures for T1–T2 cancers that do not warrant reconstruction or tracheostomy with a short hospital stay have been advised. There is no evidence against starting/continuing radiation; however, the ASCO and American Society of Radiation Oncology (ASTRO) guidelines recommend using hypofractionated regimens. Chemotherapy for palliative intent and where benefit is uncertain has been advised to be deferred and replaced by metronomic therapy. There is strong concordance among all the reviewed guidelines with respect to these indications, with the exception of the AHNS statement that recommends considering surgery after confirming the urgency of the individual case. Other review articles have also supported this philosophy.[9],[10],[11]

Management of COVID-19-positive patients

Any patient with cancer testing positive for COVID-19 should have the cancer treatment postponed, unless and until there is an imminent threat to life. Cancer-directed treatment can be commenced after the patient is cured of COVID-19 and tests negative. If at all surgery is considered, guidelines for proper personal protective equipment (PPE), negative-pressure operating rooms, and safe handling of the airway should be followed.

Precautions for health-care workers

Given that community spread has already occurred in a number of countries, most of the guidelines recommend considering every patient a carrier and using appropriate PPE (N95 masks, impermeable gowns, goggles, and face shield) while dealing with them. However, this is easier said than done because of the relative shortage of these items and the likely rise in the number of cases in the days to come, when the demand for this protective gear will be more acute.

Although the guidelines have dealt with the broad concerns, there are a few questions left unanswered. First, which cases to treat on an urgent basis and which to defer? Since the head and neck mucosa is a known reservoir of SARS-CoV-2, surgical procedures will generate aerosols and expose all personnel within the operating rooms to a high viral load, even if the patient is an asymptomatic carrier. From the patient's perspective, a delay in treatment will potentially worsen the outcomes. Similarly, offering radiation/chemoradiation as an alternative where surgery is the prime modality may also significantly worsen the outcomes, especially if delayed indefinitely. Surgeons are thus faced with the Shakespearian dilemma, “To treat or not to treat?”[12]

Most of the guidelines give broad recommendations without clarifying which surgeries may be justified as semi-urgent. The AHNS statement, as well as the review by Topf et al. provide better insight into this issue.[5],[9] It is recommended that decisions should be taken by a multidisciplinary tumor board and not by individual oncologists.

While the gravity of this issue is the same in both government and private health-care systems, our working experience shows that it is slightly more acute in the former, as many of the government institutes have a section of infrastructure (ICUs and ventilators) and manpower (surgeons and anesthetists) dedicated to the pandemic, placing constraints on all the other services and limiting the number of PPE sets and isolation wards available.

Second, perhaps the most common question being put forth by all the oncologists is whether all the patients should be tested for COVID-19 before proceeding with treatment, so as to identify the carriers. The dangers of performing surgeries for mucosal malignancies have already been mentioned. Prior knowledge of the viral status will aid in deferring the surgery, and in cases in which surgery is absolutely essential, it will help in careful planning with extreme precautions. Although the JAMA and ASCO guidelines recommend testing all patients, we have not been able to uniformly implement this in a resource-constrained setting such as ours. It may appear that patients presenting to a private setup can afford to get the test done from private laboratories and pay for procuring the PPE. However, stringent rules do not allow universal testing even in the private sector (in our state), and an overall scarcity of protective gear caused by the lockdown-hit delivery systems may create a suboptimal working environment in both the sectors of healthcare in spite of the government's best efforts during this crisis.


  Impact of the Lockdown on Patients Seeking Treatment Top


On March 24, 2020, the Government of India ordered a nationwide lockdown for 21 days, limiting the movement of the entire population to prevent the spread of the COVID-19 pandemic. Among the number of restrictions imposed, the most impactful has been restricting people from stepping out of their homes. In addition, all transport services – road, air, and rail – have been suspended with exceptions for transportation of essential goods, fire engines, police, and emergency services.

There has been a significant impact of this suspension on health-care systems. Although emergency procedures for trauma, acute cardiac events, and stroke have not been curbed, oncology care, despite being a semi-emergency, is often not given its due importance; this significantly impacts patients with cancer.

Surgery, radiation, and chemotherapy, the three therapeutic modalities for cancer, each require a different set of travel and logistic arrangements for the patient and their caregivers. As radiotherapy is administered on all working days of a week for an average of 6–8 weeks, the patients and their caregivers prefer to stay in the vicinity of the hospital to facilitate the daily commute, especially if they hail from other towns. As chemotherapy regimens for patients with head and neck cancers mainly have a 3-weekly or weekly schedule, most patients travel back home in between cycles. As most cancer centers have a surgical waitlist of at least 2–3 weeks, patients after initial preoperative evaluation come back for admission 1 day prior to the surgery. In view of these logistics, the lockdown has severely impacted the ability of our patients seeking treatment. At the end of the 2nd week of the lockdown, we analyzed the difference in the reduction in the treatment load for each therapeutic modality between the government and private setups we are affiliated with.

With regard to radiotherapy, we observed that the number of active treatments and new patient registrations combined reduced by 30% in the private setup and 70% in the government setup. The drop was observed both in patients on active treatment as well as in the number of new patients being registered. For surgical patients in the government hospital, there was an 80% reduction in the new patient load and a 50% reduction in the number of surgeries. The same figures in the private setup were 60% and 50% respectively. Here, we note an interesting comparison. In the government setup, the reduction in surgical numbers was less during the 1st week as the majority of the patients were already admitted to the hospital, awaiting surgery. The reduction was much higher in the subsequent week when scheduled patients could not travel and reach the hospital because of the restrictions. In contrast, in the private setup, we saw a more significant reduction in the number of surgeries performed during the 1st week, with a subsequent increase in these numbers during the 2nd week as patients were able to arrange their own travel and reach the hospital.

Chemotherapy does not play as significant a role in head and neck cancers as surgery and radiation. It is mainly administered concurrently with radiation or in the palliative setting. A minor fraction of patients also receives chemotherapy in the neoadjuvant setting. The impact of the lockdown on concurrent chemotherapy numbers mirrors that of radiation, as expected. Taking other indications into account, the reduction in new patient registrations was 33% in the government hospital and 15% in the private setup. For both centers, the reduction in indoor chemotherapy was not as significant; it was approximately 20% in both.

It is important to note that patients undergoing radiation therapy, which requires a daily commute to the hospital, were most affected by the lockdown. Inpatient chemotherapy was the least impacted in both the setups. The overall impact of the pandemic on the number of cancer patients availing treatment was markedly more in the government setup (70% reduction in radiotherapy and 50% reduction in surgeries). Patients who seek treatment in these government hospitals, which provide free treatment in our state, come from the lowest socioeconomic stratum of society and cannot bear the cost of arranging for frequent transport to the hospital.

As the majority of our patients have locally advanced disease, this delay in their treatment is bound to impact outcomes by causing disease progression/recurrence. With the pandemic being far from over, more patients are expected to be impacted in a similar way. These data when extrapolated to the entire country might translate into a large number of patients with cancer being adversely impacted.


  Conclusion Top


Cancer management is a semi-emergency. A delay in treatment in any form of jeopardizes survival. Patients with cancer being relatively immunocompromised are at a greater risk of contracting the SARS-CoV-2 infection, the course of which is likely to be more severe. Numerous guidelines have been published, but there is lack of clarity on how to triage patients for treatment and balance the risk conferred by the malignancy with the risk of exposing the patient and health-care workers to the CoV. In our opinion, appropriate treatment should be extended not only to those with T1–T2 tumors but also to those with locally advanced disease who may benefit from curative-intent therapy while taking adequate precautions against exposure. Pretreatment testing for COVID-19 would be ideal, but logistically difficult at present. While the suspension of free movement due to the pandemic has impacted all patients with cancer, those from low socioeconomic backgrounds seeking care in government institutions have been the worst hit because of the lack of transport facilities. The government should consider special provisions to improve travel logistics for patients with cancer to facilitate timely treatment.

Acknowledgements

We would like to acknowledge our radiation oncology and medical oncology colleagues at both the centers for acquiring data regarding patient numbers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Coronavirus Update (Live): 1,287,095 Cases and 70,523 Deaths from COVID-19 Virus Outbrea Worldometer. Available from: https://www.worldometers.info/coronavirus/. [Last accessed on 2020 Apr 06].  Back to cited text no. 1
    
2.
Bansal N, Ghafur A. COVID-19 in oncology settings. Cancer Res Stat Treat 2020;3:13-4.  Back to cited text no. 2
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3.
Dalal NV. Social issues faced by cancer patients during the coronavirus (Covid-19) pandemic. Cancer Res Stat Treat 2020;3:141-4.  Back to cited text no. 3
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4.
ASCO COVID-19 Patient Care Inforymation. Available from: https://www. Asco. Org/Asco-Coronavirus-Information/Care -Individuals-Cancer-During-Covid-19. [Last accessed on 2020 Apr 07].  Back to cited text no. 4
    
5.
AHNS Bulletin: Information for Head and Neck Oncologists during the COVID-19 Pandemic (from the Survivorship, Supportive Care and Rehabilitation Service; March 23, 2020). Available from: https://www.ahns.info/wp-content/uploads/2020/03/synthesized-physician-doc.pdf. [Last accessed on 2020 Apr 07].  Back to cited text no. 5
    
6.
Givi B, Schiff BA, Chinn SB, Clayburgh D, Iyer NG, Jalisi S, et al. Safety recommendations for evaluation and surgery of the head and neck during the Covid-19 pandemic. JAMA Otolaryngol Head Neck Surg. 2020 Mar 31. doi: 10.1001/jamaoto.2020.0780. [Epub ahead of print].  Back to cited text no. 6
    
7.
BAHNO Statement on Covid-19 | BAHNO-British Association of Head and Neck Oncologists. Available from: https://www.bahno.org.uk/bahno_statement_on_covid-19.aspx. [Last accessed on 2020 Apr 07].  Back to cited text no. 7
    
8.
Foundation for Head and Neck Oncology (FHNO) Advisory for Management of Head and Neck Cancers during COVID-19 Epidemic Period. Available from: http://www.fhno.org/pdf/Guidelines_Covid-19_. [Last accessed on 2020 Apr 06].  Back to cited text no. 8
    
9.
Topf MC, Shenson JA, Holsinger FC, Wald SH, Cianfichi LJ, Rosenthal EL, et al. A Framework for Prioritizing Head and Neck Surgery during the COVID-19 Pandemic. Head & Neck 2020. Accepted Author Manuscript. doi:10.1002/hed.26184. [Epub ahead of print].  Back to cited text no. 9
    
10.
Kowalski LP, Sanabria A, Ridge JA, Ng WT, de Bree R, Rinaldo A, et al. COVID-19 pandemic: Effects and evidence-based recommendations for otolaryngology and head and neck surgery practice. Head & Neck 2020; 1-9. https://doi.org/10.1002/hed.26164. Epub ahead of print.  Back to cited text no. 10
    
11.
Patil V, Noronha V, Chaturvedi P, Talapatra K, Joshi A, Menon N, et al. COVID-19 and head and neck cancer treatment. Cancer Res Stat Treat 20203:15-28.  Back to cited text no. 11
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12.
Noronha V, Behel V. Catch-22: COVID versus Cancer. Cancer Res Stat Treat 2020;3:1-2.  Back to cited text no. 12
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