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Welcome to this first in a series of CME/CE/CPE-certified educational ClinicalThought™ commentaries on the optimal management of patients with head and neck cancers. In this commentary, Cristina P. Rodriguez, MD, discusses the management strategies that she and her institution have developed to protect patients and personnel from COVID-19 infection and avoid interruptions in cancer therapy.
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Most patients with head and neck cancer present with locally advanced squamous cell carcinomas and are potential candidates for curative intent therapy, whether surgical or radiation based. Interruptions and delays in the administration of curative intent therapy are associated with worse outcomes. This group of patients, specifically those with non-HPV–associated squamous cell carcinomas, are older and may carry significant pulmonary, cardiac, and vascular comorbidities. This same population includes those with well-described racial and economic disparities, where financial hardship and underinsured/uninsured status limit access to medical care and pose challenges for the successful completion of cancer therapy.
With these issues in mind, when the earliest US cases of COVID-19 were recognized in Washington state, the Seattle Cancer Care Alliance/University of Washington Medical Center/Fred Hutchinson Cancer Research Center implemented procedures to protect patients and personnel from COVID-19 infection and avoid interruptions in cancer therapy. These strategies are especially aimed at preserving curative intent treatment schedules, which is particularly relevant to patients with head and neck cancer undergoing definitive therapy and who are at risk for complications due to comorbidity.
Pivoting to Telemedicine
Telehealth and telephone visits are offered to patients, with priority given to those who have completed therapy and are on long-term follow-up or those who are stable and receiving oral therapy without new symptoms. Every attempt is made to avoid delays and interruptions in treatment for patients in need of surgery, definitive or adjuvant radiation, or chemoradiation. Similarly, supportive care visits continue during radiation therapy. For patients receiving immune checkpoint inhibitors who are clinically stable and without treatment-related adverse events, we discuss transitioning to 4-week—and now 6-week—regimens, lessening the frequency of clinic visits.
Preappointment COVID-19 Screening
All patients with in-person appointments for follow-up or therapy are screened 24-72 hours prior to their appointment for symptoms of COVID-19, including fever, cough, loss of taste or smell, sore throat, headaches, and myalgias. Because these symptoms can also occur in patients with head and neck cancer without COVID-19 (due to their disease and/or treatment), it is critical to educate our screeners to ask about the onset or chronicity of these symptoms and to consult with the patient care team to determine if these are likely related to the disease process or therapy. When COVID-19 infection is suspected, the screeners recommend prior external COVID-19 testing from a local clinic or a drive-through location on our campus so that the test result is available on the day of the appointment.
Impact on Investigational Protocols
For patients receiving treatment on investigational protocols, continued therapy and compliance with clinical trials procedures are prioritized. In many of these trials, telehealth visits or telephone check-ins are permitted, especially for patients on long-term follow-up. Ultimately, concerns over utilization of healthcare resources as well as hospital and ICU bed availability from a COVID-19 community surge led to the temporary suspension of trials in which inpatient hospital stays were required or anticipated. Similarly, enrollment has been placed on a temporary hold for dose-finding phase I studies as well as phase III trials where a standard of care exists for patients.
Recognizing the psychosocial impact of the pandemic, our institution has increased the availability of social workers and mental health counseling for both patients and providers. This is particularly relevant to our patients with head and neck cancer, where high rates of depression and suicide have been described.
As the COVID-19 situation continues to evolve locally, nationally, and internationally, so have our policies. These are subject to constant reassessment and refinement, with the hopes of better serving our patients’ needs now and in the future.