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\begin{document}

\title{The Surge after the Surge: Anticipating the Increased Volume and Needs
of Head and Neck Cancer Patients after the Peak in COVID-19}



\author[1]{Arun Sharma, MD, MS, FACS}%
\affil[1]{Southern Illinois University School of Medicine}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\begin{abstract}
The novel coronavirus disease 2019 (COVID-19) pandemic continues to have
extensive effects on public health as it spreads rapidly across the
globe. Head and neck cancer patients are a particularly susceptible
population to these effects, and we expect there to be a potential surge
in patients presenting with head and neck cancers after the surge in
COVID-19. Furthermore, the impact of social distancing measures could
result in a shift towards more advanced disease at presentation. With
appropriate anticipation, multidisciplinary head and cancer teams could
potentially minimize the impact of this surge and plan for strategies to
provide optimal care for head and neck cancer patients.%
\end{abstract}%



\sloppy




Ryan Bowman, MS\textsuperscript{1}, Dana L Crosby, MD,
MPH\textsuperscript{2}, Arun Sharma, MD, MS\textsuperscript{2}

~\textsuperscript{1}Southern Illinois University School of Medicine,
Springfield, Illinois

\textsuperscript{2}Department of Otolaryngology -- Head and Neck
Surgery, Southern Illinois University School of Medicine, Springfield,
Illinois

~Grant support: None

This work has not been presented at any meetings.

Brief running title: Increased Head and Neck Cancer after COVID-19 Peak

Key words: COVID-19; SARS-CoV-2; novel coronavirus; head and neck cancer

Corresponding Author:

Arun Sharma, MD, MS, FACS

Associate Professor

Department of Otolaryngology-Head and Neck Surgery

Southern Illinois University School of Medicine

720 N Bond Street

Springfield, Illinois 62794

Office Phone: 217.545.7068

Email: {asharma74@siumed.edu}{}

\textbf{Abstract{}}

The novel coronavirus disease 2019 (COVID-19) pandemic continues to have
extensive effects on public health as it spreads rapidly across the
globe. Head and neck cancer patients are a particularly susceptible
population to these effects, and we expect there to be a potential surge
in patients presenting with head and neck cancers after the surge in
COVID-19. Furthermore, the impact of social distancing measures could
result in a shift towards more advanced disease at presentation. With
appropriate anticipation, multidisciplinary head and cancer teams could
potentially minimize the impact of this surge and plan for strategies to
provide optimal care for head and neck cancer patients.

\par\null

\textbf{Introduction}

Severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2),
which causes the novel coronavirus disease 2019 (COVID-19), has had an
unprecedented effect on the world and the medical community. The World
Health Organization declared it a pandemic on March 11, 2019, and, as of
April 25, 2020, more than 2.8 million people have been infected,
resulting in over 200,000 deaths worldwide.\textsuperscript{1-2}COVID-19
has already had extraordinary effects on how multidisciplinary head and
neck cancer (HNC) teams provide HNC patients in initial hotspots such as
Wuhan, China and in Italy as well as the United States and throughout
the world.\textsuperscript{3-5} Following previous regional disasters
such as Hurricane Katrina in 2008, there was an increase in incidence of
patients presenting with advanced head and neck
cancers.\textsuperscript{6} We should be prepared for a similar surge in
this patient population with the current pandemic after we pass the
COVID-19 incidence peak. Although estimates of peak hospital resource
use of the COVID-19 surge vary between models and geographic locations,
estimates from the Institute of Health Metrics and Evaluation (IHME)
estimate that the national peak was on April 17, 2020. However,
estimated peaks from all states currently range from April 4, 2020 to
May 14, 2020 with the possibility of another surge in the coming
months.\textsuperscript{7} The peak time of deaths from COVID-19 are
roughly similar but include an even broader range of dates.

Multidisciplinary HNC teams need to be proactive in anticipating and
preparing for the potential influx of HNC patients as public health
guidelines shift from social distancing to containment strategies. By
implementing tactics to mitigate and ultimately deal with this surge,
HNC patients can receive quality and prompt care without increased
adverse outcomes.

\emph{Reasons for the surge and ways to prevent it}

Post-Hurricane Katrina, reduced access to cancer care was significantly
associated with difficulty obtaining treatment.\textsuperscript{6} We
believe that lack of timely access to care could lead to a similar
post-COVID-19 surge of advanced stage HNC across the country. During
these unprecedented times, there are many reasons for which a patient
may be evaluated later than usual. Patients themselves may fear visiting
their doctor at the risk of potentially contracting COVID-19, while
physicians have limited their schedules and a patient could be given a
later appointment time. Clinics have limited their schedules in order to
optimize the safety of their staff and their patients. Reasons for these
restricted schedules include but are not limited to, lack of personal
protective equipment (PPE), lack of rapid COVID-19 testing, lack of
transportation, social distancing and shelter-in-place orders, limiting
office visits for patients deemed high risk of contracting COVID-19,
lack of access to telemedicine services, and staffing concerns. Fear of
contracting COVID-19 has been shown to play a significant role in
patients not seeking medical care. In Italy, hospital statistics from
the period of March 1-27, 2020, showed substantial decreases (ranging
from 73-88\%) in pediatric emergency department visits compared with the
same time periods in 2018 and 2019. All parents who were surveyed
reported avoiding hospitals for fear of infection with
COVID-19.\textsuperscript{8} In light of this, patients and their
primary care physicians should be reminded that Otolaryngology -- Head
and Neck Surgery clinics are still open and consider patient safety the
highest priority. This can be done through a variety of platforms such
as social media, phone calls, emails, virtual town halls, and online
patient portals just to name a few. Patients who are concerned about
coming to clinic should be made aware that adequate precautions are in
place to decrease the risk of contracting COVID-19 and when appropriate,
can be offered telemedicine services.

\emph{Strategies to mitigate the HNC surge}

HNC patients, along with otolaryngologists, are high-risk populations
for contracting COVID-19, primarily due to the fact that high viral
loads of SARS-CoV-2 are located in the upper aerodigestive tract and
procedures in this area (e.g. endoscopy, tracheostomy, surgery, etc.)
lead to aerosolization of viral particles.\textsuperscript{9} In
addition to this, HNC patients in particular may be susceptible to rapid
deterioration and worse outcomes (e.g. admission to an intensive care
unit, mechanical ventilation, and death) if they do contract COVID-19
due to coexisting comorbidites.\textsuperscript{10-11} Therefore, in
order to manage the surge of HNC patients, certain precautions and
strategies must be implemented by otolaryngologists to effectively treat
these patients.\textsuperscript{12} First and foremost, ample PPE should
be available before seeing any patients or doing any procedures. In
association with this, pre-appointment screening should be done on all
patients and (rapid) COVID testing should be utilized when available and
appropriate.\textsuperscript{13}

Scheduling should be streamlined to allow for timely care. Telemedicine
has been shown to be a valuable tool in this era, and although it comes
with its' own limitations, it can be optimized in order to provide care
for HNC patients.\textsuperscript{14-15} Visits that are expected to
predominantly involve reviewing results and counseling can be performed
with telemedicine. One strategy would be to schedule all patients for
telemedicine visits, except for those which require an in-office
procedure (such as a biopsy or laryngoscopy) or for whom in-person
physical examination is critical for decision-making (such as palpation
of an oral tongue cancer).

Multidisciplinary care through a head and neck tumor board has been
clearly shown to improve outcomes in patients with head and neck
cancer.\textsuperscript{16-18} During the COVID-19 pandemic, utilization
of a multidisciplinary decision-making is of critical importance,
especially when there is an influx of many patients during a time of
limited resources and high risk of COVID-19 transmission. In some
situations, surgical and non-surgical treatment options may have similar
outcomes. In such situations, the preferred option is the one which
allows for timely initiation of treatment while conserving resources and
minimizing risks to patients and healthcare workers. Given the
complexity of such decisions and influence by evolving local and
regional factors, multidisciplinary consensus is critical. Since many
otolaryngologists whose practices do not focus on HNC may not be
experiencing the clinical volume that they normally have, their clinical
skills could be of critical importance in managing an influx of HNC
patients. Having these providers available to provide care for patients
during the HNC surge could facilitate timely diagnosis, workup, and
treatment. However, close monitoring of outcomes is necessary, as is
always the case, to ensure that patients are receiving the highest level
of care.

\textbf{Conclusion}

COVID-19 continues to have widespread effects on the field of
Otolaryngology -- Head and Neck Surgery. In the coming weeks and months,
there will very likely be a surge of HNC patients with delayed
presentations due to a host of reasons. By incorporating preventative
measures and strategies aimed at addressing this post-COVID-19 surge,
multidisciplinary HNC teams can provide these patients with the
appropriate care they need.

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