Introduction
We currently find ourselves in unprecedented times. The measures needed to control the COVID-19 outbreak are directly at odds with providing comprehensive cancer care. Across the world, people are being told to stay home and severely limit their activities. But the treatment of head and neck cancer requires multidisciplinary collaboration, which directly translates to significant exposure and interactions with many different people in hospital systems. Early data from the epidemic in China suggest that a cancer diagnosis is a risk factor for severe events from COVID-19, especially if the patient recently underwent chemotherapy or surgery.1-4 Patients with cancer and iatrogenic immune suppression for the treatment of other medical conditions are likely at even greater risk of complications and death from viral infection.
Malignant tumors of the head and neck account for approximately 3% of all cancers in the United States, with about 53,260 Americans expected to be diagnosed in 2020.5 Prompt diagnosis and treatment are critical for increasing survival and preserving organ function and quality of life. A systematic review on time to diagnosis or treatment in oral, pharyngeal, and laryngeal cancer patients found higher stage and inferior survival with longer treatment delays.6,7
During the current pandemic, any decision that could lead to airway emergencies or more extensive surgeries in the near future has the potential for putting health care providers at greater risk of COVID-19 exposure.8-10 Aerosol-generating procedures, including tracheal intubation, tracheotomy, non-invasive ventilation, and manual ventilation, are associated with increased risks of acute respiratory infections among health care workers.11 Anecdotal reports from Wuhan, China, report higher rates of infection specifically among otolaryngologists.12-15 Personal protective equipment (PPE) is a currently scarce but essential resource for the aerosolizing procedures performed by otolaryngologists.
The decision to perform surgery for mucosal cancer is currently difficult in all head and neck cancer patients, but particularly complicated in patients with a secondary diagnosis or medical therapy leading to an immunocompromised state, as their risk of infection with SARS-CoV-2 is surely even more pronounced. A diagnosis of cancer in an already immunocompromised patient is also a time-sensitive matter, as impaired immunity can increase the growth and spread of a cancer.16,17 Immunocompromised patients with COVID-19 are also thought to be more likely to have severe adverse events, although the data are still limited.1,18 Combining the two factors of a cancer diagnosis and an immune suppressed state intensifies the gravity and complexity of the situation. We report two presentations of head and neck cancer in immunocompromised patients in the setting of this global pandemic and discuss our clinical rationale for the different approaches taken in each case.