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\begin{document}

\title{Changes in Head and Neck Oncologic Practice During the COVID-19
Pandemic~}



\author[1]{Robert M. Brody, MD}%
\affil[1]{University of Pennsylvania}%


\vspace{-1em}



  
  \date{June 14, 2024}


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\selectlanguage{english}
\begin{abstract}
Introduction: The COVID-19 pandemic has raised controversies regarding
safe and effective care of head and neck cancer patients. It is unknown
how much the pandemic has changed surgeon practice. Methods: A
questionnaire was distributed to head and neck surgeons assessing
opinions related to treatment and concerns for the safety of patients,
self, family, and staff. Results: A total of 67 head and neck surgeons
responded during the study period. Surgeons continued to recommend
primary surgical treatment for oral cavity cancers. Respondents were
more likely to consider non-surgical therapy for patients with early
glottic cancers and HPV-mediated oropharynx cancer. Surgeons were least
likely to be concerned for their own health and safety and had the
greatest concern for their resident trainees. Conclusions: This study
highlights differences in the willingness of head and neck surgeons to
delay surgery or alter plans during times when hospital resources are
scarce and risk is high.%
\end{abstract}%



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Robert M. Brody, MD\textsuperscript{1}, W. Greer Albergotti,
MD\textsuperscript{2}, David Shimunov, BA\textsuperscript{1}, Elizabeth
Nicolli, MD\textsuperscript{3}, Brianna N. Harris,
MD\textsuperscript{4}, Andr\selectlanguage{ngerman}és M. Bur, MD\textsuperscript{5}

\begin{enumerate}
\tightlist
\item
  Department of Otorhinolaryngology -- Head \& Neck Surgery, University
  of Pennsylvania, Philadelphia, PA
\item
  Department of Otolaryngology -- Head \& Neck Surgery, Medical College
  of Georgia / Augusta University, Augusta GA
\item
  Department of Otolaryngology- Head \& Neck Surgery, University of
  Miami, Miami, FL
\item
  Department of Otolaryngology- Head \& Neck Surgery, Scripps Memorial,
  San Diego, CA
\item
  Department of Otolaryngology- Head \& Neck Surgery, University of
  Kansas, Kansas City, KS
\end{enumerate}

\par\null

\emph{Corresponding Author}

Robert M. Brody, MD

Department of Otorhinolaryngology -- Head \& Neck Surgery, University of
Pennsylvania

3400 Spruce Street, 5 Ravdin

Philadelphia, PA, 19104

E-mail: Robert.brody2@pennmedicine.upenn.edu

\emph{Disclosures}

This work has never been published or presented anywhere. The authors
have no financial or industry relationships to disclose. There are no
sources of funding to disclose.

\emph{Running Title}

Survey of Head \& Neck Surgeon Preferences and Concerns During COVID-19
Pandemic

\emph{Keywords}

SARS-CoV-2, COVID-19, Coronavirus, Head and Neck Cancer, Treatment
Delays, Wellness

Abstract

Introduction: The COVID-19 pandemic has raised controversies regarding
safe and effective care of head and neck cancer patients. It is unknown
how much the pandemic has changed surgeon practice.

Methods: A questionnaire was distributed to head and neck surgeons
assessing opinions related to treatment and concerns for the safety of
patients, self, family, and staff.

Results: A total of 67 head and neck surgeons responded during the study
period. Surgeons continued to recommend primary surgical treatment for
oral cavity cancers. Respondents were more likely to consider
non-surgical therapy for patients with early glottic cancers and
HPV-mediated oropharynx cancer. Surgeons were least likely to be
concerned for their own health and safety and had the greatest concern
for their resident trainees.

Conclusions: This study highlights differences in the willingness of
head and neck surgeons to delay surgery or alter plans during times when
hospital resources are scarce and risk is high.

Introduction

The coronavirus disease 19 (COVID-19) caused by the severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a pandemic
by World Health Organization (WHO) on March 11,
2020.\textsuperscript{1}This pandemic has placed increased stress on
health care systems, both due to critical resource shortages and delays
in care. Health care providers now must find new ways of safely
providing cancer care without compromising patient outcomes, or
overutilizing precious resources.\textsuperscript{2} The American
Academy of Otolaryngology -- Head \& Neck Surgery has recommended
surgeons delay elective cases to allow for improved safety of staff and
patients, preservation of critical personal protective equipment (PPE),
and to expand hospital capacity during the COVID-19
pandemic.\textsuperscript{3} Additionally, the American College of
Surgeons (ACS) has provided guidance defining the acuity of cancer
surgeries, with most mucosal cancers of the upper aerodigestive tract
meeting the criteria for Tier 3a (high acuity surgery/healthy patient).
Accordingly, delays in treatment should not occur.\textsuperscript{4}
The ACS feels that ``the risk to the patient should include an aggregate
assessment of the real risk of proceeding and the real risk of delay,
including the expectation that a delay of 6-8 weeks or more may be
required to emerge from an environment in which COVID-19 is less
prevalent''.\textsuperscript{4}

Head and neck cancer care poses a unique challenge during the COVID-19
pandemic because increasing evidence has emerged that Otolaryngologists
are at significantly higher risk of infection due to exposure to the
upper airway and respiratory droplets.\textsuperscript{5,6}Additionally,
reasonable alternative treatment options are lacking for many head and
neck malignancies and treatment delay leads to increased morbidity and
mortality.\textsuperscript{7,8} Head and neck cancer is unique in that
oral cavity cancers, human papillomavirus (HPV)-negative oropharyngeal
squamous cell carcinoma (OPSCC), and advanced laryngeal cancers are
considered aggressive malignancies and there is no widely-accepted
neoadjuvant treatment option that can allow definitive surgery to be
delayed. Other subtypes such as HPV-mediated OPSCC and early laryngeal
squamous cell carcinoma can be treated either with radiation-based or
surgical-based therapy, which offer equivalent oncologic outcomes.

Despite ACS recommendations that delays in cancer treatment be avoided
during the COVID-19 pandemic, treatment delays are anticipated and are
currently occurring. This can be expected to alter the management
strategies as head and neck surgeons and radiation oncologists weigh the
risks and benefits of viral exposure both to the patient and to
operating room and clinic staff. Furthermore, patients who unknowingly
have surgery during the incubation period of COVID-19 infection appear
to be at extremely high risk of morbidity and may have approximately
20\% risk of mortality\textsuperscript{8}. There is also a high level of
concern over the risk of immunosuppression with systemic chemotherapy
during the ongoing pandemic. These risks must be balanced with the risk
of cancer progression by delaying therapy as well as the psychological
impact on patients of delayed or altered plans of
care.\textsuperscript{10-12} It has been established in the literature
that increases in the duration of time between diagnosis and definitive
therapy is associated with decreased overall and disease-free
survival.\textsuperscript{7,8} In addition, delays in surgery may result
in increased morbidity due to disease progression necessitating more
extensive tumor resection.

Because of the potential increase in morbidity and mortality, most head
and neck surgeons including the authors advocate for initiation of
treatment within one month of the patient's presentation to clinic.
However, in the COVID-19 era it is unclear what the appropriate length
of time from evaluation to initiation of treatment should be given
limited resources and new concern over potential morbidity and mortality
from early initiation of treatment.

Therefore, the primary objective of this study was to assess head and
neck surgeons' priorities and the extent to which they would consider
delaying surgery or changing treatment modality in the era of COVID-19.
This knowledge may help guide the development of guidelines and support
treatment decisions both now and during future pandemics. The secondary
objective was to understand surgeons' concerns regarding safety of
treatment for their patients during the COVID-19 pandemic as well as the
safety of their families, their staff, and themselves.

Methods

This descriptive study was performed after a waiver was obtained from
internal review board at the University of Pennsylvania. A questionnaire
assessing three separate domains was conducted. Demographics included
surgeon age, academic versus private practice, and zipcode in which the
surgeon practices. Utilizing zipcode data, participants were
subsequently grouped into two categories: those practicing in an area
with less than 25,000 confirmed cases of COVID-19 vand those practicing
in an area with greater than or equal to 25,000 confirmed cases. These
domains included surgeon preferences related to treatment delays and
referral for nonsurgical therapies; concerns regarding various
treatment-related complications secondary to COVID-19; and worry about
the health and safety of self, family, staff, and trainees. Questions
related to treatment delays and nonsurgical therapy specifically
addressed management related to early tumor stage oral cavity cancer,
locally advanced oral cavity cancer, HPV-associated oropharyngeal
cancer, early tumor stage glottic cancer, locally advanced laryngeal
cancer, and recurrent laryngeal cancer requiring salvage surgery.

The survey was administered through the Research Electronic Data Capture
(REDCap)\textsuperscript{13} platform and was distributed amongst head
and neck surgeons in different geographic regions across the United
States and Canada using message boards and social media. Questions
regarding respondents' demographic information included age, zipcode in
which they practice, and whether they practice in an academic or private
hospital. The survey was completed by 67 respondents over a 5 day period
(April 9 -- April 14, 2020). Statistical analyses were performed using
STATA/IC 15.0 software (Stata Corporation, College Station, TX).

Results

A total of 67 head and neck surgeons responded to the survey during the
study period. Fifty-nine (88.1\%) practiced in an academic setting while
the remaining 8 (11.9\%) worked in a private practice setting. The
majority of respondents were between the ages of 30 and 39 (52.2\%;
Table 1). There were no differences in responses when stratifying by age
or whether the participants were practicing in an area with a high
prevalence of COVID-19.

\emph{Primary surgical versus primary nonsurgical therapy}

For oral cavity cancers, the majority of physicians would not change
their current practice and still favored primary surgical therapy
(82.1\% early T-stage and 79.1\% locally advanced) . A small percentage
of respondents (7.5\% early T-stage, 10.4\% locally advanced) stated
that they would be more likely to refer for (chemo)radiotherapy but no
respondents were very likely to change their normal practice (Figure 1).
A majority of respondents were more likely to consider non-surgical
therapy for patients with early glottic cancers (62.1\%) and
HPV-mediated oropharynx cancer (68.7\%) during the COVID-19 pandemic as
compared to their normal practice. For locally advanced T4a laryngeal
cancers, a minority of respondents (25.7\%) were willing to deviate from
the standard of care to offer non-surgical therapy.

\emph{Willingness to delay treatment during the COVID-19 surge}

The majority of respondents were willing to delay their normal treatment
timeline by 2 weeks or 4 weeks for early tumor stage oral cavity cancer
(53.7\%), while few were willing to delay 6 weeks (10.4\%) and no
respondents were willing to delay beyond 6 weeks (Figure 2). Respondents
were least likely to delay treatment for a locally advanced oral cavity
cancer as compared to other tumors that were assessed. For early stage
glottic cancers and HPV-mediated oropharynx cancers, the largest
percentage of surgeons were willing to wait up to 4 weeks with a
minority of respondents willing to wait up to 8 weeks. Participants
responded similarly in regards to locally advanced laryngeal cancers and
recurrent laryngeal cancers with the largest group willing to wait up to
4 weeks for surgical therapy.

\emph{Concerns related to complications from COVID-19 during treatment}

Head and neck surgeons were most concerned about complications secondary
to COVID-19 infection in patients who were receiving chemotherapy
(Figure 3).

\emph{Concerns related to the well-being of self, staff, trainees, and
family during the COVID-19 pandemic}

Notably, head and neck surgeons were the least likely to be concerned
for their own health and safety as compared to that of their residents,
family, or staff. Surgeons had the greatest concern for the wellbeing of
their resident trainees during the COVID-19 pandemic. The majority of
respondents expressed moderate concern for the staff and their family
during the COVID-19 pandemic (Figure 4).

Discussion

As the COVID-19 pandemic has forced head and neck surgeons to triage
which patients should be operated urgently versus which can be delayed
indefinitely, this study helps to provide granular data regarding the
opinions of 67 head and neck surgeons across multiple geographic
locations within the United States and Canada.

Our respondents still feel it is necessary to operate on patients with
cancers of the larynx, oropharynx, and oral cavity in setting of the
COVID-19 pandemic, however there are notable differences between sites
and stages. As oral cavity squamous cell carcinoma is regarded as a
primarily surgical disease due to higher treatment related complications
and poorer outcomes with primary radiotherapy, our respondents were
unwilling to refer patients for nonsurgical therapy. This trend is
similarly noted in the setting of a recurrent laryngeal cancer as no
other curative treatment is available. It was interesting to note that a
minority of respondents were willing to refer a locally advanced T4a
laryngeal cancer for primary nonsurgical treatment. While this is not
standard of care, it may reflect the hope that a patient may respond to
radiation therapy and undergo salvage at a later date if there is only a
partial response or if the patient has a nonfunctional larynx.

Most respondents were willing to deviate from their standard practice
and recommend primary (chemo)radiotherapy for early laryngeal cancers
and HPV-mediated oropharynx cancers. While nonsurgical therapy is a
standard of care for these cancers, the fact that surgeons are more
willing to recommend them during the COVID-19 pandemic as compared to
their normal practice indicates that our respondents felt that it might
be safer for the patient and for the healthcare team if surgical
treatment was deferred.

Although surgeons may wish to shunt patients towards radiation oncology
in the hopes of limiting resource utilization and exposure in the
peri-operative setting, the burden placed on radiation oncologists must
also be considered. With 6 to 7 weeks of treatment, there is a
substantial amount of travel and exposure to health care staff during
treatment. The risk of treatment delays or breaks must also be taken
into account if the patient becomes infected or if enough staff are
quarantined resulting in a reduced capacity to treat patients.

Most surgeons were not willing to delay treatment beyond 4-6 weeks
during the COVID-19 pandemic. This is likely related to the known risk
morbidity and mortality among patients with head and neck cancer that
results from treatment delays.\textsuperscript{7,8} In a systematic
review of 51 studies, Schutte et al found that treatment delays led to
reduced overall survival and disease specific survival, as well worsened
functional and psychosocial outcomes. They recommended timely treatment
to improve outcomes in HNSCC.\textsuperscript{7} Similarly, in 956
patients, Liao et al found that delays in treatment led to lower overall
survival and higher risk of recurrence.\textsuperscript{8} This
highlights the importance of timely intervention, even in the era of
COVID-19, to maintain a high level of care. The need for timely
intervention must be weighed with opposing concerns that necessitate
delays or alterations in treatment paradigms to protect health care
workers due to a lack of PPE or availability of preoperative COVID-19
testing.\textsuperscript{6}

Additionally, there are significant concerns related to complications
from COVID-19 during treatment that need to be taken into consideration.
If patients are at high risk of mortality with SARS-CoV-2 infection due
to age or comorbidities, then it is prudent to delay surgery, especially
at the height of the pandemic. As demonstrated by the data presented
above, surgeons' willingness to delay surgery may vary. Increased risk
of complications in the setting of SARS-CoV-2 infection may result from
respiratory compromise due to aspiration pneumonia, atelectasis, or
pneumonitis after airway surgery. Patients undergoing radiation may also
have a theoretical risk of developing a more severe form of COVID-19 in
the setting of concurrent mucositis, aspiration pneumonitis, or weight
loss during radiation. Lastly, the immunocompromised state induced by
chemotherapy may also increase the risks of respiratory compromise and
failure in the setting of a COVID-19 infection.

Lastly, our respondents' answers regarding their own health as well as
the health of their family, staff, and trainees are heartening. The head
and neck surgeons responding to this survey must limit exposure to their
families while continuing to function as essential workers for their
patients on the front lines of this pandemic. Our respondents greatest
concern is related to the risk that is placed upon their staff and more
so on their residents. Although resident duty hours have been
substantially decreased amidst the COVID-19 pandemic to limit exposure,
otolaryngology residents in academic centers still perform invaluable
emergency services and provide assistance in complex cases that require
more than a single surgeon. Shielding our residents from harm during
this pandemic is of great concern as demonstrated by the findings of
this study. Lastly, head and neck surgeons seem to have the least
concern for their own health and safety during the pandemic. While this
is laudable, it is important to stress physical and mental safety
amongst our colleagues during this health care crisis.

\emph{Conclusion}

This study demonstrates the range of variability amongst head and neck
surgeons in their willingness to delay cases during times when hospital
resources are scarce and risk is high. This work will help to triage
certain cases and ensure that other cases are not inappropriately
delayed beyond a reasonable timeframe.

\emph{}

\emph{References}

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\item
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