DISCUSSION
No randomized trials provide data regarding the appropriate systems and
policies for the triage of patients with potentially fatal cancers
during a global pandemic. The infrastructure and regulations for
appropriate triage of the ill and injured that have been developed for
crisis triage during war and natural disaster serve as guides, but these
situations are not the same, as they may be more intense, but are more
limited in time and area of geographic involvement. What is safe, fair
and appropriate may not always be clear as the availability of medical
resources decreases over time, and while these are threatened in the
future, they are still selectively available in the present. Our
policies must change and evolve depending on the magnitude of the
situation.9,28
In the absence of data to guide us, we involved the most experienced
surgeons available, and extensive open discussion in multiple forums was
followed by formal committee review in order to make decisions. While in
theory the committee chairman had the final word, there was always a
consensus regarding the appropriate approach. Even primary surgeons who
were advocating for a surgical plan on their specific patient accepted
the magnitude of the situation and the reasons for decisions that were
made.
In the escalating phase of an epidemic when the hospital is trying to
keep beds open in anticipation of patient needs, what is appropriate and
ethical may be very different from when the pandemic is at its
peak.9,28 Difficult decisions may seem unjustified at
a point where we are preparing for expected volume, but still have
unoccupied beds, compared to later when the system enters crisis mode.
However it would be a fallacy to think that we can “catch up” later,
and modeling studies of pandemic crises generally confirm that proper
early triage can save lives dramatically over a “first come first
served” approach.9,28 At the same time others have
pointed out that triage poorly done, based on improper clinical
parameters, can actually lead to worse
outcomes.9,28,29,30 This could occur due to
underestimating or overestimating the severity of a patient’s condition,
and underutilizing or overutilizing resources, and can actually save
fewer lives rather than more.28,29,30 Thus recommended
decisions must be based on appropriate in depth criteria, including
understanding and reviewing histology or cytology when possible, and
reviewing or repeating imaging when appropriate.
In the absence of exact data, even more problematic is how to factor in
the changing level of risk over time of coronavirus infection in these
cancer patients, some of whom fall in high risk groups for COVID-19,
while also considering the public health goals of conserving intensive
care unit beds, ventilators, and PPE. Furthermore, we must then
calculate the risk level and relative importance of protecting
providers, not only out of fairness to the provider, but also because
the provider is a valuable resource in short supply who will be able to
treat other patients during the pandemic.9,28,29,30 At
the time of writing this manuscript, our healthcare systems (UHealth and
Jackson Memorial Hospital) have so far reported the death of one nurse,
one MRI technician, one physician faculty member and one radiology
technician as a result of COVID-19.
We emphasize the importance of communicating well with patients and
surgeons throughout the process, and reminding them to consider all
risks, including risk of COVID-19, emphasizing the Surgeon General
recommendations regarding elective surgery, and providing data as needed
regarding alternatives for cancer treatment.
Several specialty societies have published guidelines regarding cancer
management during the pandemic. These do not specify at what point they
should be instituted, and how severe the situation should be. Some of
the recommendations, allow potential misinterpretation. For example, the
Society of Surgical Oncology has suggested delay of treatment for thin
invasive melanomas, and prioritization of surgery only for thicker
melanomas.31 While the reasons for this recommendation
are understood, and there are many details to consider, the approach
seems debatable in a situation where resources are being protected, but
some are still available, as this early group of invasive melanomas are
those most likely to be cured by surgery.
The American Head and Neck Society has not published specific
guidelines. We have referred here to the publication by Day et
al23 that provides some reasonable guidelines and we
add our suggestions here. Our recommendations, in the absence of
randomized data, come from practical work triaging surgeries during this
process:
1)All head and neck cases for which a change in plan is under
consideration should be reviewed by a multidisciplinary tumor conference
to provide care recommendations specifically in the context of COVID-19
with appropriate documentation of how the pandemic has impacted
treatment recommendations.
2)A departmental surgical review committee should be established to
evaluate all cases proposed for surgical care to provide independent
review of appropriate urgency for surgical scheduling. This committee
provides a second level of review that is guided by the primary
physician’s assessment and recommendations, multidisciplinary
recommendations from tumor conference, as well as the important
independent perspective of non-head and neck surgeons with regard to
resource utilization and patient and staff safety concerns. The surgical
review committee should have real-time access to hospital ethics
committee consultation when necessary.
3) We suggest delay for 2 to 3 months of surgery for low-grade
malignancies, including well differentiated thyroid cancers and
low-grade parotid cancers, and skin cancers not threatening vital
functions.
4)We recommend that these patients be followed closely with
consideration for repeat imaging during this period to allow for
correction of the approach if the tumor is progressing.
5)When surgery is clearly the superior option for a high-grade mucosal
cancer, such as for oral cavity cancer, we would recommend proceeding to
surgical treatment. At the height of the pandemic surge this may to be
interrupted, but when capacity is still available, these patients’
survival is at stake and they should have a fair claim to available
resources.
6)The importance of available rapid accurate testing for active
Sars-CoV-2 infection in order to allow surgical care to be offered
cannot be overstated. Naturally, given the novelty of this virus,
current testing technology is in its early stages. We eagerly await more
accurate and reliable testing, including well validated data for false
negatives and false positives in the setting of preoperative patients
without symptoms of COVID-19.
7)During this brief point in time, mucosal cancers for which
non-surgical options are considered appropriate should be considered for
non-surgical treatment. Specifically, TORS and TLM are often used in
clinical scenarios where non-surgical options offer equivalent survival,
and both represent high risk procedures.
During endoscopic surgery the surgeon’s face is sometimes in close
proximity to the rigid laryngoscope during parts of the procedure. Even
when behind the microscope, they could, in theory, inhale Sars-CoV-2
particles in smoke plume. Given the significant false negative
rate24 of available tests for COVID-19, even with two
negative tests, there is still some risk to the surgeon and staff. We do
have information reporting that the rate of acquiring COVID-19 is higher
for head and neck surgeons, ophthalmologists, and oral surgeons than it
is for radiation oncologists, presumably due to the greater risk of
exposure to aerosolized or touched secretions.33
It should be acknowledged, in terms of ethics, that the decision to
irradiate patients instead of operating endoscopically is one of those
situations where we are weighing the public health risk, including the
risk to the surgical team, and transferring risk to another setting with
limited data to support it. The risk to the patient, in particular, of 6
weeks of radiation with multiple trips to the facility has not been
proven to be less than a single endoscopic intervention. Since there are
risks associated with an inpatient stay and possible lack of access to
medical resources during a surge, in addition to risk of viral exposure,
it is very hard to quantify this ”moving target” relative to 30 to 35
visits to radiation oncology. Some have pointed out that for
immunocompromised patients in particular, multiple trips to the hospital
also represent a significant risk,32 but the answer is
just not known.
Currently at our institution, all patients undergoing radiation and
chemotherapy are being tested for COVID-19 prior to start of treatment,
but not repeatedly. Patients testing positive on that first test get
treated separately at the end of the day. There is a risk that a patient
could have a true-negative test at the outset, only to develop COVID
infection later and then unknowingly expose other patients or radiation
oncology staff during any period in which the infection was not
clinically evident.
The most significant concern in the definitive radiation setting is the
risk, not to the staff, but to the patient. In our institution, there is
no routine testing of unexposed faculty or staff for COVID-19 infection.
The use of PPE by staff varies by role, with many staff members wearing
simple masks only. Radiation therapy technologists wear N95 masks, face
shields and gloves while treating head/neck cancer patients, but the
nursing staff and some physicians wear only gloves and simple masks.
Fundamentally, the difference in testing policy regarding patients
(mandatory testing) and staff (no routine testing) has the potential for
significant risk to patients over the extended timeframe of radiation
treatment.
As we move from a complete ban on elective surgery, towards
reincorporating some relatively important cases that have been awaiting
institutional clearance for surgery, significant stress will likely
occur as we try to determine to which of these patient’s medical
resources should be allocated first. This will create new conversations
and may lead to tension between services as debates develop about the
relative value of investing resources in ”sicker” patients versus ”more
salvageable patients”.
The head and neck patients triaged to delay in surgical care, primarily
the low-grade malignancies, will be the first group for re-consideration
by the surgical review committee. These patients will now face perhaps
an even more complex path on their journey to finally achieving the
surgical care they need in this unprecedented time. They will now be
evaluated alongside non-malignant cases with the potential for serious
complications with ongoing delay. Such cases might include erosive
cholesteatomas with bone loss and risk of cerebrospinal fluid leak, or
similar patients with aggressive but benign paranasal sinus disease. In
our system these will compete for operative time that has been assigned
to the Otolaryngology Department. Such comparisons are likely to be much
more nuanced than the decisions the surgical review committee has faced
to this point and may present even greater challenges to decision
making.
Prachand et al, in a general surgical setting, recently published online
regarding this dilemma and their own ”Cumulative Medically-Necessary
Time-Sensitive (MeNTS) Score”, which attempts to introduce objectivity
into this process. While we have not attempted to use this tool, such
efforts at maintaining objectivity may help introduce greater fairness
into this process. 34