Introduction
With the arrival of the coronavirus disease (SARS-CoV-2) in the U.S., care practice paradigms have drastically changed. Social-distancing remains the most effective way to limit disease spread as the cases of SARS-CoV-2 continues to rise with no available vaccine or treatment1. This has resulted in the cancellation of multiple clinics and delay of procedures to limit the spread of the virus. For cancer patients who already have decreased immunity, data from China suggests the new virus poses additional risks as case fatality of patients with cancer was higher at 5.6% compared to 2.3% of the general population2. Another case study found that patients who had undergone anti-tumor therapy within 14 days of SARS-CoV-2 diagnosis had an increased risk of developing severe events and poorer outcomes3. Liang et al. proposed three major strategies to address care for patients with cancer in this SARS-CoV-2 pandemic with postponing treatment for those with stable cancer, increasing personal protection provisions for cancer patients, and increasing monitoring if a patient becomes infected with SARS-CoV-24.
In regards to postponing treatment, the National Comprehensive Cancer Network has released broad guidelines stating that for patients with solid tumors, adjuvant therapy with curative intent should proceed, despite the threat of SARS-CoV-2 infection during treatment5. The American College of Surgeons has also released guidance for the triage of non-emergent surgical procedures, recognizing that some elective cases intend to treat diseases that progress at variable, disease-specific rates and thus must proceed6. Otolaryngology specific safety guidelines have delineated high risk procedures as those working with exposed airway and mucosal surfaces that may generate aerosols7. Thus, prior to any surgical procedure, the SARS-CoV-2 status of a patient should be assessed with a discussion for delay of surgery if the patient is positive. With the current shortage of personal protective equipment and the need to reduce infection spread, institutions have developed processes to stratify the urgency of head and neck cases, delaying certain cases based on evidence from studies on prolonged time to treatment initiation. These treatment decisions aim to balance the unknown risk of infection to the patient, exposure of the health care workers and use of valuable personal protective equipment with the progression of cancer that may increase in mortality and likelihood of recurrence with delay. Studies have noted a poorer overall survival is associated with an extended period between diagnosis to initiation of treatment with delay thresholds ranging from 20 to 120 days8. Psychiatric vulnerabilities in certain cancer patients may also be exposed with extended wait times9. However, with the realities of the lack of personal protective equipment and the need to redirected staff to SARS-CoV-2 patients, there is a move toward delaying non-urgent cases. With the uncertainties of the SARS-CoV-2 pandemic and a head and neck cancer (HNC) diagnosis, the potential mental health consequences of such delays to treatment warrant further discussion.
HNC patients suffer from unique challenges, as much of social functioning depends on the structural and functional integrity of the head and neck region. Disease process and treatment can significantly alter this. Psychological distress is also particularly prevalent in HNC patients as nearly 35% of patients suffer from symptoms of depression and anxiety10. Now, with the added complications of the SARS-CoV-2 pandemic, restrictions on movement may increase patients’ stress, depression, and fear11. In this present commentary, we discuss the unique mental health challenges and burdens of HNC patients in the times of the SARS-CoV-2 pandemic and approaches to mitigate these stressors through telemedicine to reduce future burdens to the patient and the health care system.