Introduction
We currently find ourselves in unprecedented times. The measures needed
to control the COVID-19 outbreak are directly at odds with providing
comprehensive cancer care. Across the world, people are being told to
stay home and severely limit their activities. But the treatment of head
and neck cancer requires multidisciplinary collaboration, which directly
translates to significant exposure and interactions with many different
people in hospital systems. Early data from the epidemic in China
suggest that a cancer diagnosis is a risk factor for severe events from
COVID-19, especially if the patient recently underwent chemotherapy or
surgery.1-4 Patients with cancer and iatrogenic immune
suppression for the treatment of other medical conditions are likely at
even greater risk of complications and death from viral infection.
Malignant tumors of the head and neck account for approximately 3% of
all cancers in the United States, with about 53,260 Americans expected
to be diagnosed in 2020.5 Prompt diagnosis and
treatment are critical for increasing survival and preserving organ
function and quality of life. A systematic review on time to diagnosis
or treatment in oral, pharyngeal, and laryngeal cancer patients found
higher stage and inferior survival with longer treatment
delays.6,7
During the current pandemic, any decision that could lead to airway
emergencies or more extensive surgeries in the near future has the
potential for putting health care providers at greater risk of COVID-19
exposure.8-10 Aerosol-generating procedures, including
tracheal intubation, tracheotomy, non-invasive ventilation, and manual
ventilation, are associated with increased risks of acute respiratory
infections among health care workers.11 Anecdotal
reports from Wuhan, China, report higher rates of infection specifically
among otolaryngologists.12-15 Personal protective
equipment (PPE) is a currently scarce but essential resource for the
aerosolizing procedures performed by otolaryngologists.
The decision to perform surgery for mucosal cancer is currently
difficult in all head and neck cancer patients, but particularly
complicated in patients with a secondary diagnosis or medical therapy
leading to an immunocompromised state, as their risk of infection with
SARS-CoV-2 is surely even more pronounced. A diagnosis of cancer in an
already immunocompromised patient is also a time-sensitive matter, as
impaired immunity can increase the growth and spread of a
cancer.16,17 Immunocompromised patients with COVID-19
are also thought to be more likely to have severe adverse events,
although the data are still limited.1,18 Combining the
two factors of a cancer diagnosis and an immune suppressed state
intensifies the gravity and complexity of the situation. We report two
presentations of head and neck cancer in immunocompromised patients in
the setting of this global pandemic and discuss our clinical rationale
for the different approaches taken in each case.