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.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.7 Similarly, in 956
patients, Liao et al found that delays in treatment led to lower overall
survival and higher risk of recurrence.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.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.