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