Does Routine Testing of Asymptomatic Patients Help?
A recent report from Wuhan, China on 34 asymptomatic patients who had
elective surgery during their incubation period of COVID-19 infection
demonstrated that all of them developed COVID-19 pneumonia shortly after
surgery with abnormal findings on chest computed tomographic scans. The
ICU admission and mortality rates were 44% and 20%, respectively. This
makes a very good argument supporting routine preoperative testing of
asymptomatic patients undergoing surgery. 16
Given the challenges of making treatment decisions for patients with HNC
and the significant added risk of transmission to their health care
providers, routine testing for COVID-19 status in these patients, even
if asymptomatic, is strongly recommended and is becoming more widely
adopted in most HNC treatment centers. Treatment of patients with HNC
who test positive for COVID-19 is generally deferred until they recover
from their infection. The rationale for this recommendation is two fold;
minimizing risk to the patient and to the health care providers.
As mentioned, the older age and prevalent comorbidity of patients with
HNC pose added risk of mortality if they are COVID-19 positive. This is
particularly true for surgical treatment. Major surgery for HNC
frequently involves a lengthy procedure for resection and
reconstruction, and the immediate postoperative period is complicated by
frequent challenges of fluid overload, fluid shifts, reduced lung
capacity, and possible postoperative lung atelectasis. These changes
might challenge pulmonary function, which is critical to recovery from
COVID-19 pneumonia, and may predispose these patients to the need of
ventilator support and reduce their chances of recovery.
Given the high density of viral loads in the upper aerodigestive tract
of patients who are COVID-19 positive and the aerosol-generating
potential of surgical procedures on the mucosal surfaces of the head and
neck, the risk of transmission to the surgical team and all operating
room personnel, including nursing and anesthesia, is significant.13Therefore, the need for maximal PPE such as PAPRs in
caring for such patients is mandatory. Such level of PPE is needed for
all involved personnel not just in the operating room but also over the
entire course of the patient’s recovery throughout the hospital,
including the recovery room, ICU, step-down unit, and regular hospital
floor. Even after patient discharge this level of PPE is needed in a
long-term care facility or home nursing. This is particularly true if
the patient undergoes tracheostomy, which is frequently performed as
part of HNC resection. All nurses, respiratory therapists, occupational
and physical therapists, speech language pathologists, residents,
fellows, and attending physicians providing postoperative care will need
this added level of PPE for at least a couple of weeks after surgery. In
addition to the staggering number of PPEs needed for the care of this
one patient, the risk to the hospital environment, other patients, and
mandatory isolation procedures are significant. In conclusion, it seems
clear that, for the sake of minimizing risks to the patients, health
care providers, and hospital system, major surgery for HNC should be
deferred in patients who test positive for COVID-19 unless it is a
life-saving measure.
Patients with HNC who test negative for COVID-19 should be considered
for surgery if delaying such treatment would negatively impact their
prognosis. The false-negative rate of testing is not yet known and is
influenced by the testing platform, such as viral RNA-based PCR or
immunoglobulin serology testing; and on the source, quality, and
handling of swab specimens. 17 False-negative rates of
20-40% have been reported for swab tests, and the testing accuracy may
be significantly increased if complemented with chest imaging showing
signs of infection. 18 Because of these limitations,
it is recommended that a negative test be interpreted with caution and
appropriate PPE such as N95 masks, goggles, gowns, and gloves should be
used by all health care providers involved in the surgery and
postoperative care of these patients.
For patients presenting with life-threatening emergencies in whom rapid
testing is not available or feasible, head and neck surgery and airway
procedures should be performed assuming the patient is COVID-19 positive
given the high rate of community transmission. In such cases, maximal
PPE including PAPRs should be used.
Because of these challenges associated with major oncologic surgery and
the need to conserve operating rooms, inpatient beds, ICU capacity,
ventilators, and PPE, a recommendation for using outpatient non-surgical
therapy for cancer patients has been advocated during the pandemic.
Non-surgical therapy may include radiation, chemotherapy, and
immunotherapy. These treatments may be used either definitively or in
the neoadjuvant setting in order to buy time before needing cancer
surgery. Non-surgical therapy also has inherent challenges in the face
of the COVID-19 pandemic. Chemotherapy in general is associated with
immunosuppression that may put cancer patients at a higher risk of
contracting COVID-19 or developing cancer-treatment-related
complications. 7-10 There are concerns that
immunotherapy may increase the inflammatory response to
COVID-19-associated pneumonia and promote the acute respiratory distress
syndrome that is the main mode of death from this disease.7-10 Head and neck radiation may be associated with
severe mucositis, poor oral intake, weight loss, dehydration, and
fatigue, all of which have yet unknown impact on the risk for patients
contracting COVID-19 or developing a more severe disease if they get
infected. Radiation therapy also requires daily treatment for a period
of 6 weeks, which is challenging for most patients in terms of logistics
at a time when stay-home orders are getting more widespread, quarantine
requirements are in effect when crossing state lines, and patients’
family members and caregivers are increasingly restricted from accessing
the hospitals to accompany patients during their treatment visits.11-12