Kimberley L Kiong MBBS 1 , Theresa Guo MD 1 , Christopher MKL Yao MD 1 , Neil D Gross MD 1 , Matthew M Hanasono MD 2 , Renata Ferrarotto, MD 3 , David I Rosenthal MD 4 , Jeffrey N Myers MD 1 , Ehab Y Hanna MD1, Stephen Y Lai MD 1
1 Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States 2 Department of Plastics and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States 3Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States. 4Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
Corresponding author: Stephen Y Lai, MD PhD
Professor
Patient Safety Quality Officer
The University of Texas MD Anderson Cancer Center
Department of Head and Neck Surgery
Division of Surgery
1515 Holcombe Blvd, Unit 1445
Houston, TX 77030  sylai@mdanderson.org  
This work did not receive any grant support and has not been presented at any meeting Running title: Changing Head & Neck surgical practice during COVID-19
Keywords : Otolaryngology, Oncology, SARS-CoV2
Abstract: Background: The COVID-19 pandemic has changed healthcare, challenged by resource constraints and fears of transmission. We report the surgical practice pattern changes in a Head and Neck Surgery department of a tertiary cancer care center and discuss the issues surrounding multidisciplinary care during the pandemic. Methods: We report data regarding outpatient visits, multidisciplinary treatment planning conference, surgical caseload, and modifications of oncologic therapy during this pandemic and compared this data to the same interval last year. Results: We found a 46.7% decrease in outpatient visits and a 46.8% decrease in surgical caseload, compared to 2019. We discuss the factors involved in the decision-making process and perioperative considerations. Conclusions: Surgical practice patterns in head and neck oncologic surgery will continue to change with the evolving pandemic. Despite constraints, we strive to prioritize and balance the oncologic and safety needs of patients with head and neck cancer in the face of COVID-19.
Introduction
The rapid spread of the novel coronavirus 2019 (COVID-19) has disrupted healthcare systems globally. Some of the biggest challenges include shortage of hospital beds, healthcare workers and personal protective equipment (PPE). Given these constraints, there has been a simultaneous push for a reduction in elective clinical practice, to further reduce transmission and conserve resources 1.
Cancer care is generally not considered elective and decision making about when to initiate or delay treatment during the pandemic has raised complex ethical and resource utilization issues. Yet amidst the pandemic, patients continue to develop and seek treatment for cancer. Head and neck cancers (HNC) can challenge essential functions such as eating, speaking and breathing. Tumor doubling time ranges between 15 to 99 days 2,3 and delaying treatment decreases survival and contributes to adverse outcomes 4,5. As such, there are recommendations for prompt initiation of treatment of HNC after diagnosis and to reduce the total treatment package time6,7. In an effort to limit the potential adverse effects of delaying cancer treatment during this pandemic, an increasing number of oncology guidelines have been developed, both general and specific to HNC 8,9.
At the University of Texas MD Anderson Cancer Center (MDACC), our Head and Neck surgical practice has gradually changed as a result of evolving internal and external guidelines (Table 1). Harris County, Texas reported its first COVID-19 case on March 5th, 2020. Since then, the number of cases has been steadily rising with the current incidence at 35 per 100,000 residents in Texas 10. At the institutional level, MDACC has taken many pre-emptive actions and policy changes in response to the growing pandemic (Table 1).
The institutional policies described have served to limit hospital attendances in anticipation of a surge in COVID-19 cases in the region. The number of new patients visits to the institution have decreased from 782/week in the first week of March to 207/week in the last week of March (-73.5%) while systemic treatment appointments, indicative of patients already in the process of treatment, have remained fairly stable (3864 to 3288 visits, -14.9%). As a downstream effect, the number of diagnostic imaging visits has decreased from 9616 to 3971 (first and last weeks of March respectively, -58.7%). Surgeries within the institution have shown a more drastic decrease, from 463 to 149 cases per week (-67.8%). Current institutional census at the time of writing (April 7th, 2020) shows 55% general bed occupancy and 35% ICU occupancy. The numbers will continue to change in response to the development of COVID-19 within the region, as we have not yet reached the peak of infection. Predictive models have suggested that the peak in COVID-19 cases will occur at the end of April11 and there are institutional plans on standby to repurpose physical facilities and the workforce to shift focus from oncology care to COVID-19 treatment if needed.
In the context of the developing pandemic and tightening institutional guidelines, we seek to understand the early impact of the COVID-19 pandemic on head & neck oncologic surgery practices. We performed a review of outpatient clinic and surgical caseload within the MDACC Head and Neck Surgery department during the pandemic and compared this to the same time period in the preceding year, along with the deviations in management of patients due to COVID-19.