Does Routine Testing of Asymptomatic Patients Help?

A recent report from Wuhan, China on 34 asymptomatic patients who had elective surgery during their incubation period of COVID-19 infection demonstrated that all of them developed COVID-19 pneumonia shortly after surgery with abnormal findings on chest computed tomographic scans. The ICU admission and mortality rates were 44% and 20%, respectively. This makes a very good argument supporting routine preoperative testing of asymptomatic patients undergoing surgery. 16
Given the challenges of making treatment decisions for patients with HNC and the significant added risk of transmission to their health care providers, routine testing for COVID-19 status in these patients, even if asymptomatic, is strongly recommended and is becoming more widely adopted in most HNC treatment centers. Treatment of patients with HNC who test positive for COVID-19 is generally deferred until they recover from their infection. The rationale for this recommendation is two fold; minimizing risk to the patient and to the health care providers.
As mentioned, the older age and prevalent comorbidity of patients with HNC pose added risk of mortality if they are COVID-19 positive. This is particularly true for surgical treatment. Major surgery for HNC frequently involves a lengthy procedure for resection and reconstruction, and the immediate postoperative period is complicated by frequent challenges of fluid overload, fluid shifts, reduced lung capacity, and possible postoperative lung atelectasis. These changes might challenge pulmonary function, which is critical to recovery from COVID-19 pneumonia, and may predispose these patients to the need of ventilator support and reduce their chances of recovery.
Given the high density of viral loads in the upper aerodigestive tract of patients who are COVID-19 positive and the aerosol-generating potential of surgical procedures on the mucosal surfaces of the head and neck, the risk of transmission to the surgical team and all operating room personnel, including nursing and anesthesia, is significant.13Therefore, the need for maximal PPE such as PAPRs in caring for such patients is mandatory. Such level of PPE is needed for all involved personnel not just in the operating room but also over the entire course of the patient’s recovery throughout the hospital, including the recovery room, ICU, step-down unit, and regular hospital floor. Even after patient discharge this level of PPE is needed in a long-term care facility or home nursing. This is particularly true if the patient undergoes tracheostomy, which is frequently performed as part of HNC resection. All nurses, respiratory therapists, occupational and physical therapists, speech language pathologists, residents, fellows, and attending physicians providing postoperative care will need this added level of PPE for at least a couple of weeks after surgery. In addition to the staggering number of PPEs needed for the care of this one patient, the risk to the hospital environment, other patients, and mandatory isolation procedures are significant. In conclusion, it seems clear that, for the sake of minimizing risks to the patients, health care providers, and hospital system, major surgery for HNC should be deferred in patients who test positive for COVID-19 unless it is a life-saving measure.
Patients with HNC who test negative for COVID-19 should be considered for surgery if delaying such treatment would negatively impact their prognosis. The false-negative rate of testing is not yet known and is influenced by the testing platform, such as viral RNA-based PCR or immunoglobulin serology testing; and on the source, quality, and handling of swab specimens. 17 False-negative rates of 20-40% have been reported for swab tests, and the testing accuracy may be significantly increased if complemented with chest imaging showing signs of infection. 18 Because of these limitations, it is recommended that a negative test be interpreted with caution and appropriate PPE such as N95 masks, goggles, gowns, and gloves should be used by all health care providers involved in the surgery and postoperative care of these patients.
For patients presenting with life-threatening emergencies in whom rapid testing is not available or feasible, head and neck surgery and airway procedures should be performed assuming the patient is COVID-19 positive given the high rate of community transmission. In such cases, maximal PPE including PAPRs should be used.
Because of these challenges associated with major oncologic surgery and the need to conserve operating rooms, inpatient beds, ICU capacity, ventilators, and PPE, a recommendation for using outpatient non-surgical therapy for cancer patients has been advocated during the pandemic. Non-surgical therapy may include radiation, chemotherapy, and immunotherapy. These treatments may be used either definitively or in the neoadjuvant setting in order to buy time before needing cancer surgery. Non-surgical therapy also has inherent challenges in the face of the COVID-19 pandemic. Chemotherapy in general is associated with immunosuppression that may put cancer patients at a higher risk of contracting COVID-19 or developing cancer-treatment-related complications. 7-10 There are concerns that immunotherapy may increase the inflammatory response to COVID-19-associated pneumonia and promote the acute respiratory distress syndrome that is the main mode of death from this disease.7-10 Head and neck radiation may be associated with severe mucositis, poor oral intake, weight loss, dehydration, and fatigue, all of which have yet unknown impact on the risk for patients contracting COVID-19 or developing a more severe disease if they get infected. Radiation therapy also requires daily treatment for a period of 6 weeks, which is challenging for most patients in terms of logistics at a time when stay-home orders are getting more widespread, quarantine requirements are in effect when crossing state lines, and patients’ family members and caregivers are increasingly restricted from accessing the hospitals to accompany patients during their treatment visits.11-12