Conflicting Duties
One of the major challenges specific to head and neck cancer during this pandemic involves the significant risk associated with examination, biopsy and treatment of pathology arising in the upper aerodigestive tract. Health care workers constituted a large percentage of the first cohort of infected patients. Potential aerosolization of SARS-CoA-2 virions hinders our ability to conduct routine management and requires extra resources and time to perform what before were routine examinations, endoscopy, biopsy, and surgery. Recent publications echo and reinforce the related dimensions of infection control, safety, and resource stewardship.11Givi B, Schiff BA, Chinn SB et al. Safety recommendations for evaluation and surgery of the head and neck during the COVID19 pandemic. JAMA Otolaryngol Head Neck Surg 2020 (In press). Airway management represents a discrete consideration in routine, urgent, and emergent settings, and newly published guides are also instructive.22Balakrishnan K, Schechtman S, Hogikyan ND, Teoh AYB, McGrath B, Brenner MJ. COVID-19 Pandemic: What every Otolaryngologist – Head & Neck Surgeon Needs to Know for Safe Airway Management. Otolaryngol Head Neck Surg 2020 (Epub). All of these reaffirm the importance of protecting patients as well as clinical staff from unnecessary exposure. Indeed, protection of the clinical workforce and public are fundamental ethical and professional responsibilities. However, the balance between our duty to care for patients with our duty to protect ourselves and our colleagues is not clear cut.
The American Head & Neck Society has a dynamic online resource for head and neck oncology providers.33American Head & Neck Society COVID-19 Bulletin Board. https://www.ahns.info/wp-content/uploads/2020/03/synthesized-physician-doc.pdf (Accessed 6 April 2020). The American Academy of Otolaryngology – Head & Neck Surgery Foundation’s related position statement affirms the need to avoid all clinical interactions which are not urgent/emergent, but “recognizes that ‘time sensitivity’ and ‘urgency’ are determined by individual physician judgment and must always take into account each individual patient’s medical condition, social circumstances, and needs.”44American Academy of Otolaryngology–Head and Neck Surgery. New Recommendations Regarding Urgent and Nonurgent Patient Care. https://www.entnet.org/content/new-recommendations-regarding-urgent-and-nonurgent-patient-care (Accessed 6 April 2020). Other societies have produced COVID-19 related resources and guidance that are also informative. The American College of Surgeons’ dedicated website clarifies the importance of delaying/deferring non-essential operations, and offers comprehensive support, including patient-facing messages which may be valuable to head and neck surgical oncology practices.55American College of Surgeons COVID-19 and Surgery. https://www.facs.org/covid-19 Accessed 6 April 2020. The Society for Surgical Oncology recommends that “urgent procedures… should be carefully considered for delay on a case-by case basis… and diagnoses which have equivalent results with radiation therapy and surgery should be considered for radiation therapy.”66Society for Surgical Oncology Resource for Management Options of Endocrine/Head and Neck Cancer During COVID-19. https://www.surgonc.org/wp-content/uploads/2020/03/Endocrine-Head-and-Neck-Resource-during-COVID-19-3.30.20.pdf Accessed 6 April 2020. The American Society of Clinical Oncology has general guidance for cancer providers and patients to avoid in-person encounters whenever possible, but the organization does not offer guidance specific to management of specific cancers.77American Society of Clinical Oncology COVID-19 Provider & Practice Information. https://www.asco.org/asco-coronavirus-information/provider-practice-preparedness-covid-19 Accessed 6 April 2020.
Although the duty to the patient is a cornerstone of the medical profession, it should not trump our duty to care for ourselves and those around us. Head and neck cancer practitioners should recognize the stress of the current situation on themselves, practice diligent self-care, and liberally seek counsel among colleagues, loved ones, and professionals.