Discussion
Our goal was to create effective and ethical cancer guidelines in an expeditious fashion to allow quick deployment during the COVID-19 epidemic. While a group consensus was both desired and required, time to completion was an important consideration which obligated the leadership to seek consensus individually rather than in a virtual group session. The result was a document agreed to by all which was completed within two weeks.
Our entire team agreed, that the primary treatment of choice during the COVID-19 epidemic was surgery in all surgically and medically resectable cases. Non-surgical options do exist utilizing radiation alone or chemoradiation. However, these options are fraught with increasing risks during this pandemic. In some cases, surgery results in a single day treatment that allows the patient with or without hospitalization to return home and avoid returning to the hospital. Radiation requires daily trips to the hospital for several weeks which puts both the patient and the radiation teams at risk of spread of SARS-CoV-2. Chemotherapy, when required, further immunocompromises the patient which makes them more susceptible to SARS-CoV-2 infection. Adjuvant radiation and chemotherapy can be done several weeks after surgery, safely and according to standard of care, and for many this will be after the peak of the virus spread in our community and when testing may be more readily available for screening patients.
A primary surgical approach for resectable cancers was seen as the safest pathway in cases where the pathology indicated that surgery was a standard of care option for a given anatomic site in the head and neck. For squamous cell carcinoma we made a distinction between P16+ and P16– cancers given how common oropharyngeal cancer is in our setting. Oropharyngeal cancers, in particular those which are P16+ and Human Papilloma Virus (HPV) associated, accounts for a significant percentage of the patients presenting to Head and Neck Surgeons in 2020. It has been estimated that by 2030 half of all head and neck cancers will be HPV related.24 The Center for Disease Control (CDC) website notes that 70% of all oropharyngeal cancers are caused by HPV and account for 13,500 cases annually, making this the most common HPV related cancer in the United States, exceeding cervical cancer by almost 3000 cases.25 Transoral Robotic Surgery (TORS) which was invented in 2005 and FDA cleared in 2009 has emerged as the most common surgical treatment of HPV related oropharyngeal cancer.26,27 The most frequent alternative non-surgical treatment for the management of HPV related oropharyngeal cancer is cisplatin-based chemoradiation which is associated with significant acute and chronic toxicity, including acute compromise of the immune system and significant acute and late risk of treatment related death and gastrostomy tube dependence.28 The standard of care for the treatment of oral cavity cancer worldwide is primary surgery with or without adjuvant radiation or chemoradiation.29 The standard of care requires that many laryngeal cancers be offered the option of surgery as the primary modality for organ preservation.30
The major concerns for Head and Neck Surgeons for the safety of all members of the surgical, perioperative and anesthesia teams are related to numerous factors. It is well established that large viral load of SARS-CoV-2 reside in nasal cavity and all levels of the mucosa between the nasopharynx and trachea. In addition, histological evaluation, in the primate model, of the SARS-CoV-1, a similar corona virus, indicates large viral load with the cells of the head and neck mucosa.31,32 Experimental evidence from the University of Pennsylvania indicates that appropriate surgical masks, even when virus is present in the electrocautery plume, do prevent passage of viral particles in electrocautery plume to the wearer.33 The aerosolized virus particles from SARS-CoV-2 remain viable for at least 3 hours.34 An article in Science estimates that 86% of SARS-CoV-2 infections in China were undocumented prior to the January 23, 2020 travel ban and that undocumented infections were likely responsible for spreading the disease to 79% of documented cases.35 Initially in the COVID-19 pandemic Personal Protective Equipment (PPE) and patient testing were in short supply or unavailable. Early on in the pandemic our team successfully negotiated with our hospital executives to ensure that for all head and neck cancer cases involving transection of mucosa the entire staff in the operating room would be issued N95 masks and all patients would undergo SARS-CoV-2 testing within 24 hours of the procedure. The fundamental premise of our negotiations were based on the idea that “the goal is to flatten the disease curve, not the personnel curve.”36
Preoperative testing of patients for SARS-CoV-2 may be critical for patient and staff safety. Xia et al. published a paper in which asymptomatic patients underwent a variety of surgical procedures throughout the body, including one laryngeal surgery. Thirty-four patients developed COVID-19 during the postoperative period and the mortality rate for this group was 20.5%. We recommend based on this study that asymptomatic patients who test SARS-CoV-2 positive prior to any treatment delay such treatment until they have had two negative tests within 24 hours.37
Our guidelines include a discussion of the management of routine cancer follow-up during the apogee of the COVID-19 disease incidence curve as well as during the reopening process of face-to face visits in the outpatient clinics. The pillars upon which our plan is built are: (1) multilevel triage approach to minimize the risk of COVID-19 PUI or positive patients encountering multiple personnel, (2) special precautions when performing potentially aerosolizing procedures (e.g., fiberoptic laryngoscopy and nasal endoscopy) in clinic, (3) appropriate workflow and PPE  use by staff, physicians and patients so that if an unexpected exposure to COVID-19 does occur the need for quarantine of staff or physicians is either minimized or non-existent, (4) added cleaning measures to sanitize patient exam and treatment rooms and (5) plan for clinic re-opening that ensures appropriate social distancing in the waiting room.38