DISCUSSION
No randomized trials provide data regarding the appropriate systems and policies for the triage of patients with potentially fatal cancers during a global pandemic. The infrastructure and regulations for appropriate triage of the ill and injured that have been developed for crisis triage during war and natural disaster serve as guides, but these situations are not the same, as they may be more intense, but are more limited in time and area of geographic involvement. What is safe, fair and appropriate may not always be clear as the availability of medical resources decreases over time, and while these are threatened in the future, they are still selectively available in the present. Our policies must change and evolve depending on the magnitude of the situation.9,28
In the absence of data to guide us, we involved the most experienced surgeons available, and extensive open discussion in multiple forums was followed by formal committee review in order to make decisions. While in theory the committee chairman had the final word, there was always a consensus regarding the appropriate approach. Even primary surgeons who were advocating for a surgical plan on their specific patient accepted the magnitude of the situation and the reasons for decisions that were made.
In the escalating phase of an epidemic when the hospital is trying to keep beds open in anticipation of patient needs, what is appropriate and ethical may be very different from when the pandemic is at its peak.9,28 Difficult decisions may seem unjustified at a point where we are preparing for expected volume, but still have unoccupied beds, compared to later when the system enters crisis mode. However it would be a fallacy to think that we can “catch up” later, and modeling studies of pandemic crises generally confirm that proper early triage can save lives dramatically over a “first come first served” approach.9,28 At the same time others have pointed out that triage poorly done, based on improper clinical parameters, can actually lead to worse outcomes.9,28,29,30 This could occur due to underestimating or overestimating the severity of a patient’s condition, and underutilizing or overutilizing resources, and can actually save fewer lives rather than more.28,29,30 Thus recommended decisions must be based on appropriate in depth criteria, including understanding and reviewing histology or cytology when possible, and reviewing or repeating imaging when appropriate.
In the absence of exact data, even more problematic is how to factor in the changing level of risk over time of coronavirus infection in these cancer patients, some of whom fall in high risk groups for COVID-19, while also considering the public health goals of conserving intensive care unit beds, ventilators, and PPE. Furthermore, we must then calculate the risk level and relative importance of protecting providers, not only out of fairness to the provider, but also because the provider is a valuable resource in short supply who will be able to treat other patients during the pandemic.9,28,29,30 At the time of writing this manuscript, our healthcare systems (UHealth and Jackson Memorial Hospital) have so far reported the death of one nurse, one MRI technician, one physician faculty member and one radiology technician as a result of COVID-19.
We emphasize the importance of communicating well with patients and surgeons throughout the process, and reminding them to consider all risks, including risk of COVID-19, emphasizing the Surgeon General recommendations regarding elective surgery, and providing data as needed regarding alternatives for cancer treatment.
Several specialty societies have published guidelines regarding cancer management during the pandemic. These do not specify at what point they should be instituted, and how severe the situation should be. Some of the recommendations, allow potential misinterpretation. For example, the Society of Surgical Oncology has suggested delay of treatment for thin invasive melanomas, and prioritization of surgery only for thicker melanomas.31 While the reasons for this recommendation are understood, and there are many details to consider, the approach seems debatable in a situation where resources are being protected, but some are still available, as this early group of invasive melanomas are those most likely to be cured by surgery.
The American Head and Neck Society has not published specific guidelines. We have referred here to the publication by Day et al23 that provides some reasonable guidelines and we add our suggestions here. Our recommendations, in the absence of randomized data, come from practical work triaging surgeries during this process:
1)All head and neck cases for which a change in plan is under consideration should be reviewed by a multidisciplinary tumor conference to provide care recommendations specifically in the context of COVID-19 with appropriate documentation of how the pandemic has impacted treatment recommendations.
2)A departmental surgical review committee should be established to evaluate all cases proposed for surgical care to provide independent review of appropriate urgency for surgical scheduling. This committee provides a second level of review that is guided by the primary physician’s assessment and recommendations, multidisciplinary recommendations from tumor conference, as well as the important independent perspective of non-head and neck surgeons with regard to resource utilization and patient and staff safety concerns. The surgical review committee should have real-time access to hospital ethics committee consultation when necessary.
3) We suggest delay for 2 to 3 months of surgery for low-grade malignancies, including well differentiated thyroid cancers and low-grade parotid cancers, and skin cancers not threatening vital functions.
4)We recommend that these patients be followed closely with consideration for repeat imaging during this period to allow for correction of the approach if the tumor is progressing.
5)When surgery is clearly the superior option for a high-grade mucosal cancer, such as for oral cavity cancer, we would recommend proceeding to surgical treatment. At the height of the pandemic surge this may to be interrupted, but when capacity is still available, these patients’ survival is at stake and they should have a fair claim to available resources.
6)The importance of available rapid accurate testing for active Sars-CoV-2 infection in order to allow surgical care to be offered cannot be overstated. Naturally, given the novelty of this virus, current testing technology is in its early stages. We eagerly await more accurate and reliable testing, including well validated data for false negatives and false positives in the setting of preoperative patients without symptoms of COVID-19.
7)During this brief point in time, mucosal cancers for which non-surgical options are considered appropriate should be considered for non-surgical treatment. Specifically, TORS and TLM are often used in clinical scenarios where non-surgical options offer equivalent survival, and both represent high risk procedures.
During endoscopic surgery the surgeon’s face is sometimes in close proximity to the rigid laryngoscope during parts of the procedure. Even when behind the microscope, they could, in theory, inhale Sars-CoV-2 particles in smoke plume. Given the significant false negative rate24 of available tests for COVID-19, even with two negative tests, there is still some risk to the surgeon and staff. We do have information reporting that the rate of acquiring COVID-19 is higher for head and neck surgeons, ophthalmologists, and oral surgeons than it is for radiation oncologists, presumably due to the greater risk of exposure to aerosolized or touched secretions.33
It should be acknowledged, in terms of ethics, that the decision to irradiate patients instead of operating endoscopically is one of those situations where we are weighing the public health risk, including the risk to the surgical team, and transferring risk to another setting with limited data to support it. The risk to the patient, in particular, of 6 weeks of radiation with multiple trips to the facility has not been proven to be less than a single endoscopic intervention. Since there are risks associated with an inpatient stay and possible lack of access to medical resources during a surge, in addition to risk of viral exposure, it is very hard to quantify this ”moving target” relative to 30 to 35 visits to radiation oncology. Some have pointed out that for immunocompromised patients in particular, multiple trips to the hospital also represent a significant risk,32 but the answer is just not known.
Currently at our institution, all patients undergoing radiation and chemotherapy are being tested for COVID-19 prior to start of treatment, but not repeatedly. Patients testing positive on that first test get treated separately at the end of the day. There is a risk that a patient could have a true-negative test at the outset, only to develop COVID infection later and then unknowingly expose other patients or radiation oncology staff during any period in which the infection was not clinically evident.
The most significant concern in the definitive radiation setting is the risk, not to the staff, but to the patient. In our institution, there is no routine testing of unexposed faculty or staff for COVID-19 infection. The use of PPE by staff varies by role, with many staff members wearing simple masks only. Radiation therapy technologists wear N95 masks, face shields and gloves while treating head/neck cancer patients, but the nursing staff and some physicians wear only gloves and simple masks. Fundamentally, the difference in testing policy regarding patients (mandatory testing) and staff (no routine testing) has the potential for significant risk to patients over the extended timeframe of radiation treatment.
As we move from a complete ban on elective surgery, towards reincorporating some relatively important cases that have been awaiting institutional clearance for surgery, significant stress will likely occur as we try to determine to which of these patient’s medical resources should be allocated first. This will create new conversations and may lead to tension between services as debates develop about the relative value of investing resources in ”sicker” patients versus ”more salvageable patients”.
The head and neck patients triaged to delay in surgical care, primarily the low-grade malignancies, will be the first group for re-consideration by the surgical review committee. These patients will now face perhaps an even more complex path on their journey to finally achieving the surgical care they need in this unprecedented time. They will now be evaluated alongside non-malignant cases with the potential for serious complications with ongoing delay. Such cases might include erosive cholesteatomas with bone loss and risk of cerebrospinal fluid leak, or similar patients with aggressive but benign paranasal sinus disease. In our system these will compete for operative time that has been assigned to the Otolaryngology Department. Such comparisons are likely to be much more nuanced than the decisions the surgical review committee has faced to this point and may present even greater challenges to decision making.
Prachand et al, in a general surgical setting, recently published online regarding this dilemma and their own ”Cumulative Medically-Necessary Time-Sensitive (MeNTS) Score”, which attempts to introduce objectivity into this process. While we have not attempted to use this tool, such efforts at maintaining objectivity may help introduce greater fairness into this process. 34