Impact of the COVID-19 pandemic on head and neck cancer patients: systematic review and meta-analysis.

OBJECTIVES: This manuscript presents a systematic review of the impact of the COVID-19 pandemic on head and neck cancer (HNC) patients. A meta-analysis was made to compare the number of treated/operated HNC patients in the pre-COVID-19 era versus the COVID-19 era. This investigation was based on previous reports showing a delay in the diagnosis and treatment of new cases of cancer during the pandemic. Worsening in cancer prognosis would be expected as a result of the delayed treatments. METHOD AND MATERIALS: An electronic search was conducted using the PubMed/MEDLINE, Embase, Web of Science, Scopus, and The Cochrane Library databases. Relevant articles were selected based on specific inclusion criteria. RESULTS: A total of 8,942 HNC patients were included. A higher prevalence in male (1,873) in comparison to female (1,695) was observed considering 3,568 patients. Regarding staging, the majority of cases were stage III to IV. The treatment type more frequently described was surgery. Positive diagnosis for COVID-19 in the pre-oncologic treatment was reported for 242 patients, and for post-oncologic treatment in 119 patients. Mortality by COVID-19 was reported for 27 HNC patients. The meta-analysis revealed a significantly smaller number of surgeries/oncologic treatments of HNC patients performed (2,666) in the COVID-19 era when compared to the pre-COVID-19 era (3,163) (Mantel-Haenszel odds ratio = 0.81, 95% CI = 0.65 to 1.00, P = .05). CONCLUSION: The impact of the COVID-19 pandemic on HNC patients occurred mainly in the number of surgeries/oncologic treatments, showing a significantly smaller number of surgeries/oncologic treatments performed in the COVID-19 era rather than the pre-COVID-19 era.

Impact of the COVID-19 Pandemic on Brazilian Head and Neck Surgery Centers.

OBJECTIVE: The outbreak of the COVID-19 pandemic had a considerable impact on the healthcare access, treatment, and follow-up of oncologic patients. The aim of this study was to evaluate how the COVID-19 pandemic has affected consultation and follow-up demand as well as treatment volume at Brazilian Head and Neck Surgery centers. METHODS: An anonymous online questionnaire was used for collection of data across all Brazilian Head and Neck Surgery Centers across a 3-month period (April‒June 2021). This information included the characteristics of each center, and the perceived self-reported impact of the COVID-19 pandemic on academic activities, residency training, and the diagnosis, treatment, and follow-up of patients with Head and Neck diseases between 2019 and 2020. RESULTS: The response rate across the 40 registered Brazilian Head and Neck Surgery Centers was 47.5% (n=19). The data showed a significant reduction in the total number of consultations (24.8%) and number of attending patients (20.2%) between 2019 and 2020. The total number of diagnostic exams (31.6%) and surgical procedures (13.0%) conducted over this period also decreased significantly. CONCLUSIONS: The COVID-19 pandemic had a significant national impact on Brazilian Head and Neck Surgery Centers. Future studies should examine the long-term effects of the pandemic on cancer treatment. LEVEL OF EVIDENCE: Evidence from a single descriptive study.

The stage of head and neck diagnosed malignancies in COVID-19 outbreak versus before outbreak: A retrospective study.

BACKGROUND: Global COVID-19 pandemic has affected cancer care systems. Recent studies show that the number of cases diagnosed with cancer has drastically decreased compared to the same period before the pandemic. Therefore, we are confronted with delayed diagnosis of critical cancers. AIM: The aim of this study is to investigate whether the stage of known cancers has been affected by delayed diagnosis and to compare the stages of head and neck cancers diagnosed during and before the pandemic. METHODS: The present study was conducted on 132 patients with malignant head and neck tumors referred to the otolaryngology, head and neck cancer department of Taleghani Hospital from 2019 to 2021. The stage of cancers was compared between two groups of patients with head and neck malignancy referred to the Otolaryngology, Head and Neck Department of the Taleghani Hospital before and during the COVID-19 outbreak. RESULTS: The results from tumor (T), nodes (N), and metastases (M) (TNM) staging (p-value = .015) and T score (value = 0.045) showed that the stage of tumor diagnosed in patients during the COVID-19 pandemic significantly increased compared to patients diagnosed with a tumor before pandemic. CONCLUSION: In the present study, it was observed that the early symptoms of malignant head and neck tumors have been neglected by patients during COVID-19 pandemic and resulted in delayed diagnosis. This result may be explained by the fear of COVID-19 infection in patients, which discouraged them from visiting a doctor at healthcare centers.

Head and neck cancer in the UK: what was the stage before COVID-19? UK cancer registries analysis (2011-2018).

Introduction People who present with more advanced stage head and neck cancer (HNC) are associated with poorer outcomes and survival. The burden and trends of advanced stage HNC are not fully known at the population level. The UK national cancer registries routinely collect data on HNC diagnoses.Aims To describe trends in stage of diagnosis of HNCs across the UK before the COVID-19 pandemic.Methods Aggregated HNC incidence data were requested from the national cancer registries of the four UK countries for the ten most recent years of available data by subsite and American Joint Commission on Cancer stage at diagnosis classification. Additionally, data for Scotland were available by age group, sex and area-based socioeconomic deprivation category.Results Across the UK, rates of advanced stage HNC had increased, with 59% of patients having advanced disease at diagnosis from 2016-2018. England had a lower proportion of advanced disease (58%) than Scotland, Wales or Northern Ireland (65-69%) where stage data were available. The completeness of stage data had improved over recent years (87% by 2018).Conclusion Prior to the COVID-19 pandemic, diagnoses of HNC at an advanced stage comprised the majority of HNCs in the UK, representing the major challenge for the cancer healthcare system.

Advancing head and neck cancer following the coronavirus disease 2019 pandemic.

OBJECTIVE: Delay in the diagnosis of head and neck cancer can result in significant excess morbidity and mortality. How the pandemic has affected patient presentation in Scotland is unknown. METHOD: This retrospective cohort study compared all presentations of head and neck cancer between June and October of 2019 with the same period following the peak of the pandemic in 2020 in West Scotland, a region populated by 2.5 million people. RESULTS: A total of 528 patients met our inclusion criteria. Compared with 2019, patients in 2020 were more likely to present with a higher American Joint Committee on Cancer stage (odds ratio, 1.67 (95 per cent confidence interval = 1.20 to 2.31); p = 0.002), a longer preceding symptom duration (odds ratio, 2.03 (95 per cent confidence interval = 1.44 to 2.87; p < 0.001) and to have an emergency presentation (odds ratio, 2.53, (95 per cent confidence interval = 1.15 to 5.55; p = 0.017). CONCLUSION: Patients are presenting later with more advanced head and neck cancer following the coronavirus disease 2019 pandemic.

Symptom-based remote assessment in post-treatment head and neck cancer surveillance: A prospective national study.

OBJECTIVES: To report the incidence of locoregional recurrence in head and neck cancer (HNC) patients under surveillance following treatment undergoing symptom-based remote assessment. DESIGN: A 16-week multicentre prospective cohort study. SETTING: UK ENT departments. PARTICIPANTS: HNC patients under surveillance following treatment undergoing symptom-based telephone assessment. MAIN OUTCOME MEASURES: Incidence of locoregional recurrent HNC after minimum 6-month follow-up. RESULTS: Data for 1078 cases were submitted by 16 centres, with follow-up data completed in 98.9% (n = 1066). Following telephone consultation, 83.7% of referrals had their face-to-face appointments deferred (n = 897/1072). New symptoms were reported by 11.6% (n = 124/1072) at telephone assessment; 72.6% (n = 90/124) of this group were called for urgent assessments, of whom 48.9% (n = 44/90) came directly for imaging without preceding clinical review. The sensitivity and specificity for new symptoms as an indicator of cancer recurrence were 35.3% and 89.4%, respectively, with a negative predictive value of 99.7% (p = .002). Locoregional cancer identification rates after a minimum of 6 months of further monitoring, when correlated with time since treatment, were 6.0% (n = 14/233) <1 year; 2.1% (n = 16/747) between 1 and 5 years; and 4.3% (n = 4/92) for those >5 years since treatment. CONCLUSIONS: Telephone assessment, using patient-reported symptoms, to identify recurrent locoregional HNC was widely adopted during the initial peak of the COVID-19 pandemic in the United Kingdom. The majority of patients had no face-to-face reviews or investigations. New symptoms were significantly associated with the identification of locoregional recurrent cancers with a high specificity, but a low sensitivity may limit symptom assessment being used as the sole surveillance method.

The impact of coronavirus disease 2019 on the head and neck cancer pathway in the West of Scotland.

OBJECTIVE: The coronavirus disease 2019 pandemic has greatly disrupted head and neck cancer services in the West of Scotland. This study aimed to assess the impact of the first wave of the pandemic on cancer waiting times. METHODS: A retrospective review of multidisciplinary team records was undertaken between March and May in 2019 and the same months in 2020. Time-to-diagnosis and time-to-treatment for new cancers treated with curative intent were compared between the study periods, and subclassified by referral pathway. RESULTS: A total of 236 new cancer patients were included. During the pandemic, pathways benefitted from reduced diagnostic and treatment times resulting from the restructuring of service provisions. A 75 per cent reduction in secondary care referrals and a 33 per cent increase in urgent suspicion of cancer referrals were observed in 2020. CONCLUSION: Head and neck cancer pathway times did not suffer because of the coronavirus pandemic. Innovations introduced to mitigate issues brought about by coronavirus benefitted patients, led to a more streamlined service, and improved diagnostic and treatment target compliance.

Diagnosis and treatment delay of head and neck cancers during COVID-19 era in a tertiary care academic hospital: what should we expect?

BACKGROUND: Since the spreading of SARS-CoV-2 from China, all deferrable medical activities have been suspended, to redirect resources for the management of COVID patients. The goal of this retrospective study was to investigate the impact of COVID-19 on head and neck cancers' diagnosis in our Academic Hospital. METHODS: A retrospective analysis of patients treated for head and neck cancers between March 12 and November 1, 2020 was carried out, and we compared these data with the diagnoses of the same periods of the 5 previous years. RESULTS: 47 patients were included in this study. We observed a significative reduction in comparison with the same period of the previous 5 years. CONCLUSIONS: Our findings suggest that the COVID-19 pandemic is associated with a decrease in the number of new H&N cancers diagnoses, and a substantial diagnostic delay can be attributable to COVID-19 control measures.

The COVID-19 pandemic and its consequences for the diagnosis and therapy of head and neck malignancies.

OBJECTIVE: The COVID-19 pandemic and the measures accompanying it have been accused of having a negative influence on the frequency and methods of treatment of various diseases including head and neck cancer (HNSCC). To go further into this assumption, the diagnoses made, and treatments performed at one of Germany's largest head and neck cancer centres were evaluated. PATIENTS AND METHODS: This study consisted of one single centre and involved a retrospective review of all patients with newly diagnosed or recurrent HNSCC. The diagnosis and treatment methods used in the pre-COVID-19 time period between March 1st, 2019, and March 1st, 2020, were analysed and compared with the COVID-19 time period from April 1st, 2020, until April 1st, 2021. The primary objective was defined as the number of malignant diagnoses and the secondary objectives as the disease stage and the time to therapy. RESULTS: A total of 612 patients (160♀; mean 63 yrs.) were included. 319 patients (52%) were treated in the pre-COVID-19 time. The two groups did not differ in terms of age (p=0.304), gender (p=0.941), presence of recurrent disease (p=0.866), tumour subsite (p=0.194) or the duration from presentation to the multidisciplinary tumour board until start of therapy (p=0.202). There were no significant differences in the T stage (p=0.777), N stage (p=0.067) or UICC stage (p=0.922). During the pre-COVID-19 period more patients presented with distant metastases (n= 23 vs. n=8; p=0.011). CONCLUSIONS: This study shows that there was no significant change in either the number and severity of HNSCC diagnoses or the time until start of therapy at this large head and neck cancer centre as a result of the COVID-19 pandemic.

Fewer head and neck cancer diagnoses and faster treatment initiation during COVID-19 in 2020: A nationwide population-based analysis.

BACKGROUND: Inevitably, the emergence of COVID-19 has impacted non-COVID care. Because timely diagnosis and treatment are essential, especially for patients with head and neck cancer (HNC) with fast-growing tumours in a functionally and aesthetically important area, we wished to quantify the impact of the COVID-19 pandemic on HNC care in the Netherlands. MATERIAL AND METHODS: This population-based study covered all, in total 8468, newly diagnosed primary HNC cases in the Netherlands in 2018, 2019 and 2020. We compared incidence, patient and tumour characteristics, primary treatment characteristics, and time-to-treatment in the first COVID-19 year 2020 with corresponding periods in 2018 and 2019 (i.e. pre-COVID). RESULTS: The incidence of HNC was nearly 25% less during the first wave (n = 433) than in 2019 (n = 595) and 2018 (n = 598). In April and May 2020, the incidence of oral cavity and laryngeal carcinomas was significantly lower than in pre-COVID years. There were no shifts in tumour stage or alterations in initial treatment modalities. Regardless of the first treatment modality and specific period, the median number of days between first visit to a HNC centre and start of treatment was significantly shorter during the COVID-19 year (26-28 days) than pre-COVID (31-32 days, p < 0.001). CONCLUSION: The incidence of HNC during the Netherlands' first COVID-19 wave was significantly lower than expected. The expected increase in incidence during the remainder of 2020 was not observed. Despite the overloaded healthcare system, the standard treatment for HNC patients could be delivered within a shorter time interval.

Individual head and neck screening: Initiating a dialogue about best approach.

PURPOSE: We aim to investigate the true benefits of free individual HNC screening in a high-risk urban population as well as the associated risks. MATERIALS AND METHODS: This is a retrospective descriptive study. Free HNC screening was performed from 2014 to 2019. Participants were issued a questionnaire at the time of screening. After exemption by the Institutional Review Board, completed screening questionnaires were entered into a database and descriptive statistics were generated. The primary outcome measure for this study was the detection rate for HNC. We hypothesized that screening would be low yield based on previous studies (Gogarty et al., 2016). RESULTS: This was a volunteer sample with a total of 410 participants, and the highest yield screening year was 2019 (n = 187). For all years, the cancer detection rate was 0%. In 2019, 134 (77.9%) of participants did not recognize the early symptoms of HNC, and 120 (73.2%) reported the screening program increased their awareness of the disease. 13 (7.6%) reported HPV vaccination while 126 (71.2%) were unaware that HPV has been linked with head and neck cancer. CONCLUSIONS: HNC screening is an excellent opportunity for education regarding HNC risk factors. However, it is not a cost-effective use of physician time, does not increase detection rates even in high-risk segments of the general population, and is not completely without risk in the context of COVID-19. Perhaps the focus of HNC screening should shift from individualized screening to education and health promotion.

Impact of the COVID-19 pandemic on head and neck cancer diagnosis: data from a single referral center, South Tyrol, northern Italy.

OBJECTIVE: The aim of the study was to evaluate the impact of the COVID-19 pandemic on new diagnoses of head and neck cancer (HNC) in South Tyrol, northern Italy in terms of the number of new diagnoses and worsening disease stage due to diagnostic delay. METHODS: Patients were divided into two groups: the control group with a first diagnosis of HNC in 10 months before the national lockdown (March 9th, 2020) and the study group with a first diagnosis of HNC in 10 months after lockdown. RESULTS: A total of 124 patients were included in the study. Before the spread of COVID-19, 79 new diagnoses of HNCs were registered, while in the period after the lockdown, 45 new cancers cases were diagnosed and the difference was statistically significant (p = 0.01278). Early clinical T-stage results showed 52 cases in the control group and 21 in the study group, again with a significant difference (p = 0.03711). Advanced T-stage results showed 27 cases in the control group and 24 in the study group. CONCLUSIONS: This study highlights the impact of the COVID-19 pandemic on HNCs, showing a statistically significant difference in the number of diagnoses before and after the lockdown which was related to the spread of the SARS-CoV-2 virus, and with a relevant decrease in early cT-staged HNCs.

Remote triaging of urgent suspected head and neck cancer referrals: our experience during the first wave of the COVID-19 pandemic.

PURPOSE: In response to the coronavirus disease 2019 (COVID-19) pandemic, otolaryngology departments across the United Kingdom have adopted non-face-to-face clinics with consultations being carried out remotely, via telephone or video calls. By reducing footfall on hospital sites, the aim of this strategy was to limit direct contact and curb the spread of infection. This report outlines our experience of conducting a telephone triage clinic in the assessment of urgent suspected head and neck cancer referrals during the first wave of the COVID-19 pandemic. METHODS: New patients who were referred on the urgent suspected head and neck cancer pathway were prospectively identified between 1 May 2020 and 31 August 2020. Patients were triaged remotely using telephone consultations. Risk stratification was performed using the 'Head and Neck Cancer Risk Calculator' (HaNC-RC v.2). RESULTS: Four-hundred and twelve patients were triaged remotely during the 4-month study period. Of these, 248 patients were deemed 'low risk' (60.2%), 78 were classed as 'moderate risk' (18.9%) and 86 were considered 'high risk' (20.9%) according to the HaNC-RC v.2 risk score. Twenty-four patients who were assessed during the study period were diagnosed with head and neck cancer (5.82%). CONCLUSION: The use of teleconsultation, supported by a validated, symptom-based risk calculator, has the potential to provide a viable and effective adjunct in the assessment and management of new suspected head and neck cancer patients and should be considered as part of the inherent re-shaping of clinical service delivery following the ongoing pandemic.

Risk Factors for Sleep Disturbances in Patients Scheduled for Radiotherapy of Head-and-Neck Cancer.

BACKGROUND/AIM: Many patients with head-and-neck cancer are scheduled for irradiation. This study was performed to determine the frequency of and risk factors for pre-radiotherapy sleep disturbances in these patients. PATIENTS AND METHODS: A total of 103 patients with head-and-neck cancer scheduled for radiotherapy were included in this retrospective study. Eighteen characteristics were evaluated including timing of start of radiotherapy relative to COVID-19 pandemic; age; gender; Karnofsky performance score; Charlson comorbidity index; history of another malignancy; family history of malignancy; distress score; number of emotional, physical or practical problems; request for psychological support; tumor site and stage; upfront surgery; planned chemotherapy; and brachytherapy boost. RESULTS: The frequency of pre-radiotherapy sleep disturbances was 42.7%. This was significantly associated with age ≤63 years (p=0.049), Karnofsky performance score ≤80 (p=0.002), Charlson comorbidity index ≥3 (p=0.005), history of another malignancy (p=0.012), emotional (p=0.001) or physical (p<0.001) problems, and request for psychological support (p=0.002). CONCLUSION: Sleep disturbances were frequent in patients assigned to radiotherapy of head-and-neck cancer. Recognizing risk factors for sleep disturbance helps identify patients requiring psychological support.

Remote triage incorporating symptom-based risk stratification for suspected head and neck cancer referrals: A prospective population-based study.

BACKGROUND: Remote triage for suspected head and neck cancer (HNC) referrals was adopted by many institutions during the initial peak of the coronavirus disease 2019 pandemic. Its safety in this population has not been established. METHODS: A 16-week, prospective, multicenter national service evaluation was started on March 23, 2020. Suspected HNC referrals undergoing remote triage in UK secondary care centers were identified and followed up for a minimum of 6 months to record the cancer status. Triage was supported by risk stratification using a validated calculator. RESULTS: Data for 4568 cases were submitted by 41 centers serving a population of approximately 26 million. These represented 14.1% of the predicted maximum referrals for this population outside of pandemic times, and this gave the study a margin of error of 1.34% at 95% confidence. Completed 6-month follow-up data were available for 99.8% with an overall cancer rate of 5.6% (254 of 4557). The rates of triage were as follows: urgent imaging investigation, 25.4% (n = 1156); urgent face-to-face review, 27.8%; (n = 1268); assessment deferral, 30.3% (n = 1382); and discharge, 16.4% (n = 749). The corresponding missed cancers rates were 0.5% (5 of 1048), 0.3% (3 of 1149), 0.9% (12 of 1382), and 0.9% (7 of 747; P = .15). The negative predictive value for a nonurgent triage outcome and no cancer diagnosis was 99.1%. Overall harm was reported in 0.24% (11 of 4557) and was highest for deferred assessments (0.58%; 8 of 1382). CONCLUSIONS: Remote triage, incorporating risk stratification, may facilitate targeted investigations for higher risk patients and prevent unnecessary hospital attendance for lower risk patients. The risk of harm is low and may be reduced further with appropriate safety netting of deferred appointments. LAY SUMMARY: This large national study observed the widespread adoption of telephone assessment (supported by a risk calculator) of patients referred to hospital specialists with suspected head and neck cancer during the initial peak of the coronavirus disease 2019 pandemic. The authors identified 4568 patients from 41 UK centers (serving a population of more than 26 million people) who were followed up for a minimum of 6 months. Late cancers were identified, whether reviewed or investigated urgently (0.4%) or nonurgently (0.9%), but the overall rate of harm was low (0.2%), with the highest rate being seen with deferred appointments (0.6%).

The impact of coronavirus disease 2019 on suspected head and neck cancer two-week-wait referrals.

BACKGROUND: The impact of coronavirus disease 2019 extends far beyond the immediate burden on healthcare systems caused by hospitalisation of patients with the disease itself. OBJECTIVE: To investigate the impact of the coronavirus disease 2019 pandemic on the referral rate of patients to the suspected head and neck cancer two-week-wait clinic. METHODS: A multicentre retrospective study was performed investigating data collected for all patients attending the suspected head and neck cancer two-week-wait clinic in ENT departments in the West Midlands. RESULTS: A total of 509 fast-track referrals were received from February to April in 2019, compared to 399 referrals in 2020. April 2020 saw a 62.4 per cent reduction in referral rate compared to April 2019. CONCLUSION: The coronavirus disease 2019 pandemic has resulted in changes to health-seeking behaviours, and healthcare provision and delivery. Urgent policy interventions may be required to compensate for the hidden impact that the coronavirus disease 2019 pandemic has had on those with cancer.