Conflicting Duties
One of the major challenges specific to head and neck cancer during this
pandemic involves the significant risk associated with examination,
biopsy and treatment of pathology arising in the upper aerodigestive
tract. Health care workers constituted a large percentage of the first
cohort of infected patients. Potential aerosolization of SARS-CoA-2
virions hinders our ability to conduct routine management and requires
extra resources and time to perform what before were routine
examinations, endoscopy, biopsy, and surgery. Recent publications echo
and reinforce the related dimensions of infection control, safety, and
resource stewardship.11Givi B, Schiff BA, Chinn SB et al. Safety
recommendations for evaluation and surgery of the head and neck during
the COVID19 pandemic. JAMA Otolaryngol Head Neck Surg 2020 (In press).
Airway management represents a discrete consideration in routine,
urgent, and emergent settings, and newly published guides are also
instructive.22Balakrishnan K, Schechtman S, Hogikyan ND, Teoh
AYB, McGrath B, Brenner MJ. COVID-19 Pandemic: What every
Otolaryngologist – Head & Neck Surgeon Needs to Know for Safe Airway
Management. Otolaryngol Head Neck Surg 2020 (Epub). All of these
reaffirm the importance of protecting patients as well as clinical staff
from unnecessary exposure. Indeed, protection of the clinical workforce
and public are fundamental ethical and professional responsibilities.
However, the balance between our duty to care for patients with our duty
to protect ourselves and our colleagues is not clear cut.
The American Head & Neck Society has a dynamic online resource for head
and neck oncology providers.33American Head & Neck Society
COVID-19 Bulletin Board.
https://www.ahns.info/wp-content/uploads/2020/03/synthesized-physician-doc.pdf
(Accessed 6 April 2020). The American Academy of Otolaryngology –
Head & Neck Surgery Foundation’s related position statement affirms the
need to avoid all clinical interactions which are not urgent/emergent,
but “recognizes that ‘time sensitivity’ and ‘urgency’ are determined by
individual physician judgment and must always take into account each
individual patient’s medical condition, social circumstances, and
needs.”44American Academy of Otolaryngology–Head and Neck
Surgery. New Recommendations Regarding Urgent and Nonurgent Patient
Care.
https://www.entnet.org/content/new-recommendations-regarding-urgent-and-nonurgent-patient-care
(Accessed 6 April 2020). Other societies have produced COVID-19
related resources and guidance that are also informative. The American
College of Surgeons’ dedicated website clarifies the importance of
delaying/deferring non-essential operations, and offers comprehensive
support, including patient-facing messages which may be valuable to head
and neck surgical oncology practices.55American College of
Surgeons COVID-19 and Surgery. https://www.facs.org/covid-19
Accessed 6 April 2020. The Society for Surgical Oncology recommends
that “urgent procedures… should be carefully considered for
delay on a case-by case basis… and diagnoses which have
equivalent results with radiation therapy and surgery should be
considered for radiation therapy.”66Society for Surgical
Oncology Resource for Management Options of Endocrine/Head and
Neck Cancer During COVID-19.
https://www.surgonc.org/wp-content/uploads/2020/03/Endocrine-Head-and-Neck-Resource-during-COVID-19-3.30.20.pdf
Accessed 6 April 2020. The American Society of Clinical Oncology has
general guidance for cancer providers and patients to avoid in-person
encounters whenever possible, but the organization does not offer
guidance specific to management of specific cancers.77American
Society of Clinical Oncology COVID-19 Provider & Practice
Information.
https://www.asco.org/asco-coronavirus-information/provider-practice-preparedness-covid-19
Accessed 6 April 2020.
Although the duty to the patient is a cornerstone of the medical
profession, it should not trump our duty to care for ourselves and those
around us. Head and neck cancer practitioners should recognize the
stress of the current situation on themselves, practice diligent
self-care, and liberally seek counsel among colleagues, loved ones, and
professionals.