Care of immunocompromised patients with head and neck cancer during the COVID-19 pandemic: Two challenging and informative clinical cases

Learning through a Pandemic: The Current State of Knowledge on COVID-19 and Cancer

The ongoing coronavirus disease 2019 (COVID-19) pandemic has left patients with current or past history of cancer facing disparate consequences at every stage of the cancer trajectory. This comprehensive review offers a landscape analysis of the current state of the literature on COVID-19 and cancer, including the immune response to COVID-19, risk factors for severe disease, and impact of anticancer therapies. We also review the latest data on treatment of COVID-19 and vaccination safety and efficacy in patients with cancer, as well as the impact of the pandemic on cancer care, including the urgent need for rapid evidence generation and real-world study designs. SIGNIFICANCE: Patients with cancer have faced severe consequences at every stage of the cancer journey due to the COVID-19 pandemic. This comprehensive review offers a landscape analysis of the current state of the field regarding COVID-19 and cancer. We cover the immune response, risk factors for severe disease, and implications for vaccination in patients with cancer, as well as the impact of the COVID-19 pandemic on cancer care delivery. Overall, this review provides an in-depth summary of the key issues facing patients with cancer during this unprecedented health crisis.

Impact of the COVID-19 pandemic on cancer patients and psycho-oncology providers: Perspectives, observations, and experiences of the American Psychosocial Oncology Society (APOS) membership

OBJECTIVE

To understand: (1) psycho-oncology providersX2019; perspectives on and observations of the psychological responses of their cancer patients during the pandemic, and (2) psycho-oncology providersX2019; own experiences delivering care.

METHODS

In this concurrent mixed methods study, a survey was distributed to psychosocial providers who were members of the American Psychosocial Oncology Society (APOS). Survey respondents were invited to participate in a one-on-one audio-recorded interview via phone or secure ZoomX00AE;.

RESULTS

76 self-identified psycho-oncology providers responded to the survey and 11 participated in a one-on-one interview. Approximately half reported that patients responded in unique ways to COVID-19 stress relative to other populations. Three themes emerged from qualitative analyses: (1) unique burden on patients, (2) cancer patientsX2019; pandemic response and its relationship to their cancer experience, and (3) unexpected positive changes. Providers emphasized that the cancer experience may have prepared patients for the existential distress of the pandemic and described patientsX2019; resiliency. Two themes emerged regarding delivery of care: (1) new professional and personal challenges and (2) provider resiliency.

CONCLUSIONS

Although providers observed that the pandemic placed new burdens on patients, they emphasized that the cancer experience may have prepared patients for the existential distress of the pandemic and described patientsX2019; resiliency. To overcome challenges, psycho-oncology providers used innovative strategies to support patients and foster their own mental health. This article is protected by copyright. All rights reserved.

The Effects of COVID-19 on Cancer Care Provision: A Systematic Review

This systematic review aims to gather primary data from cancer institutions that have implemented changes to cancer service provision amid the COVID-19 outbreak to inform future intervention and health care facility response strategies. A comprehensive literature search was done on Global Health Medline and EMBASE using pertinent key words and MeSH terms relating to COVID-19 and Cancer service provision. A total of 72 articles were selected for inclusion in this systematic review. Following the narrative synthesis that was conducted of the literature, 6 core themes that encompassed common cancer service intervention adopted by institutions were identified: (1) Testing and Tracking, (2) Outreach and Communication, (3) Protection, (4) Social Distancing (5) Treatment Management, (6) Service Restructuring. Since cancer patients are a high-risk population amid the COVID-19 pandemic, these areas of targeted intervention can be used to inform necessary actions in institutions facing similar risks, based on previous learning from numerous cancer centers globally.

SARS-CoV-2 Infection in Cancer Patients: Effects on Disease Outcomes and Patient Prognosis

The severity of coronavirus disease 2019 (COVID-19) symptoms and outcomes vary immensely among patients. Predicting disease progression and managing disease symptoms is even more challenging in cancer patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cancer therapies, including chemotherapy, radiotherapy, and immunotherapy, often suppress the immune system, rendering cancer patients more susceptible to SARS-CoV-2 infection and the development of severe complications. However, data on the effects of immunosuppression on COVID-19 outcomes in cancer patients remain limited. Further investigations are warranted to better understand the implications of SARS-CoV-2 infection in cancer patients, particularly those that are immunocompromised. In this review, we outline the current knowledge of the effects of SARS-CoV-2 infection in cancer patients.

Head and Neck Practice in the COVID-19 Pandemics Today: A Rapid Systematic Review

Introduction  Head and neck specialists and otorhinolaryngologists are greatly exposed to coronavirus disease 2019 (COVID-19) transmission in their everyday praxis. Many articles are being published regarding medical staff protection and patient management during the pandemic. Objective  To provide an easy access to and a trustful review of the main aspects that have changed in the head and neck surgery and otorhinolaryngology practice due to the COVID-19 pandemic. Data Synthesis  The search terms used were: ( head and neck or otorhinolaryngology or ORL or thyroid ) AND ( severe acute respiratory syndrome coronavirus 2 [ SARS-COV-2] or COVID-19 or CORONAVIRUS ). The results were limited to the year of 2020. Articles were read in English, Portuguese, French, German, and Spanish or translated from Chinese. All included articles were read by at least two authors. Thirty-five articles were included. Most articles suggest postponing elective surgeries, with exception to cancer surgeries, which should be evaluated separately. Twenty-five articles recommended some kind of screening prior to surgery, using polymerase chain reaction (PCR) tests and epidemiological data. Extra precautions, such as use of personal protective equipment (PPE), are suggested for both tracheostomies and endoscopies. Fifteen articles give recommendation on how to use telemedicine. Conclusion  The use of PPE (N95 or powered air-purifying respirator [PAPR]) during procedures should be mandatory. Patients should be evaluated about their COVID-19 status before hospital admission. Cancer should be treated. Tracheostomy tube cuff should be inflated inside the tracheal incision. All COVID-19 precautions should be kept until there is a validated antiviral treatment or an available vaccine.

Penn Medicine Head and Neck Cancer Service Line COVID-19 management guidelines

INTRODUCTION

The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus has altered the health care environment for the management of head and neck cancers. The purpose of these guidelines is to provide direction during the pandemic for rational Head and Neck Cancer management in order to achieve a medically and ethically appropriate balance of risks and benefits.

METHODS

Creation of consensus document.

RESULTS

The process yielded a consensus statement among a wide range of practitioners involved in the management of patients with head and neck cancer in a multihospital tertiary care health system.

CONCLUSIONS

These guidelines support an ethical approach for the management of head and neck cancers during the COVID-19 epidemic consistent with both the local standard of care as well as the head and neck oncological literature.

Ethical surgical triage of patients with head and neck cancer during the COVID-19 pandemic

BACKGROUND

Coronavirus has serially overtaken our metropolitan hospitals. At peak, patients with acute respiratory distress syndrome may outnumber mechanical ventilators. In our Miami Hospital System, COVID-19 cases have multiplied for 4 weeks and elective surgery has been suspended.

METHODS

An Otolaryngologic Triage Committee was created to appropriately allocate resources to patients. Hospital ethicists provided support. Our tumor conference screened patients for nonsurgical options. Patients were tested twice for coronavirus before performing urgent contaminated operations. N95 masks and protective equipment were conserved when possible. Patients with low-grade cancers were advised to delay surgery, and other difficult decisions were made.

RESULTS

Hundreds of surgeries were canceled. Sixty-five cases screened over 3 weeks are tabulated. Physicians and patients expressed discomfort regarding perceived deviations from standards, but risk of COVID-19 exposure tempered these discussions.

CONCLUSIONS

We describe the use of actively managed surgical triage to fairly balance our patient's health with public health concerns.

False-positive reverse transcriptase polymerase chain reaction screening for SARS-CoV-2 in the setting of urgent head and neck surgery and otolaryngologic emergencies during the pandemic: Clinical implications

Background

No reports describe falsepositive reverse transcriptase polymerase chain reaction (RT‐PCR) for novel coronavirus in preoperative screening.

Methods

Preoperative patients had one or two nasopharyngeal swabs, depending on low or high risk of viral transmission. Positive tests were repeated.

Results

Forty‐three of 52 patients required two or more preoperative tests. Four (9.3%) had discrepant results (positive/negative). One of these left the coronavirus disease (COVID) unit against medical advice despite an orbital abscess, with unknown true disease status. The remaining 3 of 42 (7.1%) had negative repeat RT‐PCR. Although ultimately considered falsepositives, one was sent to a COVID unit postoperatively and two had urgent surgery delayed. Assuming negative repeat RT‐PCR, clear chest imaging, and lack of subsequent symptoms represent the “gold standard,” RT‐PCR specificity was 0.97.

Conclusions

If false positives are suspected, we recommend computed tomography (CT) of the chest and repeat RT‐PCR. Validated serum immunoglobulin testing may ultimately prove useful.

Care of immunocompromised patients with head and neck cancer during the COVID-19 pandemic: Two challenging and informative clinical cases

Background and Methods

There is an added level of complexity in the management of head and neck cancer patients with underlying immunosuppressive disorders during the COVID‐19 pandemic. Head and neck oncologists are tasked with balancing the dual risks of cancer progression in the setting of impaired tumor immunity and increased susceptibility to life‐threatening complications from exposure to viral infection for patients and providers. Through two cases of immunocompromised patients with newly diagnosed head and neck malignancies, we aim to provide guidance to clinicians struggling with how to best counsel and manage this unique subset of patients under these difficult circumstances.

Results

After careful consideration of the options, we took different approaches in the care of these two patients.

Conclusions

Ultimately, there is no uniform set of rules to apply to this heterogeneous group of immunocompromised patients. We provide some general principles to help guide patient management during the current pandemic.