Discussion
Once a patient is diagnosed with HNC, they enter into the continuum of
cancer survivorship. A patient is deemed a cancer survivor from the
moment of diagnosis. This terminology encourages providers and patients
to consider the impact of diagnosis and treatment earlier as multiple
studies have highlighted the unique experience of HNC patients as they
progress through changes in swallowing, speech, and
nutrition12. These factors have been studied as a part
of quality of life measures which highlight the importance of not only
cancer survival, but also a patient’s experience of life after
diagnosis. It is critical to consider these factors in the context of
the SARS-CoV-2 pandemic.
HNC patients have reported feelings of isolation with a lack of social
support following diagnosis13. The high morbidity and
mortality associated with HNC along with stigma associated with the
facial disfigurement following treatment can result in decreased quality
of life (QOL) that may affect survival14. HNC patients
at three Veterans’ Affairs Hospitals reported QOL scores in pain,
eating, and speech domains which were associated with
survival15. A prospective study on HNC patients found
QOL scores were associated with short-term, moderate, and long-term
survival. Long-term survivors demonstrated the best QOL trajectory at 12
months following diagnosis, specifically in the domains of eating and
speech16. Both studies showed no association of
emotional scores with overall survival. However, there has been evidence
that mental adjustment responses with either a “fighting spirit”
versus hopelessness is an important prognostic factor in determining
both death and recurrence17. The association between
QOL and survival remains complex and requires continued exploration as
cancer survivor numbers continue to increase18.
In addition to patient experience, the role of cancer specific
characteristics and the patient’s biological biomarkers have been
investigated for its relation to QOL and mental health. For patients
with human papillomavirus (HPV)-positive oral cavity and oropharyngeal
cancers, there was a larger decrease in QOL from pretreatment to
immediate posttreatment, suggesting that treatment intensity compared to
non-HPV cancers may negatively affect QOL
trajectories19. This significant decrease in QOL may
also make HPV-positive patients more susceptible to mood disorders. An
investigation into mental health insurance claims found that HNC
patients had a higher prevalence of mental health diseases at 20.6%,
higher than the national estimate at 17.9%. Following HNC diagnosis,
the prevalence increased to 29.9%20. A separate study
highlighted that the prevalence of a functional genetic polymorphism of
the serotonin transporter gene was not significantly different between
control depression patients and HNC depression patients who had
completed treatment21. Of note, 19% of patients
developed depression after undergoing concurrent chemoradiation,
suggesting a strong interaction of treatment with depression. However,
depression may arise at any time during the cancer survivorship
continuum. For HNC patients in the United Kingdom, the pretreatment
phase was noted to be a time of high anxiety and depression that was
associated with a poor QOL22.
The burden of HNC diagnoses can extend beyond a mental challenge for
patients. Caring for HNC patients can be a grand task as caregivers help
patients navigate the complex follow-up appointments and changes in
abilities to communicate and eat. HNC treatment can also result in poor
outcomes for the caregiver, highlighting a need for caregiver
interventions23. An additional financial burden is
also placed on the patient and caregivers as Massa et. al noted a higher
median annual medical expense and relative out-of-pocket expenses for
patients with HNCs when compared to other cancers. This higher financial
burden is placed upon HNC survivors who are already more often members
of a minority race/ethnicity, poor, and less educated with lower general
and mental health status24.
With HNC patients already a vulnerable population, delaying treatment in
the times of the SARS-CoV-2 pandemic can place additional strain on the
mental health and quality of life of patients, resulting in future
burdens on the health care system. It is critical to help patients
maintain their quality of life through this pandemic as it may affect
their overall outcomes of survival. Recognizing the psychological toll
social isolation may place on the population, China provided multiple
telemental health services that encompassed virtual counseling,
training, and psychoeducation25. Online behavioral
therapy for depression, anxiety, and insomnia along with multiple books
with guidelines for public psychological self-help and counselling were
accessible during the times of the SARS-CoV-2
pandemic26. In the U.S., the CMS has loosened
telehealth guidelines, increasing the platforms on which physicians may
communicate with patients, while the AAO-HNS has called for the adoption
of telemedicine to decrease unnecessary exposure to both the patient and
physician27,28. To improve survivorship experience, we
encourage the use of such resources to address the cancer patient’s
quality of life while institutions continue to triaging urgent surgeries
to balance the risk of infection to HNC patients.