Discussion
Cancer is the second leading cause of death globally, accounting for an
estimated 24.5 million incident cancer cases and 9.6 million deaths, or
one in six deaths, in 2018.8 Head and neck cancer in
India has a distinct demographic profile, risks factors, food habits,
and personal and family history. HNC is a major public health problem in
India, mainly due to the widespread use of tobacco. In contrast to the
west, where it is the 6th most common cancer, HNC in
India is the commonest cancer of males in India.3Already burdened with the high patient load and high percentage of
late-stage HNC patients, the spread of COVID-19 has further deteriorated
the situation.
As of April 14, 2020, corona virus disease 2019 (COVID-19) has affected
1,914,916 persons worldwide. The death toll in the highest affected
countries like Italy is approaching 12 000 people, with Spain not far
behind. The USA has reported more than 164 000 cases of the disease,
including more than 38 000 cases in New York City
alone.9 India, a country of 1.35 billion people, has
also come in the grasp of this highly contagious disease with its first
case reported on 30 January in the state of Kerala.10Now the footprint of COVID-19 has spread in almost all states, affecting
more than 11000 people and with the death of more than 370 people as on
14thApril 2020.9
Due to the rising number of COVID-19 patients in India, almost all
government hospitals and teaching health care institutions are on high
alert and doctors are the main task force for managing this pandemic.
After the announcement of 21 days lock down throughout the whole India
on the 24th march 2020 midnight by the Indian government, all elective
surgeries and outpatient services at majority of hospitals were withheld
to control this menace and vacating the facilities in stage wise manner
to harness the resources. Only emergency services were continued for the
management of life threatening problems.11 Most of the
major government hospitals were aligned to assess their resources and
convey the present status of the availability of ICU beds, ventilators
and beds availability. Gradually, beds in the wards were vacated by
discharging stable patients and only critical patients were kept in
hospitals. Beds of each department catering emergency patients were
asked to join hands and combine their beds in a limited area on a
sharing basis so that other areas can be made available as isolation
wards with sufficient number of beds for the growing number of COVID-19
patients.
Recently to contain the spread of disease, the Indian government has
earmarked selected facilities which will be dedicated for COVID-19
management. They have proposed three types of COVID dedicated facilities
as COVID care centre (CCC), Dedicated COVID Health Centre (DCHC) and
Dedicated COVID Hospitals (DCH). All these facilities will have separate
ear marked areas for suspected and confirmed cases. Suspected and
confirmed cases will not be allowed to mix under any circumstances. Out
of these both DCHC and DCH would be the existing hospitals and most of
them are secondary to tertiary care government
hospitals.12 HNC surgeries together with other cancer
surgeries are majorly affected after major health care institutions were
converted into dedicated COVID-19 centres. Meanwhile, few dedicated
cancer centres are able to continue doing HNC surgeries but in limited
numbers by following their own institutional guidelines. But this
situation is dynamic and an expected exponential increase in the number
of COVID-19 patients and probable community spread may lead to
overburdened health care facilities and more stringent policies to take
up new cases.
India, which has a high burden of head and neck cancer, is compounded
with long waiting lists in all hospitals of India. A problem that is
particularly worse in government funded hospitals, which cater to the
poorest of society. With further delays in surgery during the pandemic
of COVID-19, the burden will exponentially increase. The biggest problem
will be to manage such a high load of these malignancies after the
situation is normalized. The patients may become inoperable and deemed
only for palliative treatment. The Government of India is taking a lot
of measures to contain this disease and purchasing a large number of
ventilators to cater the expected increase of COVID-19 patients in the
near future. But we also need guidelines and a mechanism to surgically
treat at least those head and neck cancer patients which are in dire
need of surgery for a reasonable survival.
The practice in other countries where the infection is more severe than
in India has been to create new and innovative care pathways. In the
United Kingdom, NHS England has rapidly supported the creation of
‘cancer hubs’, where cancer patients from multiple tumour groups are
fast tracked on priority basis. To ensure full stakeholder
participation, the hubs have suspended conventional regulatory
requirements to referring surgical teams to operate at the hub. The hub
is maintained as COVID-19 free by requiring patients to self-isolate
when they have been accepted for intervention and regular testing for
COVID-19 in the pre-treatment period. Patients needing urgent cancer
surgeries are referred to such dedicated centres and are scheduled for
treatment as decided by the tumour board. Their tumour boards conduct
virtual multidisciplinary team (MDT) meetings and decisions are taken
accordingly.13 The American College of Surgeons (ACS)
has given guidelines for triage of cancer surgeries during this pandemic
and recommended the decision to be taken by the MDT team based on the
available resources and situation pertaining in their
region.14
During the current pandemic, the important points to consider are that
all head and neck procedures including simple clinical examinations are
potentially aerosol generating and should be considered high risk.
Testing of COVID-19 is limited and cannot be performed in all patients.
Protective supplies, such as N95 masks, PPE gowns, gloves and other
protective materials are in short supply or unavailable in many
institutions. As the illness progresses our systems may be burdened with
potential shortage of beds and health care manpower. Also there will be
difficulty and uncertainty in mobility of patients due to lockdowns and
quarantine. Availability of blood and blood products may become a
challenge. ICU Bed/ ventilators may be at a premium and scarce. Cancer
patients are likely to be more vulnerable in India during COVID-19, so
decisions to treat the patient should be taken on the basis of risk
benefit ratio during this epidemic period.
At present there are no national guidelines for cancer patients from the
government of India, so we have to either depend on institutional, state
or association guidelines. The foundation for head and neck oncology
(FHNO) has given guidelines which covers diagnosis, treatment and follow
up of HNC patients and is described in Table 3.15