Brazilian Society of Surgical Oncology (BSSO) considerations on head and neck cancer during COVID-19 pandemic

Keywords:

Head and neck neoplasms - Surgical oncology - Oncology service - Hospital - Health planning guidelines

Descritores:

Neoplasias de cabeça e pescoço - Cirurgia oncológica - Serviço de oncologia - Hospital - Diretrizes de planejamento em saúde

Most head and neck cancers are aggressive and delays to offer appropriate treatment could lead to tumor progression, poor outcomes, and increased mortality rates. For these patients treatment cannot be postponed.

The registered incidence and mortality rates of head and neck cancer, especially in oral cavity and larynx, in Brazil are among the highest in the world. More than 60% are diagnosed at advanced clinical stages and surgery associated to radiotherapy or radio and chemotherapy are the treatment of choice for most cases. Due to difficulties in the access to the public system, the reduced number of qualified professionals (head and neck surgeons), and the lack of specialized hospitals with multidisciplinary teams trained to treat these highly complex patients, the waiting lists to start the treatment, are quite expressive. This results in a remarkable long waiting time to start treatment in our routine practice. If cancellation of elective procedures becomes the rule during COVID-19 pandemic, an already severe situation will soon become chaotic. Untreated patients will have tumor progression, several will become untreatable, and many will die. It has been already documented in China, affecting clinical trials, appointments, and continuity in care.^[ [1] ^]

Head and neck surgery specialty treats patients with cancer located in the following locations: skull base, orbit, nasal cavity, paranasal sinuses, salivary glands, nasopharynx, oropharynx, oral cavity, hypopharynx, larynx, thyroid, skin, bone and soft tissues, lymphomas and neck metastases. Most patients are older than 50 years, but even children and young adults can be diagnosed with head and neck cancer. The specialists in this field also deal with benign diseases, such as goiters, hyperparathyroidism and other diseases.

Aiming to save hospital beds for COVID-19 patients, a recommendation for cancellation of elective procedures have been proposed in most countries. It is reasonable recommendation for patients with uncomplicated benign diseases, such as goiters, cysts, etc. However, patients even with benign diseases as huge goiters with respiratory compression, or neck spaces infections or trauma, need emergency care and must be operated. The only types of cancer that can wait some weeks, and even few months, to be treated, are tiny basal cell carcinomas of the skin, well differentiated thyroid carcinomas and some low-grade salivary gland tumors.

All other patients with head and neck cancer must be treated, and treatment should be the standard of care! If a reduction of hospital beds and operating rooms become unavoidable during the next weeks, the priority must be the treatment of patients with early stage tumors, given the usually no need for postoperative care in Intensive Care Unit, hospital discharge occurs in 24 hours or less, and because it is not acceptable to wait and have tumor progression. Radiotherapy can be an option for patients that do not have clinical conditions or refuse surgical treatment, especially for early stage oropharynx and larynx cancers. It is important to emphasize that radiation demands repeated hospital visits, and then an increase in the risk of COVID-19 infection due to the public exposure during travel between home and hospital, waiting rooms in hospitals and to health care professionals.

The standard of care established is in accordance with the guidelines of the World Health Organization, Ministry of Health of Brazil and Medical Societies. Any modifications due to the patients' clinical condition or temporary hospital limitations must be discussed in a multidisciplinary tumor board.

Ideally, all surgical patients must be tested for COVID-19 approximately 48 hours before the schedule procedure. If it is positive, and there is no immediate risk, the procedure should be postponed for 2 or 3 weeks. If the procedure cannot be postponed and the COVID-19 test is positive, the operation must be done in an operating room with negative pressure, and all the surgical team, including the anesthesiologists, must use adequate Personal Protective Equipment (PPE): hair cover, protective coverall gown, glasses and/or face shields, N95 masks, double gloves and double shoe covers. COVID- 19 negative patients can be operated in a regular room, but the team must use complete PPE. Surgeons and the team must care about protection all the time, because numerous have died after contamination during surgical procedures. Because the aerosol production, the highest risk are during endonasal procedures, procedures using high-speed drills, any access to the upper aerodigestive tract (TORS, TOLS or even open procedures) and tracheostomies.

These recommendations on head and neck cancer management during COVID-19 pandemic in Brazil were developed by a committee of respected head and neck surgeons, with extensive experience in head and neck cancer surgery, leaders who work in some of the largest and most respected Brazilian institutions.

• REFERENCES

• Wang H, Zhang L. Risk of COVID-19 for patients with cancer. Lancet Oncol 2020; Apr; 21: e181 https://doi.org/10.1016/S1470-2045(20)30149-2