Discussion
Once a patient is diagnosed with HNC, they enter into the continuum of cancer survivorship. A patient is deemed a cancer survivor from the moment of diagnosis. This terminology encourages providers and patients to consider the impact of diagnosis and treatment earlier as multiple studies have highlighted the unique experience of HNC patients as they progress through changes in swallowing, speech, and nutrition12. These factors have been studied as a part of quality of life measures which highlight the importance of not only cancer survival, but also a patient’s experience of life after diagnosis. It is critical to consider these factors in the context of the SARS-CoV-2 pandemic.
HNC patients have reported feelings of isolation with a lack of social support following diagnosis13. The high morbidity and mortality associated with HNC along with stigma associated with the facial disfigurement following treatment can result in decreased quality of life (QOL) that may affect survival14. HNC patients at three Veterans’ Affairs Hospitals reported QOL scores in pain, eating, and speech domains which were associated with survival15. A prospective study on HNC patients found QOL scores were associated with short-term, moderate, and long-term survival. Long-term survivors demonstrated the best QOL trajectory at 12 months following diagnosis, specifically in the domains of eating and speech16. Both studies showed no association of emotional scores with overall survival. However, there has been evidence that mental adjustment responses with either a “fighting spirit” versus hopelessness is an important prognostic factor in determining both death and recurrence17. The association between QOL and survival remains complex and requires continued exploration as cancer survivor numbers continue to increase18.
In addition to patient experience, the role of cancer specific characteristics and the patient’s biological biomarkers have been investigated for its relation to QOL and mental health. For patients with human papillomavirus (HPV)-positive oral cavity and oropharyngeal cancers, there was a larger decrease in QOL from pretreatment to immediate posttreatment, suggesting that treatment intensity compared to non-HPV cancers may negatively affect QOL trajectories19. This significant decrease in QOL may also make HPV-positive patients more susceptible to mood disorders. An investigation into mental health insurance claims found that HNC patients had a higher prevalence of mental health diseases at 20.6%, higher than the national estimate at 17.9%. Following HNC diagnosis, the prevalence increased to 29.9%20. A separate study highlighted that the prevalence of a functional genetic polymorphism of the serotonin transporter gene was not significantly different between control depression patients and HNC depression patients who had completed treatment21. Of note, 19% of patients developed depression after undergoing concurrent chemoradiation, suggesting a strong interaction of treatment with depression. However, depression may arise at any time during the cancer survivorship continuum. For HNC patients in the United Kingdom, the pretreatment phase was noted to be a time of high anxiety and depression that was associated with a poor QOL22.
The burden of HNC diagnoses can extend beyond a mental challenge for patients. Caring for HNC patients can be a grand task as caregivers help patients navigate the complex follow-up appointments and changes in abilities to communicate and eat. HNC treatment can also result in poor outcomes for the caregiver, highlighting a need for caregiver interventions23. An additional financial burden is also placed on the patient and caregivers as Massa et. al noted a higher median annual medical expense and relative out-of-pocket expenses for patients with HNCs when compared to other cancers. This higher financial burden is placed upon HNC survivors who are already more often members of a minority race/ethnicity, poor, and less educated with lower general and mental health status24.
With HNC patients already a vulnerable population, delaying treatment in the times of the SARS-CoV-2 pandemic can place additional strain on the mental health and quality of life of patients, resulting in future burdens on the health care system. It is critical to help patients maintain their quality of life through this pandemic as it may affect their overall outcomes of survival. Recognizing the psychological toll social isolation may place on the population, China provided multiple telemental health services that encompassed virtual counseling, training, and psychoeducation25. Online behavioral therapy for depression, anxiety, and insomnia along with multiple books with guidelines for public psychological self-help and counselling were accessible during the times of the SARS-CoV-2 pandemic26. In the U.S., the CMS has loosened telehealth guidelines, increasing the platforms on which physicians may communicate with patients, while the AAO-HNS has called for the adoption of telemedicine to decrease unnecessary exposure to both the patient and physician27,28. To improve survivorship experience, we encourage the use of such resources to address the cancer patient’s quality of life while institutions continue to triaging urgent surgeries to balance the risk of infection to HNC patients.