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\begin{document}

\title{Considerations for Head and Neck Oncology Practices During the
Coronavirus Disease 2019 (COVID-19) Pandemic: The Wuhan and Toronto
Experience}



\author[1]{Antoine Eskander, MD, ScM}%
\affil[1]{Sunnybrook Health Sciences Centre}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
The practices of head and neck surgical oncologists must evolve to meet
the unprecedented needs placed on our healthcare system by the
Coronavirus Disease 2019 (COVID-19) pandemic. Guidelines are emerging to
help guide the provision of head and neck cancer care, though in
practice, it can be challenging to operationalize such recommendations.
Head and neck surgeons at Wuhan University faced significant challenges
in providing care for their patients. Similar challenges were faced by
the University of Toronto during the severe acute respiratory syndrome
(SARS) pandemic in 2003. Herein, we outline our combined experience and
key practical considerations for maintaining an oncology service in the
midst of a pandemic.%
\end{abstract}%



\sloppy


Vincent Wu MD1*, Christopher W. Noel MD1,2*, David Forner MD2,3*,
Zhi-Jian Zhang MD PhD 4 , Kevin M. Higgins MD MSc 1 , Danny J.
Enepekides MD MPH 1 , John M. Lee MD MSc 1 , Ian J. Witterick MD MSc 1 ,
John J. Kim MD 5 , John N. Waldron MD MSc 5 , Jonathan C. Irish MD MSc 1
, Qing-Quan Hua MD PhD 4 , Antoine Eskander MD ScM1,2 1

\par\null

Department of Otolaryngology -- Head and Neck Surgery, University of
Toronto, Toronto, Canada; 2 Institute of Health Policy, Management and
Evaluation, University of Toronto, Toronto, Canada; 3Division of
Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax,
Canada; 4Department of Otolaryngology -- Head and Neck Surgery, Renmin
Hospital of Wuhan University, Wuhan, China 5Radiation Medicine Program,
Princess Margaret Cancer Centre, University Health Network and
Department of Radiation Oncology, University of Toronto, Toronto, Canada
*equal contribution

Corresponding Author:

Dr. Antoine Eskander

Sunnybrook Health Sciences Centre

2075 Bayview Ave., Room M1 102

Toronto, Ontario M4N 3M5, Canada

(\href{mailto:antoine.eskander@mail.utoronto.ca}{\nolinkurl{antoine.eskander@mail.utoronto.ca}})

Conflict of Interest and Funding: None

Disclosures: None

Word Count: 2787

\par\null

Introduction

Coronavirus Disease 2019 (COVID-19), caused by the SARS-CoV-2 virus,
emerged in December 2019 with an initial epicentre focused in Wuhan,
China. As of April 9, 2020, the COVID-19 pandemic has infected over
1,500,000 people worldwide and resulted in nearly 90,000
deaths\textsuperscript{1}. The COVID-19 pandemic carried profound
implications on the head and neck oncology practice in Wuhan and is a
rapidly emerging concern in Canada. Projections vary, though the
Canadian federal government estimates that between 30 and 70 percent of
Canadians could become infected with coronavirus\textsuperscript{2}.
Toronto's experience with severe acute respiratory syndrome (SARS) in
2003 highlighted the dangers of inadequate preparation and protocols
when faced with a novel and dangerous coronavirus\textsuperscript{3,4}.
Rapid nosocomial spread of SARS led Toronto to become one of the most
impacted regions in the world\textsuperscript{3,4}. Fortunately, from
this experience, significant institutional memory exists within the
University of Toronto partner hospitals\textsuperscript{5}. Our
healthcare systems are better prepared for, and are uniquely positioned
to comment on, the challenges faced with COVID-19.

In order to meet the unprecedented needs facing healthcare systems
across the world, head and neck surgeons must evolve and modify the care
provided to patients in the midst of this pandemic. The Canadian
Association of Head \& Neck Surgical Oncology (CAHNSO) has recently
published thoughtful guidelines for the management of patients with head
and neck cancer during COVID-19 \textsuperscript{6}. In combination with
other guidelines and expert opinions, suggestions on how to proceed with
our patients are accumulating for COVID-19 \textsuperscript{7-9}.
Ontario Health (Cancer Care Ontario) developed pandemic clinical
practice guidelines in 2009 which have been recently updated to reflect
the province's strategy for COVID-19 \textsuperscript{10,11}. A priority
classification system is currently used to triage resources to oncology
patients with the greatest needs. Most head and neck cancer care remains
at the highest level of priority, and the need to provide ongoing head
and neck oncology care remains clear. However, application and
operationalization of these various guidelines can differ across
institutions and real-world experience is needed. This paper describes
the regional institutional practices in Toronto, Canada and Wuhan,
China, and how we have operationalized such guidelines. We outline key
practice considerations for personal protective equipment (PPE),
triaging and decision-making for new referrals, ongoing surgical care,
and follow-up practices from the perspective of two large cancer
institutions with experiences in pandemic management.

Prevention of Transmission

Early reports from Wuhan, China noted that Otolaryngologist -- Head and
Neck Surgeons were at a disproportionately increased risk of infection.
In the early stages, transmission during a single skull base case at a
partner hospital in Wuhan resulted in widespread transmission amongst
surgeons and healthcare workers, resulting in several deaths including
some senior colleagues (personal communication). Recently, hospitals in
British Columbia, Canada have also reported several Otolaryngologists
being infected with COVID-19 after performing endoscopic sinus surgery
before appropriate PPE guidelines were established (personal
communication).

The SARS-CoV-2 viral particles have been reported to be highly
concentrated within the nasal cavity, nasopharynx, and
oropharynx\textsuperscript{12}. Given the scope of Otolaryngology --
Head and Neck Surgery, there is the concern for aerosolization of viral
particles during procedures that include flexible
nasopharyngolaryngoscopy, transoral examination, sinonasal surgery,
airway surgery, and major head and neck surgery\textsuperscript{13}.

The use of PPE is paramount given that head and neck procedures and
examinations are performed on the upper aerodigestive tract, where high
viral loads are encountered\textsuperscript{12}. Stemming from the Wuhan
experience in combating COVID-19, specific recommendations were made
with regards to workflow and PPE for Otolaryngology -- Head and Neck
Surgery\textsuperscript{14}. National and international societies are
drawing attention to this issue with groups like the Australian Society
for Otolaryngology -- Head and Neck Surgery, and the British Association
of Otorhinolaryngology recently releasing guideline
statements\textsuperscript{15,16}. Recently, guidelines on proper PPE
usages were also released by the Canadian Society of Otolaryngology --
Head and Neck Surgery\textsuperscript{17}.

While we will not repeat all guideline recommendations here, clearly a
high degree of caution should be exercised when performing procedures
that enter the nasal cavity, oral cavity, larynx, or pharynx.
Indications for endoscopy must be made clear, as to avoid any
unnecessary procedures, and to minimize exposure to head and neck
surgeons. In many clinical scenarios, endoscopy can be delayed or
avoided in the pandemic setting with increased reliance on history,
other physical examination maneuvers, and imaging. In Wuhan, airborne
precautions were taken during all head and neck examinations. To protect
healthcare providers, the Canadian Society of Otolaryngology -- Head and
Neck Surgery has stated that airborne precautions should be taken for
all aerosolizing procedures including, but not limited to, the use of
N95 respirators, face shields or goggles, gloves, gowns, disposable
medical caps, and shoe covers\textsuperscript{17}. In cases of limited
PPE, avoidance or deferral of full physical examination may be
warranted.

In the setting of increasing PPE demands and dwindling medical supplies,
measures have been instituted to ensure provision of essential equipment
to medical personnel. In Toronto, this has included repurposing research
labs and equipment such as 3D printers in order to print and manufacture
PPE, such as face-shields, along with nasopharyngeal swabs for viral
testing.

In a further effort to conserve PPE and minimize exposure, the number of
individuals inside operating rooms have been reduced to the bare minimum
required for completion of cases and additional monitoring methods have
been implemented. We have restricted access to the operating room to a
single entry and exit point. A nurse observes all donning and doffing of
PPE while providing support and instructions to ensure high quality and
compliance. Moreover, there are no trainees in the room for portions of
the procedure that may lead to aerosolized exposure. For instance, if a
patient is undergoing an oral cavity resection and neck dissection, the
neck dissection is performed first with involvement of trainees, while
the oral cavity resection is performed separately with only staff
physicians in the room. As an additional measure, within the University
of Toronto hospitals, we are currently saving N95 masks. Efforts have
been put towards developing a process for N95 mask re-sterilization
utilizing equipment similar to other centres in the US, though this is
not yet needed nor standardized across Ontario\textsuperscript{18,19}.

Triaging New Referrals

Ontario has one of the most mature and regionalized head and neck cancer
programs in the world, with all care being provided at one of seven
designated cancer centres\textsuperscript{20-23}. To meet the needs of
this pandemic, both Wuhan and Toronto initiated a centralized system
within their regionalized cancer centres for the intake of new
referrals. For example, all new referrals to Sunnybrook Health Sciences
Odette Cancer Centre in Toronto are now first virtually reviewed by a
team consisting of medical, radiation, and surgical oncologists.
Together, the determination is made in regard to any additional testing
required prior to patient consultation. If at all possible, patients are
seen virtually via the Ontario Telehealth Network (OTN), which allows
for two or three-way audio with video support, allowing family members
to be present, even if not physically with the patient. This is
particularly important within our elderly population, minimizing social
contacts, while maintaining physical distancing. The virtual interaction
through OTN is particularly useful if the physical examination will not
change the next steps in management (i.e. pathology review, discussion
of treatment options, or where the need for additional imaging and
testing remains). This step allows for the collection of information
from patients, while reducing the risk of exposure with face-to-face
consultations, and has been shown to be an effective avenue for patient
care\textsuperscript{24}. In circumstances that necessitates in person
consultation, such as the need for biopsy, patients are seen in person.

Multidisciplinary care is a staple in the effective management of head
and neck cancer patients. All patients continue to be discussed weekly
through case conferences where staff discuss remotely. Where alterations
to the standard of care are necessary based on healthcare constraints,
there is increased discussions within the multidisciplinary care team to
determine best treatment course, and full disclosures with the patients
are provided. In Toronto, multidisciplinary clinics remain active with
all essential multidisciplinary allied healthcare professionals present,
including speech-language pathology, social work, physiotherapy,
dietetics and nutrition services, and all-relevant oncology specialties.
We have successfully incorporated our multidisciplinary team in OTN
consultations and in-person follow-up are offered under necessary
circumstances as outlined above.

As surgical waitlists grow in the face of reduced operating room
resources, formalized systems for reviewing patients are necessary to
create a dynamic list that is able to accommodate changing disease
progression and patient needs. For example, a centralized list is being
used at Sunnybrook Health Sciences Centre to contact and monitor
patients on a regular basis, while providing them with ongoing
reassurance.

Ongoing Care and Post-Treatment Surveillance

With regards to ongoing care for head and neck oncology patients,
follow-ups are arranged virtually over OTN or via telephone whenever
possible. In-person follow ups are reserved for specific indications,
including patients who develop new or concerning symptoms, those that
require a biopsy or procedure (i.e. new oral lesion that needs biopsy,
new voice symptoms, or needs endoscopic examination), and rarely patient
preference/desire. Currently, a rotating schedule has been implemented
for head and neck surgeons at several hospitals in Toronto, for
evaluation of follow-up patients. For instance, at the Sunnybrook Health
Sciences Odette Cancer Centre, a three-week rotation has been put into
practice for the three head and neck surgeons. With such a schedule,
surgeons are all personally socially distanced from one another,
protecting the capacity for ongoing patient care in cases of illness or
need for formal quarantine.

Pre-Operative Screening

Patients scheduled to undergo head and neck oncological surgery in
Wuhan, China were asked to self-isolate for a period of 14 days prior to
the operation date. Screening was performed for symptoms of COVID-19 and
patients were required to have two negative viral swabs on polymerase
chain reaction (PCR) prior to the surgery. At the University of Toronto,
varied practices are being used across hospitals, but all are
extensively focused on screening for symptoms of COVID-19. Several
hospitals are ensuring patients undergoing surgery have at least one
negative viral swab (PCR testing) prior to the operation. It must be
noted, however, that a risk of transmission remains despite negative
testing, as the sensitivity of PCR by viral swab (\textasciitilde{}70\%)
is imperfect\textsuperscript{25-27}. Head and neck surgeons must
therefore consider the continued use of appropriate PPE despite negative
testing. With all operative cases, it is imperative to balance the
benefits of surgery against the risks during this pandemic for each
individual patient.

Close consideration of baseline functional status and the presence of
comorbidities remains important in surgical decision making. Head and
neck cancer patients are often male, elderly, and
frail\textsuperscript{28}. These considerations increase susceptibility
to post-operative complications and are additionally associated with
both increased risk of COVID-19 diagnosis and
adverse\textsuperscript{28-31}. At the Renmin Hospital of Wuhan
University, mortality rates for patients who were unintentionally
scheduled for elective surgery during the COVID-19 incubation period
exceeded 20\%, with 44\% requiring intensive care unit
admission\textsuperscript{29}. Risks are further amplified as patients
with cancer are disproportionately affected by COVID-19, having over two
times higher odds of being diagnosed with the
infection\textsuperscript{32}, and over five times higher odds of
experiencing severe adverse events\textsuperscript{33}.

Surgical Management

The timeline and duration of COVID-19 is uncertain, and consequently,
triaging surgical cases poses an enormous challenge. Both the CAHNSO as
well as Wuhan University have held the view that surgical management
should be offered when a worse outcome is expected should surgery be
delayed more than 2-6 weeks. In practice this means operating largely on
patients with advanced mucosal disease, high grade salivary malignancy
with rapid progression, advanced melanoma, and other pathologies where
surgery could be potentially curative. Salvage surgery is being
approached with great caution given the poor oncologic results and
necessity to limit institutional resource use where
possible\textsuperscript{34,35}. The Stanford University group have
recently outlined their stratification of urgency according to disease
process and show general agreement with these
suggestions\textsuperscript{36}.

Within the operating room, significant thought has been put towards
minimizing exposure and conserving PPE. Resident trainees are either not
involved in cases or are brought in only for portions of the procedure
appropriate for their level of training. In head and neck oncology,
clinical equipoise often exists between various treatment modalities. In
an effort to limit operating room use and build intensive care unit
capacity, for patients who could expect equivalent results for radiation
or surgery, the former is preferred. An example is early stage glottic
cancer, where transoral laser microsurgery has traditionally been
discussed as a treatment option. As this is a high-risk aerosol
generating procedure, with similar oncologic outcomes to primary
radiotherapy, the latter is being preferentially used. Head and neck
cancer sites must also consider the potential future need for primary
radiation in the treatment of oral cancer. However, each patient must be
managed on a case-by-case basis, while considering other possible side
effects, such as chemotherapy and radiation induced immunosuppression.

Where surgery is required, we use a pre-huddle outside the operating
room prior to patient arrival that includes all team members. All
necessary surgical and anesthetic equipment is confirmed so that
circulating nurses do not have to enter and leave the room. Surgical
teams remain outside of the operating room during intubation and
extubation. At our institution in Toronto, in keeping with two cycles of
operating room air clearance, this equates to a 20-minute wait for each
intubation and extubation event. Given the nature of many oncological
procedures, the surgical team must remain vigilant, and accurate
communication between the anesthetic, nursing, and surgical teams is
paramount.

Reconstructive options should be further considered in the pandemic
setting, both as a function of the need for prophylactic tracheostomies
and as a consideration for reducing the total intraoperative time. Where
feasible, in Toronto, we currently consider transitioning to regional
flap reconstruction or delaying reconstruction altogether. Free flaps
are still required but are used judiciously. Patients should be
counselled about these management decisions, their risks, and future
steps to correct any unsatisfactory outcomes, such as tethering.

The use of secondary intention may, in select circumstances,
additionally negate the need for up-front tracheostomy and assists in
reducing the overall length of the procedure. We recognize in certain
cases this is not possible, and individual patient safety must be
weighed, as well as the risk of increased aerosolization should an
uncontrolled airway intervention be required. Our institutions have also
elected to reduce manipulation of tracheostomies as much as possible.
The use of non-fenestrated cannulas, delay of tracheostomy tube changes,
and corking of deflated, cuffed tubes have been employed to facilitate
this goal\textsuperscript{37,38}.

From an adjuvant therapy perspective, both the radiation oncology and
medical oncology services across Toronto hospitals are adapting their
practices to help mitigate risk to head and neck cancer patients in the
wake of COVID-19. For instance, there has been increased consideration
placed towards hypofractionated or accelerated radiation schema, as well
as weekly outpatient cisplatin regimens for select cases; both with the
goal of reducing hospital visits. In cases where a regionalized cancer
centre in Ontario is no longer able to safely offer cancer services,
protocols are in place to transition care to another provincial care
centre.

Summary

In 2003, SARS was immediately devastating to cancer care in both Canada
and China. In Ontario, SARS resulted in many hospitals being closed for
6 weeks, leading to treatment delays and even longer wait times in an
already strained system. With this crisis, however, came the opportunity
to better cancer care delivery. The SARS pandemic highlighted the
shortcomings of Ontario's public health system and helped catalyze
initiatives to improve health care accessibility including
regionalization of head and neck cancer care and the establishment of
quality metrics\textsuperscript{39}. Periods of immense stress on the
health care system can ultimately drive system improvement. They are
also periods of reflection on the capacity of a sometimes already
stretched system. In Ontario, operating room use, and hospital
occupancy, is generally high and reliant on efficient through-put.
However, pre-COVID-19 there was very little allowance for large
aberrations in volumes. With a large decrease in hospital capacity and
operating room resources, surgical delays and rationing have been
required.

In the interim, the abovementioned modifications enable head and neck
oncology services to continue in the wake of COVID-19, albeit in a
subset of patients such as those at greatest risk of progression due to
high grade disease. Meeting the system capacity needs of COVID-19 must
be balanced with the oncology risk to our patients -- both present and
future. Despite providing continued care for select, high risk patients,
there is an ongoing accumulation of cases that will strain the
healthcare system after resources again become available. Learning from
past experiences and colleagues at the epicentre of the current
pandemic, we present here institutional considerations that reflect the
multitude of developing guidelines.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Table 1:} Challenges faced by head and neck oncologic practices
in the wake of COVID-19 and associated recommendations & \textbf{Table
1:} Challenges faced by head and neck oncologic practices in the wake of
COVID-19 and associated recommendations\tabularnewline
\textbf{Prevention of Transmission} & Avoidance of unnecessary
procedures and physical exams; Full PPE for all aerosolizing
procedures.\tabularnewline
\textbf{Triaging New Patient Referrals} & Virtual multidisciplinary
screening prior to patient assessment; Virtual case conference
discussion; In-person consultations limited to instances where
procedure/physical examination is essential.\tabularnewline
\textbf{Ongoing Care/Post Treatment Surveillance} & Virtual follow-up
care whenever possible; In-person assessment by a small group of
rotating providers.\tabularnewline
\textbf{Pre-Operative Screening} & Patient to self-isolate prior to
surgery; In COVID-19 positive patient, surgery only in emergent cases;
In COVID-19 unknown/negative patients, testing should be sought
immediately prior to surgery.\tabularnewline
\textbf{Surgical Management} & In certain instances, treatment with
primary (chemo)radiation over surgery may be preferred; Surgical
management only in instances where worse oncologic outcome expected if
delayed more than four weeks; Limiting operating room personnel to
essential team members; Minimization of team member movement in and out
of operating room during all surgical cases; Reconstructive options
should be considered in the context of a pandemic setting and limited
resources; Surgical team can consider staying immediately outside of
operating room during intubation/extubation.\tabularnewline
\bottomrule
\end{longtable}



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