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\begin{document}

\title{Treating head and neck tumors during the SARS-CoV-2 epidemic, 2019-2020:
Sichuan Cancer Hospital}



\author[1]{Yong-Cong Cai, et al.}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Since December 2019, a number of patients with novel coronavirus
pneumonia (NCP) have been identified in Wuhan, Hubei Province, China.
NCP has rapidly spread to other provinces and cities in China and other
countries in the world. Due to the rapid increase in reported cases in
China and around the world, on January 30, 2020, the World Health
Organization (WHO) Emergency Committee announced that NCP is a Public
Health Emergency of International Concern (PHEIC). However, there are
relatively few suggestions and measures for tumor patients, especially
patients with head and neck tumors. This article summarizes the
prevention and control of disease in our medical institution to provide
a reference for front-line head and neck surgeons.{}%
\end{abstract}%



\sloppy


\textbf{Full author list}

Yong-Cong Cai, MD\textsuperscript{1}, Wei Wang, MD\textsuperscript{1},
Chao Li, MD, PHD\textsuperscript{1}, Din-fen Zeng\textsuperscript{1},
Yu-Qiu Zhou, MD\textsuperscript{1}, Rong-Hao Sun, MD\textsuperscript{1},
Hua Jiang\textsuperscript{1}, Hui Guo\textsuperscript{2}, Shao-Xin
Wang\textsuperscript{1}, Jian Jiang, MD\textsuperscript{1}

\textsuperscript{1.} Department of Head and Neck Surgery, Sichuan Cancer
Hospital \& Institute, Sichuan Cancer Center, School of Medicine,
University of Electronic Science and Technology of China, Chengdu,
610041, China.



\textbf{Introduction}

Since December 2019, a number of patients with novel coronavirus
pneumonia (International name, 2019 novel coronavirus disease
(COVID-19); China's domestic name, novel coronavirus pneumonia (NCP))
have been identified in Wuhan, Hubei Province, China {[}1, 2{]}. With
the spread of the epidemic, patients with NCP have been reported in many
cities in China as well as in many countries and regions around the
world, such as South Korea, Australia, the United States and Italy
{[}3-6{]}. Currently, the main source of infection is severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients.
People with asymptomatic infection may also become a source of
infection. Airborne droplets and contact are the main routes of
transmission {[}7{]}. As of 9 am on March 25, 2020, there were 81850
confirmed cases in China and 3287 cumulative deaths; there were 339081
confirmed cases and 15487 cumulative deaths in other countries.

One study summarized and analyzed the proportion of patients with NCP
with tumors and the prognosis of these patients, presenting the first
published clinical evidence of the risk level of patients with tumors in
the NCP epidemic {[}8{]}. Because of reduced immune function, patients
with tumors, especially those associated with chronic underlying
diseases, are susceptible populations for SARS-CoV-2 infection. For
patients with head and neck tumors, particularly those with laryngeal
cancer, hypopharyngeal cancer and thyroid tumors with dyspnea, prompt
surgical treatment or tracheotomy is needed. For these patients with
head and neck tumors, during the NCP epidemic, developing a treatment
plan is very important. The National Health Commission of the People's
Republic of China has also recently issued guidelines for the diagnosis
and treatment of this disease, and these guidelines have been revised
several times in the short time since the outbreak began, with the
latest being the sixth edition. However, there are relatively few
suggestions and measures for patients with tumors, especially those with
head and neck tumors. This article summarizes the prevention and control
of disease in our medical institution to provide a reference for
front-line head and neck surgeons.

\textbf{The situation of tumor patients during the epidemic:}

During the epidemic, patients with tumors have represented a very
special patient group. A study that specifically targeted 1,590 patients
with NCP with previous medical records in 575 hospitals found that there
were 18 patients with a history of cancer. Compared with NCP patients
without cancer, NCP patients with a history of cancer were older (63.1
vs. 48.7 years), and a higher proportion of NCP patients with cancer had
a history of smoking (22.2\% vs. 6.8\%), shortness of breath (47.1\% vs.
23.5\%) or severe symptoms according to computed tomography (CT) imaging
(94.4\% vs. 70.8\%). More importantly, the study found that patients
with tumors had a higher risk of developing severe disease than did
non-tumor patients. Moreover, for all comorbidities, patients with a
cancer history had the highest risk of severe disease. In addition,
researchers also found that tumor patients with NCP worsened faster than
did non-tumor patients (median time from onset to severe symptoms was 13
days vs 43 days, P\textless{}0.0001). Therefore, the research team
proposed three strategies for patients with tumors during the NCP
outbreak and other possible epidemics of severe infectious diseases in
the future: first, in endemic areas, for clinically stable patients with
tumors, delayed chemotherapy or elective surgery should be considered;
second, patients with tumors and cancer survivors should strengthen
their personal protection; and third, if patients with tumors are
infected with SARS-CoV-2, especially elderly patients or patients with
other comorbidities, extra monitoring or treatment should be provided
for priority treatment {[}8{]}.

\textbf{Organizational guarantee}

After the outbreak of NCP, our hospital attached great importance to and
implemented the corresponding prevention and control measures for
patients with head and neck tumors according to the characteristics of
these patients. The Department of Head and Neck Surgery quickly set up
an Emergency Incident Command Team (EICT). The members include the
department director, head nurse, medical and nursing team leaders,
infectious disease doctors, infectious disease nurse, and protective
material management nurse. The role of this group is to scientifically
analyze departmental epidemic situations, reasonably integrate existing
resources, develop appropriate infection management procedures and
systems that conform to the characteristics of this department, and
complete the rational allocation of personnel and materials to fully
control the dynamic situation in the department regarding epidemic
prevention and control. All staff was required to study the latest
diagnostic, treatment and preventive measures for NCP every week.

\textbf{3. Innovation in clinical procedures}

The primary measures for prevention and control during this epidemic are
to reduce the population flow and close contact among personnel,
effectively cut off the infection transmission routes, avoid the
occurrence of new NCP cases, and allow prompt and effective quarantine
and treatment for people with suspected and confirmed infection.
However, due to the establishment of fever clinics or the admission and
treatment of suspected cases, hospitals are also the hardest hit areas
by cross-infection. For general hospitals, some non-fatal chronic
diseases can be handled by reducing or stopping outpatient and inpatient
treatment. General hospitals should focus on treating patients with
critical severe diseases. For specialized cancer hospitals, the annual
death toll due to cancer is much higher than the annual death toll from
all currently known infectious diseases, and tumor patients with immune
dysfunction are more prone to concurrent infection during the epidemic,
leading to fatal complications. Therefore, according to the
characteristics of our specialized cancer hospital and the epidemic
situation, we set up a three-level triage system in the clinics, changed
the layout and environment of the existing department structure, and
carried out path-based screening for ward admission(Fig1).

\par\null\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/2020/2020}

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\textbf{3.1 Establishing a triage area in the} \textbf{fever clinic for
tumor patients} Our hospitals has effectively separated tumor patients
with suspected NCP from tumor patients with fever of unknown origin,
promoted the use of masks by anyone visiting the hospital and enhanced
community respiratory protection awareness through WeChat, official
accounts, official websites and other online media.

\textbf{3.2 Implementing the} \textbf{three-level triage system in the
emergency department and clinics}

\textbf{First-level triage} : The clinics and emergency department were
in charge of triage, which was completely separated from the general
counseling station. The essential materials (surgical masks, handheld
thermometers, hand sanitizer, etc.) were prepared at the triage sites,
and the basic information for the triaged patients (basic information,
epidemiological history) was recorded. The epidemiological history, such
as the travel history to the epidemic areas or close contact with
patients with suspected NCP, was inquired, and the body temperature was
measured. Once patients with fever or patients with an epidemiological
history were identified, patients and any accompanying persons were
immediately given and guided to wear surgical masks. The patient was
transferred to the fever clinic by the triage nurse.

\textbf{Second-level triage} : When treating patients, the medical
personnel in each diagnostic area of the clinics re-checked the patients
and their families regarding their epidemiological history, such as
travel history to epidemic areas or close contact with patients with
suspected NCP, and recorded vital signs, such as body temperature,
pulse, respiration, etc.

\textbf{Third-level triage} : The clinic and emergency physicians asked
patients detailed questions regarding fever and cough and obtained
further epidemiological history information and asked the patients to
sign the ''Integrity Commitment regarding the Epidemiological History
with Novel Coronavirus Pneumonia''.

\textbf{3.3} \textbf{Actively control the frequency of patient visits
and reduce population aggregation and population flow} The risks and
recommendations for the diagnosis and treatment of patients with head
and neck tumors during the prevention and control of the NCP epidemic
were announced through multiple channels, such as the hospital's
official account and official website and various WeChat groups for
continuing nursing care. An appointment system was implemented to limit
outpatient numbers and reduce outpatient visits. Additionally, online
specialist consultations were set up, and an online platform was used to
establish an integrative medical and healthcare team for online
consultation.

\textbf{4. Reformation of the layout of the department structure}

During the NCP outbreak, the Department of Head and Neck Surgery
implemented closed-loop one-way entry and exit management on the basis
of existing infrastructure on the ward: entrances and exits signs were
clearly set up in the elevator hall entering the ward, and dedicated
personnel maintained order and conducted personnel registration and
screening. Only one patient was admitted to each room, with up to one
accompanying person, and visitations were declined. Medical staff during
hospitalization were relatively fixed, and medical personnel and
patients were fully protected. Three quarantine wards were set up to
facilitate the in situ quarantine of suspected patients. A suspected
patient quarantine ward was set up in the inpatient unit in a relatively
independent space, which was a negative pressure ward.

\textbf{5. Principles of hospitalization treatment}

Patients received in-hospital treatment according to the following
principles: emergency and severe patients need to be treated first, and
non-emergency and mild patients can be treated later, taking into
account complications and underlying diseases; elective surgeries need
to be postponed; and the treating doctor needs to be contacted if a
patient's condition changes during routine follow-up. The speed and
quantity of admission were controlled to ensure the safety of patients
and medical personnel during the epidemic. For patients with benign head
and neck tumors or slow-progressing malignant tumors, such as low-risk
differentiated thyroid cancer, because the tumor will not progress
rapidly in the short term and cause serious complications, the
in-hospital treatment of such patients has been postponed until the
epidemic stabilizes.

\textbf{6.} \textbf{Preparation for admission and screening}

After the outpatient doctor completed the third-level triage and issued
the admission orders, an appointment was scheduled. In addition, a
network communication platform was established with the patients or
their families, and the network communication lists for patients
admitted to the Department of Head and Neck were distributed to the
patients and their families. Network screening of the preadmission
epidemic situation was performed. Additionally, a complete blood count
was conducted, and chest CT examinations were performed if necessary. At
the time of admission, each patient's body temperature was checked at
the entrance of the surgical building. If the body temperature was
normal, patients were admitted to the head and neck surgical unit. Body
temperature was screened again at the entrance of the unit by the
nurses, who used secondary protective measures. Body temperature was
measured with an electronic thermometer, the close contact history with
NCP patients was obtained, the patient and any accompanying persons
signed the ''Integrity Commitment regarding Patient and Family
Epidemiological History with Novel Coronavirus Pneumonia'', and the
patient and any accompanying persons completes the sign-in sheets. If
there were no abnormalities, patients went to the nurse station to
complete the admission procedure. In addition to regular basic and
specialist assessments, the patients were mainly assessed for
respiratory function and past respiratory disease history.

\textbf{Preoperative examination}

The doctor in charge prescribed blood tests and chest CT, as they are
mandatory examinations for the NCP epidemic. The staff made a joint
appointment and provided the date to the patient. The patient entered
the unit and the surgical building with an examination reservation sheet
and a wristband. Nurses assessed patient self-care and managerial
abilities. If there were no abnormalities, under normal circumstances,
patients could only be accompanied by the accompanying person when
agreement for the endoscopic examination had to be signed by a family
member, and the accompanying person wore an accompanying badge and
wristband. The purpose of these measure was to control population flow
in the medical technology department area and reduce the number of
cross-infections.

\textbf{Surgical patients}

Operations were performed only when normal results according to
evaluations by the Head and Neck Surgery Center, Internal Medicine
Center and Anesthesiology Center could be achieved. The patient was
admitted to the operating room under the following conditions: with a
chest CT scan within the prior 7 days, having signed the ''Integrity
Commitment regarding the Epidemiological History with Novel Coronavirus
Pneumonia'', wearing a mask, and having a surgical information sheet
indicating vital signs. Postoperative vital signs were closely
monitored, and the risks of exposure to NCP were strictly assessed.
Patients were encouraged to get out of bed as soon as possible after
surgery, with precise nutrition management.

\textbf{Postoperative multidimensional integrative medical care at home}

During the NCP epidemic, tumor patients at home still have different
degrees of risks of immune dysfunction and susceptibility to infection
during the postoperative rehabilitation period. We not only pay
attention to the prevention and control of virus infection of inpatients
and the NCP epidemic in the hospital but also provide at-home
psychological support and care related to NCP to patients with tumors.
Through a nursing WeChat platform and a third-party online platform, we
implemented integrative medical care at home and sent notifications
regarding information about protection against NCP for patients with
tumors.

\textbf{Reexamination and follow-up of patients with head and neck
tumors}

For the follow-up of patients during the NCP epidemic, online follow-up
or follow-up by telephone is preferred to reduce population flow and
cross-infection. For patients with differentiated thyroid cancer and
other diseases with relatively slow progression and patients recovered
at the 1-year follow-up, the follow-up time was extended to 1-3 months.
For patients who must complete follow-up, neighborhood community
hospitals are recommended for the necessary examinations, and guidance
is provided after the examination results are provided online. During
follow-up, medical staff is in charge of both anticancer and
antiepidemic responsibilities. In addition to inquiring about
cancer-related information, the medical staff must also provide health
guidance related to epidemic prevention.

From February 1 to March 10,2020, during the epidemic of new coronavirus
infection, our head and neck surgery center completed 97 operations,
including 86 for thyroid cancer ,5 for oral cancer (4 for free flap
reconstruction and 4 for tracheotomy),2 for parotid gland ,1 for
squamous cell carcinoma of the scalp ,2 for cervical lymph node biopsy
and 1 for laryngeal cancer. Seven patients had postoperative fever, the
highest body temperature was 39\selectlanguage{ngerman}°, and all patients returned to normal
body temperature on the third day after operation; A case of thyroid
cancer patients with fever on the first day after operation with cough
symptoms, the lung CT did not rule out a new type of coronavirus
infection, so a new type of coronavirus test, two consecutive tests were
negative, the patient's body temperature returned to normal on the third
day after operation.All patients were followed up 2 weeks after
operation, without fever symptoms, and all doctors and nurses had no
fever symptoms.

\textbf{Summary}

It is very rare for head and neck surgery departments in cancer
hospitals to face sudden epidemic situations, such as the NCP epidemic.
There are relatively few clinical prevention and control measures and
nursing experience, which causes enormous challenges regarding
diagnosis, treatment and nursing in the Department of Head and Neck
Surgery. Individualized diagnosis and treatment and care should be
carried out according to the characteristics of the tumor. For
examinations, treatment and nursing care involving the mouth, care
should be taken regarding the personal protection of medical personnel.
Therefore, under the premise of raising awareness of epidemic prevention
and control in the whole hospital, the source of infection should be
controlled, population aggregation and population flow need to be
reduced, disinfection and isolation measures need to be strictly
enforced, and the transmission routes need to be effectively cut off,
thereby minimizing and eliminating cross-infection among doctors,
nurses, and patients. Under the premise of the prevention and control of
the epidemic, we also should focus on humanity, performing
epidemiological monitoring and postoperative rehabilitation care for
patients and their families. We believe that through the efforts of
everyone, we will be able to overcome this virus and overcome cancer.

\textbf{Conflict Of Interest} We have no conflict of interest.

\textbf{Funding} None

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