Introduction
With the arrival of the coronavirus disease (SARS-CoV-2) in the U.S.,
care practice paradigms have drastically changed. Social-distancing
remains the most effective way to limit disease spread as the cases of
SARS-CoV-2 continues to rise with no available vaccine or
treatment1. This has resulted in the cancellation of
multiple clinics and delay of procedures to limit the spread of the
virus. For cancer patients who already have decreased immunity, data
from China suggests the new virus poses additional risks as case
fatality of patients with cancer was higher at 5.6% compared to 2.3%
of the general population2. Another case study found
that patients who had undergone anti-tumor therapy within 14 days of
SARS-CoV-2 diagnosis had an increased risk of developing severe events
and poorer outcomes3. Liang et al. proposed three
major strategies to address care for patients with cancer in this
SARS-CoV-2 pandemic with postponing treatment for those with stable
cancer, increasing personal protection provisions for cancer patients,
and increasing monitoring if a patient becomes infected with
SARS-CoV-24.
In regards to postponing treatment, the National Comprehensive Cancer
Network has released broad guidelines stating that for patients with
solid tumors, adjuvant therapy with curative intent should proceed,
despite the threat of SARS-CoV-2 infection during
treatment5. The American College of Surgeons has also
released guidance for the triage of non-emergent surgical procedures,
recognizing that some elective cases intend to treat diseases that
progress at variable, disease-specific rates and thus must
proceed6. Otolaryngology specific safety guidelines
have delineated high risk procedures as those working with exposed
airway and mucosal surfaces that may generate
aerosols7. Thus, prior to any surgical procedure, the
SARS-CoV-2 status of a patient should be assessed with a discussion for
delay of surgery if the patient is positive. With the current shortage
of personal protective equipment and the need to reduce infection
spread, institutions have developed processes to stratify the urgency of
head and neck cases, delaying certain cases based on evidence from
studies on prolonged time to treatment initiation. These treatment
decisions aim to balance the unknown risk of infection to the patient,
exposure of the health care workers and use of valuable personal
protective equipment with the progression of cancer that may increase in
mortality and likelihood of recurrence with delay. Studies have noted a
poorer overall survival is associated with an extended period between
diagnosis to initiation of treatment with delay thresholds ranging from
20 to 120 days8. Psychiatric vulnerabilities in
certain cancer patients may also be exposed with extended wait
times9. However, with the realities of the lack of
personal protective equipment and the need to redirected staff to
SARS-CoV-2 patients, there is a move toward delaying non-urgent cases.
With the uncertainties of the SARS-CoV-2 pandemic and a head and neck
cancer (HNC) diagnosis, the potential mental health consequences of such
delays to treatment warrant further discussion.
HNC patients suffer from unique challenges, as much of social
functioning depends on the structural and functional integrity of the
head and neck region. Disease process and treatment can significantly
alter this. Psychological distress is also particularly prevalent in HNC
patients as nearly 35% of patients suffer from symptoms of depression
and anxiety10. Now, with the added complications of
the SARS-CoV-2 pandemic, restrictions on movement may increase patients’
stress, depression, and fear11. In this present
commentary, we discuss the unique mental health challenges and burdens
of HNC patients in the times of the SARS-CoV-2 pandemic and approaches
to mitigate these stressors through telemedicine to reduce future
burdens to the patient and the health care system.