Abstract
Elderly head and neck cancer patients are at increased risk of adverse
outcomes during and after treatment of head and neck cancer. COVID-19
severity and mortality can be expected to be significantly greater in
elderly head and neck cancer patients, given that increased age,
comorbidities, and presence of malignancy are known risk factors for
disease severity and mortality in COVID-19 patients. Therefore, their
management requires multidisciplinary consensus and patient input. A
thorough geriatric assessment, which has been shown to be beneficial
prior to the COVID-19 pandemic, could be particularly helpful in this
patient population with the added dimension of COVID-19 risk. In many
cases, prudent treatment plan modification may allow for overall best
outcomes. Furthermore, recruitment of social services and, when
appropriate, palliative care, may allow for optimal management of these
patients.
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), has been designated as a pandemic
by the World Health Organization (WHO).(1, 2) There remain many
uncertainties about the disease and its optimal management;(3) even
greater uncertainties are present in management of diseases not directly
related to COVID-19 during the pandemic. Since initial reports suggest
high viral load in the pharynx and respiratory secretions, there are
important ramifications for optimal management of patients with head and
neck cancer. This is especially true of patients with mucosal
malignancies and those who require tracheotomy or laryngectomy.(4-6) As
is standard for management of head and neck cancers, multidisciplinary
tumor board and conferences are critical for ensuring the safety of
patients, caregivers, family members, healthcare providers, and the
greater community.(6-8) Elderly patients with head and neck cancer are a
unique subset as they are at increased risks of adverse outcomes; 70%
of deaths from head and neck cancer occur in patients over the age of
70.(9) Therefore, their management deserves close attention,
multidisciplinary consensus, and shared decision making.
The National Institute on Aging and US Census Bureau define elderly
patients as those over the age of 65.(10) However, much of the oncology
literature uses cutoffs ranging from 70-80 for classifying patients as
elderly or geriatric.(9, 11) Regardless of the age cutoff to define
“elderliness”, age is best thought of a continuous variable, with
increased risks occurring as a continuum rather than after a certain
chronological age. Furthermore, the impacts of age on survival and
functional outcomes are modified by comorbidities, frailty, and
functional status.(9, 12-14) Increasing age, presence of malignancy, and
comorbidity are associated with increased disease severity in
COVID-19,(1, 15-17) which puts elderly head and neck cancer patients at
risk of poor outcomes from both diseases.
Treatment of head and neck cancer can involve surgery, radiation
therapy, systemic therapy, or a combination of these. Advanced cancers
generally require multimodality therapy. Whether and how the current
COVID-19 pandemic should modify treatment modalities is currently
unclear, especially for elderly patients.(6) However, COVID-19 patients
who are 80 years old or older have a mortality risk of 13%.(18)
Furthermore, 95% of deaths from COVID-19 occur in patients over 60;
50% of deaths occur in patients over 80.(19) Given concerns about
hospital-acquired COVID-19,(17) surgery should certainly be reconsidered
for elderly patients as it can result in exposure to COVID-19, which is
particularly concerning given the risk of disease severity and
mortality. However, administration of both radiation therapy and
systemic therapy require repeated visits, although inpatient settings
can sometimes be avoided. Therefore, until more robust data becomes
available, treatment decisions will need to be individualized and take
into account patient disease and status, local COVID-19 burden, and
resource availability.
The International Society of Geriatric Oncology consensus is to
recommend a geriatric assessment (GA) in older patients with cancer.(11)
GA includes assessment of functional status, comorbidity, cognition,
mental health status, fatigue, social status and support, nutrition, and
presence of geriatric syndromes. The benefits of such an assessment
include more accurate prediction of adverse outcomes, detection of
unidentified problems, improved estimation of residual life expectancy,
appropriate employment of geriatric interventions, and appropriate
cancer treatment selection.(11) The potential impact of COVID-19
infection could be assessed within this GA framework to allow for
optimal shared decision making. Therefore, an 85 year old head and neck
cancer patient with multiple comorbidities and limited social support
may be best served by delaying or altering the treatment plan given the
potential harm that could occur with COVID-19 infection. However, a 70
year old patient with a similar cancer but no comorbidities and strong
social support may be able to proceed with treatment, with appropriate
precautions for both the patient and healthcare providers. Certainly,
such decisions would need to be made after multidisciplinary discussion,
extensive counseling, and shared decision making.
Early involvement of comprehensive palliative care and social services
are often an integral part of management of elderly head and neck cancer
patients, especially in the setting of recurrent or metastatic
disease.(13) Such services are likely to be particularly helpful during
the current COVID-19 pandemic.
The current COVID-19 pandemic is altering how we manage head and neck
cancer in a multitude of ways. This is particularly evident in elderly
head and neck cancer patients. This particularly vulnerable population
is even more susceptible to adverse outcomes during the COVID-19
pandemic. For those reasons, we have a responsibility to provide
multidisciplinary care, thorough assessment of risks and benefits of any
possible interventions, shared decision making, social resources, and,
when appropriate, comprehensive palliative care for elderly head and
neck cancer patients.
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