Historical Perspective
During the severe acute respiratory syndrome (SARS) pandemic of 2002-2003, surgical care was dramatically impacted around the world.7-9 In Toronto, a global hotspot of the pandemic, policies enacted to reduce elective operations and conserve resources were highly effective: ambulatory and elective inpatient operations declined 70% and 57% year-over-year, respectively, while non-elective operations requiring inpatient admission post-operatively declined less than 10%.9 Similar declines were seen in Hong Kong, where one academic otolaryngology department had 79% lower surgical volume and 59% lower outpatient clinic visits.8 Oncologic surgery was not delineated in these reports specifically. In less severe viral epidemics, such as the H1N1 influenza epidemic in 2009, oncologic surgery has rarely been targeted for cancellation. The Japanese experience during the H1N1 epidemic revealed only a 0.4% increase in cancellation rates.10
Head and neck oncologic surgery will often be classified as “urgent” surgery with limited decrease in volume expected under the current policy restrictions. However, pandemic preparedness plans from the United States’ Institute of Medicine and the Canadian National Advisory Committee on SARS and Public Health emphasize adherence to the three-stage pandemic triage plan with surgical care de-escalation dictated by the current pandemic stage.9,11 Cancer surgical care typically would be impacted upon reaching triage level 3 (Table 1). The pandemic plans also recommend use of centralized committees within healthcare institutions to continually review and make decisions on de-escalation of services, taking into consideration (a) consequences to patients, (b) resource requirements, and (c) ability to provide the necessary resources given altered standards of care.11 Professional societies are recognized as critical to guide recommendations within individual surgical specialties.11 As some head and neck surgical cases are inevitably canceled, it will also be important to monitor for growing surgical backlogs, which posed significant financial and resource hardships on the Canadian system during their recovery from the SARS pandemic.9