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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 5  |  Page : 7-12

The pattern of care in head-and-neck cancer: Comparison between before and during the COVID-19 pandemic


Department of Medical Oncology, Tata Memorial Centre, HBNI, Mumbai, Maharashtra, India

Date of Submission19-Apr-2020
Date of Decision20-Apr-2020
Date of Acceptance20-Apr-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_161_20

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  Abstract 


Background: Coronavirus disease 2019 (COVID-19) has led to a redistribution of the medical resources. However, there are limited data on the treatment patterns in head-and-neck cancer during this pandemic. Therefore, this study was aimed at comparing the pattern of care in head-and-neck cancer before and during the pandemic.
Methods: This was a retrospective study of patients visiting the adult medical head-and-neck cancer unit of our hospital, between February 01, 2020, and April 15, 2020. The patients were divided for analysis into three groups: pre-COVID (February 01, 2020–February 29, 2020), start-COVID (March 01, 2020–March 31, 2020), and established-COVID (April 01, 2020–April 15, 2020). The patient footfalls, baseline characteristics, and pattern of treatment during the three time periods were compared. A two-sided P = 0.05 was considered statistically significant.
Results: The number of patients in the pre-COVID, start-COVID, and established-COVID time periods was 219, 281, and 57, respectively. The median number of footfalls per working day in the pre-COVID, start-COVID, and established-COVID time periods was 84 (interquartile range [IQR], 70.5–89), 47 (IQR, 41.25–57.75), and 24 (IQR, 22.5–28), respectively (P = 0.000). There was no difference in the tumor-related baseline characteristics. In patients receiving neoadjuvant chemotherapy, the proportion of patients receiving the three-drug regimen was lowest in the established-COVID period (29.3% vs. 35.9% vs. 7.7%, respectively; P = 0.000). There was no difference in the pattern of selection of concurrent radio-sensitizing agents (P = 0.779). In patients receiving palliative treatment, the proportion of those receiving oral metronomic chemotherapy was higher in the established-COVID period than that in the pre-COVID and start-COVID periods (47.4% vs. 34.3% vs. 69.2%, respectively; P = 0.192).
Conclusion: The early trend suggests that the number of patients visiting the hospital has decreased during the COVID-19 pandemic. The treatment pattern during the pandemic may be different for palliative regimens and neoadjuvant chemotherapy regimens.

Keywords: Coronavirus, COVID, COVID-19, head-and-neck cancer, pattern of care, SARS-CoV-2, systemic therapy


How to cite this article:
Patil VM, Srikanth A, Noronha V, Joshi A, Dhumal S, Menon N, Prabhash K. The pattern of care in head-and-neck cancer: Comparison between before and during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3, Suppl S1:7-12

How to cite this URL:
Patil VM, Srikanth A, Noronha V, Joshi A, Dhumal S, Menon N, Prabhash K. The pattern of care in head-and-neck cancer: Comparison between before and during the COVID-19 pandemic. Cancer Res Stat Treat [serial online] 2020 [cited 2020 May 30];3, Suppl S1:7-12. Available from: http://www.crstonline.com/text.asp?2020/3/5/7/283315




  Introduction Top


The novel coronavirus disease 2019 (COVID-19) pandemic is on the rise.[1] The increase in the number of cases has led to a significant burden on the health-care resources.[2] Intensive care units, ventilators, workforce, and other monetary resources are being diverted toward the prevention and management of COVID-19 cases.[2] Management of many medical ailments has taken a back seat because of such resource allocations.

Cancer treatment is considered a nonemergency treatment and, hence, is suggested to be well planned with multidisciplinary care.[3] Management of cancer patients is resource consuming and requires social support.[4] In the current COVID-19 pandemic, there is limited evidence-based guidance for the management of patients with cancer. Multiple international and national bodies have provided guidance in this situation.[5],[6],[7] However, a very limited proportion of this is based on the actual patient data. There are concerns regarding the administration of systemic agents in cancer patients, as they make the patients susceptible to COVID-19 infection due to immunosuppression. Moreover, patients with cancer who have this infection have a higher risk of mortality and complications according to the Chinese data.[8] Hence, there is a dilemma about whether to administer such therapy. In view of the lack of literature in this situation, we performed a retrospective comparative study to assess the pattern of care of treatment in patients visiting the adult medical oncology head-and-neck cancer unit. The primary objective of this study was to assess whether there was a modification in the use of systemic therapy in patients with cancer undergoing treatment.


  Methods Top


General methodology and ethics

This was a retrospective study performed in the Department of Medical Oncology in the head-and-neck outpatient department at Tata Memorial Center, a major academic tertiary care cancer center in Mumbai, Maharashtra, India. The information was obtained from the hospital records. The study was conducted according to the principles laid down by the International Conference on Harmonization Good Clinical Practice guidelines, the Declaration of Helsinki, and Schedule Y (Drugs and Cosmetic Act, 1940), and the guidelines established by the Indian Council of Medical Research.

Selection of patients

All patients visiting the head-and-neck cancer medical oncology unit from February 01, 2020, to April 15, 2020, were selected for this analysis. The patients were divided into three groups: pre-COVID, start-COVID, and established-COVID. Even though a clear demarcation of the three periods was not possible, February (February 01–29, 2020) was considered the month that represented the pre-COVID time period, and March (March 01–30, 2020) and April (April 01–15, 2020) were considered to represent the start-COVID and established-COVID periods, respectively. This was done because the number of patients in our city affected with COVID-19 was zero in the month of February 2020; the number started rising in March 2020, and an exponential rise was seen in April 2020.[9]

Data collection

Data were collected under two major headings: “Resources” and “Patterns of care.” The resources included the availability of workforce (doctors, nurses, patient navigators, and paramedical staff) and financial assistance. For the pattern of care, the following data were collected: age, gender, Eastern Cooperative Oncology Group performance status (PS), site of the tumor, stage, the intent of treatment, chemotherapy status, and chemotherapy modification, if any.

Data analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS version 20, Armonk, NY; IBM Corp) and RStudio (R version 3.6.2 [2019-12-12] The R foundation for statistical computing platform). Continuous variables were described using median with interquartile range (IQR), whereas the noncontinuous variables were described using proportions with 95% confidence interval. The continuous variables were compared using Mood's median test, and the noncontinuous variables were compared using the Fisher's exact test. A two-sided P = 0.05 was considered statistically significant.


  Results Top


Timeline

A timeline of the COVID-19 events in India and their impact on patient numbers are shown in [Figure 1]. The number of patients in the pre-COVID, start-COVID, and established-COVID time periods was 219, 281, and 57, respectively. The median footfalls per working day in the pre-COVID, start-COVID, and established-COVID time periods were 84 (IQR, 70.5–89), 47 (IQR, 41.25–57.75), and 24 (IQR, 22.5–28), respectively (P = 0.000).
Figure 1: Patient footfall on Y-axis against working days from February 01, 2020, to April 15, 2020

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Baseline characteristics

The baseline characteristics of the patients are shown in [Table 1]. Differences were observed in the gender distribution and place of stay; however, the tumor-related baseline characteristics were similar [Table 1].
Table 1: Baseline characteristics

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Resources

The per-day availability of resources during the three time periods is shown in [Table 2]. There was a statistically significant difference in the availability of medical oncology trainees (P = 0.000), social workers (P = 0.000), and patient navigators (P = 0.000) during the COVID time periods [Table 2].
Table 2: Per-day resource availability characteristics

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Pattern of care

Intention of treatment

Out of the 219 patients in the pre-COVID group, 125 (57.1%) patients were planned for curative-intent treatment, while 94 (42.9%) received palliative-intent treatment. The corresponding numbers in the start-COVID group were 153 (54.4%) and 128 (45.6%), respectively; the corresponding numbers in the established-COVID group were 38 (66.7%) and 19 (33.3%), respectively. There was no difference in the pattern of the intention of treatment between the three time periods (P = 0.236).

Palliative patients

In the pre-COVID group, 37 patients (39.4%) were planned for best supportive care (BSC), 26 (27.7%) for intravenous palliative chemotherapy, 27 (28.7%) for oral metronomic chemotherapy, and 4 (4.3%) for checkpoint inhibitors. In the start-COVID group, 55 (43%) patients were planned for BSC, 39 (30.5%) for intravenous palliative chemotherapy, 23 (18%) for oral metronomic chemotherapy, 5 (3.9%) for immunotherapy, 4 (3.1%) for palliative radiation, and 2 (1.6%) for observation (salivary gland primary with asymptomatic metastasis). In the established-COVID group, 6 patients (31.6%) were planned for BSC, 4 (21.1%) for intravenous palliative chemotherapy, and 9 (47.4%) for oral metronomic chemotherapy. There was no statistically significant difference in the distribution of the overall treatment plan selection for patients in the three time periods (P = 0.216). However, there was a difference in the type of regimen selected for treatment; a higher proportion of patients received the oral metronomic regimen (47.4% vs. 34.3% vs. 69.2%, respectively) in the established-COVID period, though it was not statistically significant [Figure 2], P = 0.192].
Figure 2: Treatment regimens selected for palliative treatment. The numbers depicted on bar diagrams are absolute numbers. The Y-axis depicts the corresponding percentage. COVID-19: Coronavirus disease 2019

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Curative patients

The distribution of curative treatments required in the three time periods is shown in [Table 3]. There was no statistically significant difference in the distribution of type of treatments (P = 0.175).
Table 3: Chemotherapy protocols planned during the pre-coronavirus disease 2019, start-coronavirus disease 2019, and established-coronavirus disease 2019 periods

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Neoadjuvant chemotherapy

The distribution of neoadjuvant regimens is shown in [Figure 3]a and [Figure 3]b. The distribution of chemotherapy regimens was statistically significantly different across the three time periods (P = 0.000). There was a steep decline in the use of the TPF (docetaxel, platinum, and 5- fluorouracil) regimen (29.3% vs. 35.9% vs. 7.7%, respectively) in the established COVID-19 period [Figure 3].
Figure 3: (a) The absolute number of various neoadjuvant regimens used during the three time periods. (b) The relative percentages of various neoadjuvant regimens used during the three time periods. TPF: Docetaxel, platinum, and 5-fluorouracil. TP: Docetaxel and platinum. PP: Paclitaxel and platinum. OMCT: Oral metronomic regimen of methotrexate and celecoxib ±- erlotinib. GP: Gemcitabine platinum (used in nasopharynx). COVID-19: Coronavirus disease 2019

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Concurrent chemotherapy

The distribution of concurrent chemotherapy regimens is shown in [Figure 4]a and [Figure 4]b. The difference in the distribution of the chemotherapy regimens was not statistically significant across the three time periods (P = 0.779). However, there was a steep decline in the use of the three-weekly cisplatin regimen in the established COVID-19 period to 0% (data not shown).
Figure 4: (a) The absolute number of various concurrent chemotherapy regimens used during the three time periods. (b) The relative percentages of various neoadjuvant regimens used during the three time periods. Cis-Nimo: Cisplatin-nimotuzumab, COVID-19: Coronavirus disease 2019. CT: Chemotherapy

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COVID-19 infection

As of April 18, 2020, there was only one patient who reported COVID-related symptoms, but tested negative for COVID-19.


  Discussion Top


To the best of our knowledge, this is the first report depicting the changes in the pattern of treatment in head-and-neck cancer during the COVID pandemic. The report highlights the decrease in patient footfalls and the numbers due to the imposed lockdown measures and institutional pandemic-screening policies.[9],[10] The statistically significant decrease in the numbers testifies to the success of these methods. However, it also raises a question regarding the treatment of new cancer cases. Considering the limited availability of cancer care centers in India,[4] the new policy needs to focus on how potential patients can reach the tertiary cancer centers.

Interestingly, there was an initial rise in the number of patients in the early pandemic period. This highlights the increased patient load which came to our hospital probably because of the resource allocations toward COVID in other nondedicated cancer hospitals. The baseline characteristics highlight the differential demographic distribution of patients during the period. Surprisingly, a higher number of patients who came to the hospital in the established-COVID period were not from Maharashtra. This probably occurred because of the strict lockdown measures instituted by the Government of India, as a result of which, patients from other states who had come to Maharashtra for cancer treatment could not return to their home states and had to stay in Mumbai for their treatment.

Our results highlight that the tumor characteristics and the overall treatment plan were similar in the three time periods. However, logical changes had been made by the treating medical oncologists in selecting the treatment regimens. Palliative treatment regimens were dominated by oral metronomic chemotherapy during the established-COVID period. Oral metronomic chemotherapy consisting of methotrexate-celecoxib with or without erlotinib is associated with improved outcomes over intravenous cisplatin with a lower rate of adverse events.[11],[12] These regimens are also associated with an improvement in the quality of life.[11],[13] Hence, these regimens seem to be more suitable in the current situation. Another important aspect seen in the study was that BSC was offered to some of the patients during all the three time periods. It is important to understand that patients who are unfit for chemotherapy and have a poor PS do not benefit from chemotherapy. Even in the curative settings, the three-drug TPF regimen was used considerably less in the COVID-19 period. This was because of the significant morbidity associated with this regimen,[14] which in normal circumstances can be handled by an expert medical oncologist. However, in the current COVID-19 situation, the immunosuppression resulting from this regimen might predispose the patient to the COVID-19 infection and its complications. There was no major change in the drug selection for concurrent chemoradiation during the three time periods. Of note, the use of a three-weekly cisplatin regimen was stopped in the established-COVID-19 period. The use of three-weekly cisplatin has shown an improvement in the locoregional control over the weekly 30 mg/m2 regimen of cisplatin.[15] However, there was no difference in the disease-free survival and overall survival. The use of cisplatin, weekly 40 mg/m2 regimen, has a higher rate of immunosuppression than the three-weekly cisplatin regimen.[16] Hence, this decision seems to be influenced by the higher nonmyelosuppressive side effects of three-weekly cisplatin, the need for hydration, and in-door admission.[15],[17]

Our study has its own strengths and limitations. The study provides a comprehensive record of all consecutive patients visiting the medical oncology head and neck outpatient department. The large number of patients (>500) involved in the study enabled us to draw firm conclusions regarding the pattern of care change. The large number of patients who started treatment in February 2020 and then continued in March 2020 also attests the safety of these regimens. However, the follow-up is too short to draw firm conclusions regarding the COVID-19-related infections in patients treated in the second half of March 2020 and April 2020. The treatment outcomes with these changes are unknown. However, by the time we have the 2-year outcome data for these changes, there is a high likelihood that the pandemic would have ended and then these data would not be of much importance. The current need is to have guidance on the treatment patterns in this pandemic; these data provide us with vital information in this regard.


  Conclusion Top


The early trend suggests that the number of patients visiting the hospital have decreased during the COVID-19 pandemic. The treatment patterns during the pandemic may be different for palliative regimens and neoadjuvant chemotherapy regimens.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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