Introduction
The novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) causing coronavirus disease 2019 (COVID-19) emerged in December 2019 and has spread on a global level leading to unprecedented health, social, and economical unrest. The virus is spread via respiratory droplets and causes mortality in up to 7% of infected patients1. Curative treatment and vaccines are non-existent, and the only protection is the prevention of spread of virus particles. Many asymptomatic patients might be carriers of disease, while current testing paradigms might have false negative rates as high as 40%2. As such, all patients and healthcare providers are considered a potential source of disease.
On March 11th, 2020, the World Health Organization (WHO) declared the SARS-CoV-2 outbreak a pandemic3, at a time when the Center for Disease Control (CDC) reported 1,215 positive cases in the United States4. At the time of this report, the United States has reached 395,011 cases4. At the current rate of disease progression, intensive care unit (ICU) beds are projected to be at or over capacity with COVID-19 patients across the country. Health institutions in several states have implemented mandatory postponement of elective and/or non-urgent cases to decrease nonessential patient density in hopes of decreasing COVID-19 transmission and preserving hospital resources. As the current pandemic is rapidly evolving, the American College of Surgeons has recommended triaging surgeries according to a three-tier state of hospital resource availibility5. In the field of head and neck surgical oncology, postponing a surgery can significantly impact survival due to the increased risk of cancer progression. Furthermore, early reports suggest that cancer patients are at higher risk for COVID-19 associated severe events such as ICU admissions requiring mechanical ventilation or death6,7. Given the cancer patients’ vulnerability to COVID-19 complications and potential hospital resource limitations, judicious selection of oncologic surgical cases is of utmost importance, not only in an attempt to alleviate the burden on the healthcare system, but also to ensure the safety of patients, their families, as well as their healthcare providers. Ultimately, one must balance healthcare priorities and the risk of cancer progression.
In this report, we outline guidelines based on expert consensus opinions from our experienced multidisciplinary team for the triage and prioritization of head and neck surgical cases in a subsite-specific manner. We present these guidelines to serve as a reference for practicing head and neck clinicians during this serious and unprecedented situation, recognizing that feasibility, pandemic intensity, and resource availability will vary widely geographically and over time.
Methods
The MD Anderson Head and Neck Surgery Consortium incorporates faculty and advanced practice providers from the five subsections of the Department of Head and Neck Surgery at the University of Texas MD Anderson Cancer Center: Head and Neck Surgical Oncology, Head and Neck Endocrine Surgery, Oral Oncology and Maxillofacial Prosthodontics, Ophthalmology, and Speech Pathology and Audiology. In a collaborative effort, the following guidelines were prepared to provide clinicians subsite-specific guidance for triaging surgical case acuity. Expertise was sought from our Radiation Oncology and Medical Oncology colleagues for non-surgical treatment options when surgery could be reasonably deferred, and for patients requiring multi-modality therapy. These guidelines are intended to serve as direction in a time of crisis such as the COVID-19 pandemic and not as a strategy for permanent change in patterns of practice.
Our weekly Multidisciplinary Planning Conference is currently conducted over a web conferencing platform in accordance with institutional and national social distancing recommendations. When a case is selected for surgery, a case posting request is placed and sent to the Division of Surgery Surgical Posting Committee for daily institutional review. This committee is comprised of surgical department chairs and quality officers, the Operating Room Committee leadership, and anesthesiologists. In Head and Neck Surgery, the guidelines described below are currently being used to assess treatment decisions and to make recommendations to the Division of Surgery Surgical Posting Committee. Approved cases are forwarded to the surgical scheduling team. An institutional bioethicist is available as needed.
Head and Neck Surgery – Treatment/Management Guidelines during the COVID-19 pandemic
The following guidelines based on current expert clinical opinion are provided for management of patients with HNC during the COVID-19 pandemic given the potential limited resources available. Given the acute nature of this clinical dilemma, there is not sufficient time to perform clinical trials for level-one evidence. Our guidelines emphasize surgical treatment of intermediate and advanced disease where nonsurgical options are not available, and risk of disease progression would significantly affect patient function or disease outcome.
General considerations
· Ideally, where testing is readily and rapidly available, SARS-CoV-2 testing should be performed on all patients with mucosal lesions prior to HNS evaluation, and/or, at the least, 1 day prior to the planned surgery.
· Selected patients may be closely observed allowing for deferral/rescheduling of surgery.
· Significant functional loss or life-threatening disease requires immediate attention.
· Telemedicine is an essential tool in several medical fields during these times and has been recommended to be used when deemed appropriate by the American Academy of Otolaryngology-Head and Neck Surgery8.
· At our institution, as a general guideline for scheduling, cases are deferred when performed for prophylactic intent, benign diseases, conditions unlikely to be adversely affected by an 8-12-week surgical delay, or for conditions which have available and appropriate alternative therapies.
· In-depth discussion and review is performed when patients have a severely depressed performance status, high comorbidity burden and/or advanced age, or when surgical cases may require significant blood transfusion (>4 units), ICU care, or a prolonged hospitalization is anticipated.
· While multi-modality input is sought after pre-operatively for patients requiring multi-modality therapy, we suggest deferring all head and neck radiation and medical oncology consultations to when needed to minimize exposure risks, unless neoadjuvant treatment is considered.
· Flexible naso-pharyngo-laryngoscopies are limited to when medically necessary. When performed, they are recorded by the healthcare provider for shared review to eliminate duplicate exposure risk.
SARS-CoV-2 Positive
No resection until viral resolution unless significant functional threat or life-threatening situation as patients testing positive are associated with a high rate of mortality in the post-operative period9
o Powered air-purifying respirator (PAPR) equipment required for all involved in the case
o Minimize nonessential personnel in the operating room (trainees, advanced practice providers, visitors, etc.)
SARS-CoV-2 Negative
Patient must pass symptom screening and appropriate testing completed 1 day prior to intended surgery date
Disease Subsites
Oral Cavity (high risk for viral aerosolization)
o Premalignant disease
· Defer with telemedicine visits
· Review clinical photographs to help rule out invasive cancer missed by biopsy
o Early malignant disease
· Consider short-term deferral with weekly telemedicine visits10
· Proceed with primary surgery
· Continue to monitor while stable; proceed to surgery if primary progresses or if there is any evidence of cervical node involvement
o Intermediate malignant disease
· Proceed with primary surgery
o Advanced malignant disease
· Consider neoadjuvant systemic therapy (discussion on a case-by-case basis – consider the risk of immunosuppression)
HPV status should be identified. As recommended by Topf et al., if necessary, HPV-negative patients should be prioritized11.
o Early disease
§ Consider short-term deferral with weekly telemedicine visits
§ Favor non-surgical treatment
§ Consider surgical treatment if high likelihood of single modality treatment, depending on the experience of the surgical team and institutional resources
o Intermediate disease
§ Consider deferral with weekly telemedicine visits
§ Favor non-surgical treatment
o Advanced disease
· Proceed with non-surgical treatment
Larynx/Hypopharynx (high risk for viral aerosolization)