Getting timely, safe care to head and neck cancer patients in a pandemic

While the eyes of the world became fixated on the global health emergency created by the COVID-19 pandemic in the spring of 2020, MUSC Hollings Cancer Center’s Head and Neck Oncology Team was growing concerned about a secondary emergency created by COVID-19 shutdowns: cancer care being pushed to the back burner.

As talks of conserving personal protective equipment and converting operating rooms into intensive care units became a reality, head and neck cancer specialists across the world turned to one another for advice on how to continue providing patients with the care they needed. Realizing there was no guide for doing so, they created their own.

Hollings head and neck surgical oncologist Terry Day, M.D., and academicians and surgeons from Harvard, UCLA, New York University, Louisiana State University and other institutions across the globe joined together to publish “Head and Neck Cancer Care in a Pandemic: Prioritizing Safe Care,” an up-to-the-moment textbook that aims to serve as a reference for clinicians treating patients with cancers of the head and neck. The first volume, which consists of 27 chapters, was compiled by experts across leading medical institutions on the front lines of the pandemic.

While delaying treatment for any type of cancer can have a devastating effect on clinical outcomes, head and neck cancers require special consideration, as these cancers affect functional structures of the body that are required for talking, swallowing and breathing.

 

“Head and neck cancer patients are different. The cancer is growing on their faces, tongues, voice boxes, throats or other areas that when the tumors grow, they impact patients’ lifestyles,” said Day, who also serves as director of the MUSC Wellin Head and Neck Tumor Center. “You can see them. The tumors are bleeding, and they’re blocking the patient’s ability to eat, drink and talk. Survival is going to drop the longer you delay treatment.”

Although there wasn’t a clear initial strategy for continuing cancer care on a national level, Day said Hollings recognized that delaying care wasn’t an option.

As Day was on the Department of Otolaryngology’s rapidly created COVID-19 advisory committee, he and others on the head and neck oncology team began to hear cries from patients and their families that cancers were growing and causing other problems that could also result in death. The team met to develop a priority protocol to continue to provide high-quality head and neck cancer care that would include a variety of perspectives.

“COVID-19 was the emergency being talked about in the media, but what people didn’t realize is that other patients’ lives were being affected when their deadly diseases were being ignored due to an infectious disease,” said Day. “It became a battle of many physicians and surgeons in the U.S. and internationally to figure out how we were going to continue to take care of cancer patients in a safe manner while we were still responding to this novel and evolving emergency.”

Developing a roadmap

Head and neck surgeons across the globe began to coordinate protocols through email groups and text messaging to stay up to date by the minute as the pandemic spread and guidelines, protocols and laws changed.

While hospitals across the world have faced similar challenges in treating these cancers, experts recognized that there is not a one-size-fits-all approach that applies to every institution. Protocols are affected by policies at the hospital, city and state levels, meaning each health system needed to adapt modifications customized to their own setting. The book is meant to be a guide for creating a clinical plan that serves each organization’s needs.

 

The editors and authors reviewed and compiled what they felt were the most important lessons learned at their respective institutions and decided which topics people needed to know more about. They also discussed which aspects of cancer care should take priority and how established management could be reasonably and safely modified with the constraints of the pandemic.

Topics covered in the book include the epidemiology of the virus that causes COVID-19 and how it relates to head and neck cancer, how to modify procedures for the safety of both patients and health care workers and the ethical considerations of delaying care. The book also dives into considerations based on the cancer’s location, educating medical students and the social impacts of the pandemic, such as how things like communication and bereavement may look different in the COVID-19 era.

Chris de Souza, DNB, an ear, nose and throat (ENT) surgeon who practices in Mumbai, India, and a contributor to the book, hopes the book will provide practical approaches for health care workers who are trying to navigate challenges caused by the pandemic. He and Shaun Nguyen, M.D., director of clinical research in MUSC’s Department of Otolaryngology, helped to organize the textbook and identify experts and topics that could reach clinicians and patients in all parts of the world.

“The pandemic has caused universal suffering. The presentation of the disease and the suffering it has caused remain the same no matter where you are,” said de Souza. “This book provides solutions and treatment modalities and strategies distilled through many hours of selfless dedication to assisting patients suffering from this disease.”

Hollings Cancer Center head and neck experts shared their customized protocols with surgeons around the world while also taking advice from the wisdom of its global partners to inform its own policies, making sure to incorporate a variety of expert perspectives to provide the best care for patients.

Continuing safe care at Hollings

While the pandemic still presents challenges, cancer care at Hollings never stopped, said Day, and the center is taking care of 100% of the patients who need it. Hollings’ head and neck cancer patient volume is higher than normal, as the center has stepped in to assist smaller regional hospitals when they’ve been overwhelmed.

“Unfortunately, due to COVID-19, a lot of the patients we’re seeing today could’ve been diagnosed and treated in the spring, but they either delayed going to their doctors or their doctors’ offices weren’t open to see and diagnose them, so now we’re seeing later-stage cancer than we typically would,” said Day.

Julie Molony, the tumor center’s head and neck nurse navigator, and patient coordinator Margaret Ann King both helped to compile and distribute protocols as they were developed. They attribute Hollings’ success in advocating for these patients to the dedication of the center’s staff, who kept the clinic safe while continuing cancer care.

 

“I am most proud of how well our team worked together and handled the stress of the virus, in spite of how it could have affected us and our families, as well as calming the fears of our cancer patients with compromised immune systems,” said Molony. “Safety and quality care have always been our main priorities. I am proud to work with such a great team.”

When the pandemic began, clinic staff worked tirelessly to triage patient calls, review new referrals, set up virtual visits and present patients to Hollings’ tumor boards to develop recommended treatment strategies. The team developed social distancing protocols, modified procedures and continually revised policies based on the latest science.

Despite new guidelines for supplies and social distancing, treatment has remained the same, with the addition of new resources for patient visits that don’t require in-person procedures or exams. Cancer patients who live out of town can now receive a virtual visit or second opinion by one of the head and neck surgeons within 24 hours.

As new information becomes available on COVID-19 antibodies, vaccines and how the disease progresses and is transmitted, the authors plan to update and rerelease the book to disseminate the information quickly.

“It may still be a long time before we have these answers,” Day said, “but I think as long as people are organizing the process in the way that suits their local patients and health systems, we’ll be much better prepared for the next time.”

In addition to Day, the team that helped ensure the continuation of safe care included head and neck surgeons Eric Lentsch, M.D.; David Neskey, M.D.; Joshua Hornig, M.D.; Betsy Davis, D.M.D.; Rhet Tucker, D.M.D.; Evan Graboyes, M.D.; and Judith Skoner, M.D.; and also medical oncologist John Kaczmar, M.D.; radiation oncologist Anand Sharma, M.D.; and nurses, advanced practice providers and other members of the head and neck oncology team.

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