Delay in Head and Neck Cancer Therapy
The postponement of head and neck oncologic surgical cases must be
weighed against potential morbidity associated with delay. Head and neck
squamous cell carcinoma (HNSCC) can progress and upstage during a
prolonged time to treatment initiation (TTI).15 This
may lead to an increase in mortality and likelihood of recurrence
whether treated with a surgical or non-surgical
approach.15-22 In addition, delayed TTI can evoke
patient anxiety as the patient may feel that not enough is being done to
address their cancer.23 To establish a benchmark for
quality of care and for determining what constitutes a tolerable amount
of delay, prior studies have used 21 days from clinic evaluation to
definitive surgery as a quality metric cutoff,24,25though reported threshold for delayed TTI has ranged from 20–120 days
using different selection methods.17
Some argue that biasing toward a non-surgical approach for the treatment
of HNSCC is indicated to conserve hospital resources, especially PPE,
particularly for oropharyngeal, laryngeal, and hypopharyngeal cancers.
While this certainly warrants discussion, the potential to acquire
SARS-CoV-2 while immunocompromised, undergoing daily radiation
treatments and frequent infusions would appear to present additional
patient risks and increase total use of PPE. We have elected to continue
a primary surgical approach when recommended at our multidisciplinary
head and neck tumor board. We feel that a non-surgical approach may
actually result in increased cumulative exposure for the patient and
healthcare system. Furthermore, at our institution, radiation oncology
has been equally affected by the COVID-19 pandemic and has experienced
difficulty with resources and staffing, resulting in a delay in
radiation therapy for less urgent patients. The American Society for
Radiation Oncology (ASTRO) has released guidelines for the treatment of
patients during the COVID-19 pandemic which does include striving for
the shortest possible course of radiotherapy including hypofractionation
when appropriate.26