Discussion
Our goal was to create effective and ethical cancer guidelines in an
expeditious fashion to allow quick deployment during the COVID-19
epidemic. While a group consensus was both desired and required, time to
completion was an important consideration which obligated the leadership
to seek consensus individually rather than in a virtual group session.
The result was a document agreed to by all which was completed within
two weeks.
Our entire team agreed, that the primary treatment of choice during the
COVID-19 epidemic was surgery in all surgically and medically resectable
cases. Non-surgical options do exist utilizing radiation alone or
chemoradiation. However, these options are fraught with increasing risks
during this pandemic. In some cases, surgery results in a single day
treatment that allows the patient with or without hospitalization to
return home and avoid returning to the hospital. Radiation requires
daily trips to the hospital for several weeks which puts both the
patient and the radiation teams at risk of spread of SARS-CoV-2.
Chemotherapy, when required, further immunocompromises the patient which
makes them more susceptible to SARS-CoV-2 infection. Adjuvant radiation
and chemotherapy can be done several weeks after surgery, safely and
according to standard of care, and for many this will be after the peak
of the virus spread in our community and when testing may be more
readily available for screening patients.
A primary surgical approach for resectable cancers was seen as the
safest pathway in cases where the pathology indicated that surgery was a
standard of care option for a given anatomic site in the head and neck.
For squamous cell carcinoma we made a distinction between P16+ and P16–
cancers given how common oropharyngeal cancer is in our setting.
Oropharyngeal cancers, in particular those which are P16+ and Human
Papilloma Virus (HPV) associated, accounts for a significant percentage
of the patients presenting to Head and Neck Surgeons in 2020. It has
been estimated that by 2030 half of all head and neck cancers will be
HPV related.24 The Center for Disease Control (CDC)
website notes that 70% of all oropharyngeal cancers are caused by HPV
and account for 13,500 cases annually, making this the most common HPV
related cancer in the United States, exceeding cervical cancer by almost
3000 cases.25 Transoral Robotic Surgery (TORS) which
was invented in 2005 and FDA cleared in 2009 has emerged as the most
common surgical treatment of HPV related oropharyngeal
cancer.26,27 The most frequent alternative
non-surgical treatment for the management of HPV related oropharyngeal
cancer is cisplatin-based chemoradiation which is associated with
significant acute and chronic toxicity, including acute compromise of
the immune system and significant acute and late risk of treatment
related death and gastrostomy tube dependence.28 The
standard of care for the treatment of oral cavity cancer worldwide is
primary surgery with or without adjuvant radiation or
chemoradiation.29 The standard of care requires that
many laryngeal cancers be offered the option of surgery as the primary
modality for organ preservation.30
The major concerns for Head and Neck Surgeons for the safety of all
members of the surgical, perioperative and anesthesia teams are related
to numerous factors. It is well established that large viral load of
SARS-CoV-2 reside in nasal cavity and all levels of the mucosa between
the nasopharynx and trachea. In addition, histological evaluation, in
the primate model, of the SARS-CoV-1, a similar corona virus, indicates
large viral load with the cells of the head and neck
mucosa.31,32 Experimental evidence from the University
of Pennsylvania indicates that appropriate surgical masks, even when
virus is present in the electrocautery plume, do prevent passage of
viral particles in electrocautery plume to the
wearer.33 The aerosolized virus particles from
SARS-CoV-2 remain viable for at least 3 hours.34 An
article in Science estimates that 86% of SARS-CoV-2 infections in China
were undocumented prior to the January 23, 2020 travel ban and that
undocumented infections were likely responsible for spreading the
disease to 79% of documented cases.35 Initially in
the COVID-19 pandemic Personal Protective Equipment (PPE) and patient
testing were in short supply or unavailable. Early on in the pandemic
our team successfully negotiated with our hospital executives to ensure
that for all head and neck cancer cases involving transection of mucosa
the entire staff in the operating room would be issued N95 masks and all
patients would undergo SARS-CoV-2 testing within 24 hours of the
procedure. The fundamental premise of our negotiations were based on the
idea that “the goal is to flatten the disease curve, not the personnel
curve.”36
Preoperative testing of patients for SARS-CoV-2 may be critical for
patient and staff safety. Xia et al. published a paper in which
asymptomatic patients underwent a variety of surgical procedures
throughout the body, including one laryngeal surgery. Thirty-four
patients developed COVID-19 during the postoperative period and the
mortality rate for this group was 20.5%. We recommend based on this
study that asymptomatic patients who test SARS-CoV-2 positive prior to
any treatment delay such treatment until they have had two negative
tests within 24 hours.37
Our guidelines include a discussion of the management of routine cancer
follow-up during the apogee of the COVID-19 disease incidence curve as
well as during the reopening process of face-to face visits in the
outpatient clinics. The pillars upon which our plan is built are: (1)
multilevel triage approach to minimize the risk of COVID-19 PUI or
positive patients encountering multiple personnel, (2) special
precautions when performing potentially aerosolizing procedures (e.g.,
fiberoptic laryngoscopy and nasal endoscopy) in clinic, (3) appropriate
workflow and PPE use by staff, physicians and patients so that if an
unexpected exposure to COVID-19 does occur the need for quarantine of
staff or physicians is either minimized or non-existent, (4) added
cleaning measures to sanitize patient exam and treatment rooms and (5)
plan for clinic re-opening that ensures appropriate social distancing in
the waiting room.38