Head and neck surgery recommendations during the COVID-19 pandemic.

Abstract

We read the recent international consensus recommendations from Hisham Mehanna and colleagues1Mehanna H Hardman JC Shenson JA et al.Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus.Lancet Oncol. 2020; 21: e350-e359Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar in The Lancet Oncology regarding head and neck surgical practice in the setting of resource constraint due to the COVID-19 pandemic with great interest. However, the sections dedicated to the prioritisation of treatment should be considered controversial, even though the methodology employed is well regarded. The monograph characterised treatment of advanced head and neck cancer with “do not delay surgery; operate within 4 weeks of diagnosis”, while adopting a more permissive policy toward T1–T2 N0 oral cancer and T1 N0 laryngeal cancer: “do not delay surgery beyond 8 or 12 weeks”. Although it seems logical to assign high treatment priority to advanced tumours in a setting of resource constraint,2Bilimoria KY Ko CY Tomlinson JS et al.Wait times for cancer surgery in the United States: trends and predictors of delays.Ann Surg. 2011; 253: 779-785Crossref PubMed Scopus (200) Google Scholar the limited data testing the precept do not fully support these recommendations. Head and neck squamous cancers progress at a rate that can be measured in the course of typical clinical practice.3Jensen AR Nellemann HM Overgaard J Tumor progression in waiting time for radiotherapy in head and neck cancer.Radiother Oncol. 2007; 84: 5-10Summary Full Text Full Text PDF PubMed Scopus (210) Google Scholar Node progression due to prolonged time to treatment initiation replaces stage I–II with stage III–IV cancer. The survival impact of such progression is reflected in the staging system.4Amin MB Edge S Greene F AJCC cancer staging manual. 8th edn. Springer, Place of publication2017Crossref Google Scholar In a setting of resource constraint the crucial issue should be consideration of which outcome is most affected by prolonged time to begin treatment. Which is more detrimental to survival: T1 N0 progressing to T1 N1 or T3 N2b developing greater node burden? Murphy and colleagues5Murphy CT Galloway TJ Handorf EA et al.Survival impact of increasing time to treatment initiation for patients with head and neck cancer in the United States.J Clin Oncol. 2016; 34: 169-178Crossref PubMed Scopus (248) Google Scholar addressed this question for squamous cancers. A treatment delay of 31–60 days adversely affects survival for stage I–II head and neck cancer (HR 1·17; 95% CI 1·12–1·23), but not stage III-IV (1·02; 0·99–1·07). A similar relation exists for longer delays of 61–90 days for early stage (HR 1·54; 95% CI 1·41–1·68) and advanced stage (1·08; 1·02–1·14) squamous cancer. Delay in treatment more significantly affects survival of stage I–II head and neck cancer than stage III–IV. Although it seems logical to operate on a patient soon to become formally unresectable or develop more advanced nodal disease, the data suggest that stage I–II patients (with a more favourable prognosis before progression) will derive greater benefit. The COVID-19 pandemic creates challenges in the management of patients with head and neck cancer. Allocation of scarce resources will be difficult. Available data, not solely expert opinion, should be employed when assigning priorities. We declare no competing interests. Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensusThe speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Full-Text PDF Head and neck surgery recommendations during the COVID-19 pandemic – Author's replyWe thank Thomas J Galloway and colleagues for their letter. We agree that available evidence, not solely expert opinion, should always be considered. However, the COVID-19 pandemic has resulted in an unprecedented situation in which there are little or no available data, and where the extrapolation of existing evidence is not appropriate in many cases. Hence, there is a need for robust expert opinion recommendations.1 Full-Text PDF