The Impact Of Covid On Cancer Patients

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Am J Clin Oncol. 2020 Apr 23 : 10.1097/COC.0000000000000712. Published online 2020 Apr 23. doi: 10.1097/COC.0000000000000712 PMCID: PMC7188063 PMID: 32304435

The Impact of the COVID-19 Pandemic on Cancer Patients

Osama M. Al-Quteimat, MSc, BCOP* and Amer Mustafa Amer, BSc, MSc†

Osama M. Al-Quteimat

*Pharmacy Services Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE

Find articles by Osama M. Al-Quteimat

Amer Mustafa Amer

†Inpatient Pharmacist, The Specialty Hospital, Amman, Jordan

Find articles by Amer Mustafa Amer Author information Copyright and License information Disclaimer *Pharmacy Services Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE †Inpatient Pharmacist, The Specialty Hospital, Amman, Jordan Corresponding author. Reprints: Osama M. Al-Quteimat, MSc, BCOP, Pharmacy Services Department, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, UAE. E-mail: ea.ibahdubacinilcdnalevelc@oetuqlA. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections. This article has been cited by other articles in PMC. Go to:

Abstract

In December 2019, a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of coronavirus disease 2019 (COVID-19). Severe complications have been reported to occur in 33% of patients with COVID-19 and include acute respiratory distress syndrome, acute renal failure, acute respiratory injury, septic shock, and severe pneumonia. Currently, there is no specific treatment or approved vaccine against COVID-19 and many clinical trials are currently investigating potential medications to treat COVID-19. The immunosuppressed status of some cancer patients (whether caused by the disease itself or the treatment) increases their risk of infection compared with the general population. This short review aims to focus on the impact of COVID-19 on a cancer patient and discuss management options and recommendation in addition to highlighting the currently available clinical guidelines and resources.

Key Words: COVID-19, cancer, oncology Go to:

CORONAVIRUS DISEASE 2019 (COVID-19)

Coronaviruses are a large family of viruses that can cause disorders ranging from a mild cold to severe diseases. Some coronaviruses are zoonotic, which means that they spread from animals to humans. In December 2019, a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of COVID-19. Typical symptoms of COVID-19 include fever, cough, shortness of breath, and muscle pain. Severe complications have been reported to occur in 33% of patients with COVID-19 and include acute respiratory distress syndrome, acute renal failure, acute respiratory injury, septic shock, and severe pneumonia.1

Currently, there is no specific treatment or approved vaccine against COVID-19, and the clinical management primarily includes implementing recommended infection prevention and control measures and supportive management of complications. Thus far, treatment is provided according to the clinical condition of the patient; supportive treatment such as oxygen therapy, hydration and fever/pain management, and antibiotics, if bacterial co-infection is present, is recommended.1

Many clinical trials are currently investigating potential medications to treat COVID-19 including remdesivir (a prodrug in development), immunoglobulins, arbidol hydrochloride combined with interferon atomization, ASC09F plus oseltamivir, ritonavir plus oseltamivir, lopinavir plus ritonavir and some other drug (https://clinicaltrials.gov/ct2/results?cond=2019nCoV&term=&cntry=&state=&city=&dist=), but no specific treatment or vaccine is approved yet. In addition, chloroquine phosphate (used to prevent and treat malaria and some inflammatory conditions) was found to have acceptable safety and demonstrated efficacy in the treatment of COVID-19-associated pneumonia.2

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COVID-19 AND CANCER

The immunosuppressed status of some cancer patients (whether caused by the disease itself or the treatment) increases their risk of infection compared with the general population. Immunosuppression may also expose cancer patients to serious complications from an infection, which may result in treatment delay and unnecessary hospitalizations that could negatively affect disease prognosis.

It has been reported by Liang et al3 that patients with cancer have an increased risk of severe infections, with an ~3.5-fold increase in the risk of needing mechanical ventilation or ICU admission or dying compared with patients without cancer. Cancer patients’ increased susceptibility to severe complications of COVID-19 can be attributed to the immunosuppressed status caused by the malignancy and anticancer treatments, such as chemotherapy or surgery. Patients who had received chemotherapy or undergone surgery in the 30 days before presenting with COVID-19 were found to have a higher risk of severe events than patients who had not been treated with chemotherapy or surgery. It was also found that cancer history conferred the highest risk for severe complications and was correlated with poorer outcomes from COVID-19. Notably, lung cancer patients did not have a higher probability of severe complications compared with patients with other cancer types.3

Zhang et al4 reported the case of a 57-year-old Chinese male patient with lung cancer who presented with fever, cough, shortness of breath, myalgia, and diarrhea and later tested positive for COVID-19. The patient’s lung cancer was initially treated with gefitinib (an epidermal growth factor receptor [EGFR] inhibitor) starting in February 2016, and the patient was subsequently started on osimertinib monotherapy in September 2017, when the gefinitib resistance-causing mutation EGFR T790M was detected upon disease progression. COVID-19 was treated with lopinavir/ritonavir (a combination of protease inhibitors typically used to treat HIV1 infection). Improved pneumonia was reported after 2 weeks of treatment. Three follow-up RT-PCR tests for SARS-CoV-2 were found to be negative, indicating a cure for COVID-19. In the reported case, the patient’s clinical condition and performance status permitted continued osimertinib treatment despite the diagnosis of COVID-19.

Wang and Zhang5 pointed out that during the COVID-19 pandemic, the primary risk for patients with cancer is limited access to required health care and inability to receive necessary medical services in a timely fashion, especially in high-risk epidemic areas like Wuhan, China, where there is a high demand on medical staff and health care facilities. Health care providers must pay attention to the treatment-related adverse effects in lung cancer patients who are treated with immune checkpoint inhibitors (such as severe myocarditis and pneumonitis): such side effects may negatively affect the patients’ survival; thus, it is vital to identify and treat such conditions promptly.

A recently published retrospective cohort study recruited 28 cancer patients with confirmed COVID-19 from 3 hospitals in Wuhan, China to assess the risk factors associated with ICU admission, mechanical ventilation or death. The study reported that COVID-19-infected cancer patients have a high risk of poor clinical outcomes severe event and mortality.

Cancer treatment within 14 days of COVID-19 diagnosis was reported as a risk factor for developing severe events. Acute respiratory distress syndrome (28.6%), septic shock (3.6%), and acute myocardial infarction (3.6%) are among the documented severe complications in the study population. Interestingly, 28.6% of the study patients developed COVID-19 infection while hospitalized which is mainly attributed to the nosocomial transmission. Such findings highlight the importance of implementing strict infection control measures and treating cancer patients in an outpatient setting instead of hospitalization whenever feasible. The authors of this study have recommended that cancer patients currently on cancer treatments should undergo thorough screening for COVID-19 infection and avoid immunosuppressive therapy in case of COVID-19 infection.6

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GUIDELINES AND CLINICAL RESOURCES

Many clinical resources, including guidelines for COVID-19 prevention and management, have recently been published to guide cancer patients, health care professionals, and cancer centers on the proper recommendations and measures to fight this contagious disease and to maximize the use of the available resources in order to sustain health services to cancer patients. One of these resources is a patient information reference issued by the British Columbia Cancer Center that includes many frequently asked questions by cancer patients and offers proper instructions on the required precautions regarding detection of signs and symptoms of COVID-19, social distancing, personal protective equipment use, and hospital visits.7 In addition, the Cancer Council of Australia has issued a patient-friendly brochure in many different languages to familiarize cancer patients, including those who are currently being treated, with all of the necessary information regarding COVID-19 and the approved measures of prevention.8

Recently, the National Institute for Health and Care Excellence (NICE) issued a clinical guideline for the delivery of systemic anticancer treatments to cancer patients with COVID-19. The NICE guideline provides many recommendations based on the currently available evidence regarding many COVID-19-related and cancer-related issues, including communicating with patients, managing patients with confirmed or suspected COVID-19, staff who are self-isolating, prioritizing patients for treatment, modifications to usual service, and treatment breaks. Such preliminary guidelines can be helpful tools at this time for health care providers to provide the best available care to cancer patients until more detailed and evidence-based guidelines are available.9

In addition, the European Society of Medical Oncology (ESMO) has developed an updated online clinical resource page to highlight all COVID-19-related clinical issues pertaining to cancer. The ESMO clinical resource can provide physicians with proper recommendations based on recent updates about COVID-19 in cancer patients, including information on self-protection, treatment continuity, risk of procedures, and key actions to deliver optimal care to cancer patients in these exceptional circumstances.10

The Royal College of Radiologists has also recently established a clinical resource that includes guidelines on the management of many cancers, including breast, upper and lower gastrointestinal, prostate, lung, central nervous system, sarcoma, thyroid, melanoma, gynecologic, and urethral cancers, during the COVID-19 pandemic. These guidelines provide detailed recommendations on treatment with radiotherapy, including types of radiotherapy; administered doses; and when to continue, delay, or stop radiotherapy.11

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MANAGEMENT AND RECOMMENDATIONS

Whether to continue cancer therapy or to stop it is still a subject of debate, as the risk of cancer progression after stopping cancer therapy remains controversial. Further clinical trials in cancer patients with COVID-19 are urgently needed before any recommendation can be generalized.

In some solid tumors including lung and pancreatic cancer and hematologic cancers including acute leukemia and high-grade lymphoma, timely diagnosis and treatment are warrantied. While in early-stage diseases such as breast, prostate, cervical, and nonmelanoma skin delaying cancer treatment may be an option during the COVID-19 pandemic in high-risk patients.

In general, it is recommended that patients receiving curative cancer therapy should continue their treatment despite the potential risk of COVID-19 infection during anticancer therapy. Delaying treatment of metastatic disease results in deteriorated performance status, admission for symptom palliation, and progressive disease.12 Surgeries can be delayed in some cases based on the clinical judgment of the treating physicians. For example, selected early-stage hormone-positive breast cancer patients can continue their hormonal therapy for additional months if needed. Thus, it is recommended that the risks and benefits of treatment delay be assessed for each patient individually in order to identify candidates who would be eligible for treatment delay without major negative health consequences.12

Because of the severe clinical deterioration associated with COVID-19 in cancer patients, 3 essential strategies may be used to mitigate the COVID-19 crisis, or any future infection affecting cancer patients. The first strategy is postponing chemotherapy treatment or elective surgical procedures in stable cancer cases at high-risk locations. The second is implementing strict personal precautions in cancer patients or cancer survivors. The third strategy is providing more intensive care and treatment to COVID-19-infected patients with cancer who are old or have other comorbidities.3

Online medical counseling and appropriate diagnosis and treatment of critical cases to minimize patients’ exposure to COVID-19 may be required during the virus outbreak.5 In addition to implementing strict personal precautions to avoid COVID-19 infection, some experts have recommended using outpatient health care facilities to treat non–small cell lung cancer patients with advanced disease whenever feasible during the COVID-19 pandemic. In addition, they recommended ruling out COVID-19 infection before admitting patients to the hospital for cancer therapy.13

Kutikov et al14 have proposed specific recommendations which can be used to guide the decision process on delaying or continuing cancer treatment during COVID-19 pandemic. The proposed guide is based mainly on categorizing patients into low, medium or high risk of disease progression with cancer treatment delay. For example; it is considered safe to delay treatment for >3 months with low risk of disease progression in patients with chronic hematologic cancers and. Surgery and radiotherapy can also be delayed for the same risk group including patients with nonmelanoma skin cancer, nonlocally advanced breast cancer, low or intermediate-risk prostate cancer, low-grade lymphoma and other low-risk cancer diseases. In contrast, treatment delay is not recommended in patients who are at high risk of disease progression with treatment delay including patients with high grade or aggressive cancers, colon cancer with obstruction, malignancy suspicious ovarian, liver or pancreatic mass and small cell lung cancer14 (Table (Table11).

TABLE 1

Lists Some Examples on Low and High-risk Conditions Where Cancer Treatment Delay Can Affect Clinical Outcomes14,15

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INITIATIVES AT HEALTH CARE INSTITUTIONS

One of the cornerstone strategies for any health care institution to fight COVID-19 is to implement robust infection and environmental control. Identifying and triaging patients suffering from respiratory symptoms is also important to contain SARS-CoV-2 and minimize exposure.

Some health care organizations have adopted strict measures banning travel to certain high-risk areas to protect their facilities and prevent the spread of COVID-19 by. Dana-Farber Cancer Institute and MD Anderson Cancer Center, 2 of the leading health care institutions, have recently banned all business travel to “CDC-defined impacted areas” to limit health care providers’ exposure to COVID-19. Institutions, along with others, have also encouraged their employees to consider restricting personal travel and to exercise caution during personal time.16

Virtual health services, including telephone or online appointments, especially for routine checkups or prescription refills, can also be implemented as appropriate to reduce crowding in health care facilities to reduce exposure and efficiently utilize clinical resources. Moreover, having institutional management guidelines and an emergency plan with equipped isolation areas is required to accommodate any surge in COVID-19 patients.

During this difficult time, it is imperative for any health care organization to address health care providers’ well-being and to fulfill their physical and emotional needs by offering the required support to prevent, identify and properly manage any burnout, psychological stress, or safety concerns, especially for those providing direct patient care, such as physicians, respiratory therapists and nurses.

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ETHICAL ASPECTS

During COVID-19 outbreak, many health care systems are facing challenges due to the high demand on pharmaceutical, equipment, and medical supplies that resulted in critical shortages which can force the clinicians to take tough decisions to restrict using advanced therapeutic options including mechanical ventilators to selected patients based on many factors including age, comorbidities or the expected clinical outcomes. Such difficult scenarios may raise ethical considerations regarding the allocation and use of the current limited resources to treat the most critically ill patients with complications or severe conditions. During this crisis, it is vital to apply medical ethics in the clinical practice aiming to treat and cure as many patients as possible with the best use of the available resources.

Rationing treatment, canceling appointments, and delaying surgeries are challenging decisions. In patients with confirmed COVID-19 and advanced-stage cancer or severe comorbidities requiring mechanical ventilation, poor prognosis is usually expected. In such cases, end-of-life and palliative care plans must be discussed. When faced with limited resources during the COVID-19 pandemic, a cancer treatment multidisciplinary team (which may include medical ethicists and palliative care specialists) must decide which patients will receive complicated or critical care based on the expected clinical outcomes.12

The American College of Surgeons (ACS) Committee on Ethics has prepared some guiding principles to help the clinicians and the health care institutions in the decision-making process regarding the allocation of resources during the COVID-19 outbreak.17 Such recommendations can be very helpful in resolving the expected ethical dilemma which may affect the emotional health status of the overwhelmed health care providers, due to the high demand for clinical resources and the need to rationalize its use.

Finally, ensuring the continuum of care in cancer patients is vital and is considered a major priority during this time, as many hospitals and health care centers are overwhelmed with increased numbers of COVID-19 cases, high demand on medical supplies (including personal protective equipment), and shortages of health care providers in areas facing an especially high number of cases. Clinical judgment is paramount in determining whether to continue or withhold cancer therapy in patients with suspected or confirmed COVID-19. Health care providers caring for cancer patients are advised to review the latest, rapidly changing literature pertaining to cancer and COVID-19 to provide evidence-based management on a case-by-case basis. There is an urgent need for well-designed trials to identify the clinical consequences of continuing or withholding cancer therapy and the proper prevention, management, and treatment of COVID-19 in the oncology and hematology settings.

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Footnotes

The authors declare no conflicts of interest.

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REFERENCES

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- - Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies.[Biosci Trends. 2020] Gao J, Tian Z, Yang X Biosci Trends. 2020 Mar 16; 14(1):72-73.
- - Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.[Lancet Oncol. 2020] Liang W, Guan W, Chen R, Wang W, Li J, Xu K, Li C, Ai Q, Lu W, Liang H, Li S, He J Lancet Oncol. 2020 Mar; 21(3):335-337.
- - Risk of COVID-19 for patients with cancer.[Lancet Oncol. 2020] Wang H, Zhang L Lancet Oncol. 2020 Apr; 21(4):e181.
- - This Time I Mean It![J Natl Compr Canc Netw. 2020] Tempero M J Natl Compr Canc Netw. 2020 Jan; 18(1):1.
- - Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.[Lancet Oncol. 2020] Liang W, Guan W, Chen R, Wang W, Li J, Xu K, Li C, Ai Q, Lu W, Liang H, Li S, He J Lancet Oncol. 2020 Mar; 21(3):335-337.
- - Risk of COVID-19 for patients with cancer.[Lancet Oncol. 2020] Wang H, Zhang L Lancet Oncol. 2020 Apr; 21(4):e181.
- - This Time I Mean It![J Natl Compr Canc Netw. 2020] Tempero M J Natl Compr Canc Netw. 2020 Jan; 18(1):1.

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[PubMed] [Ref list]

https://www.jto.org/article/S1556-0864(20)30191-X/fulltext

[PubMed] [Ref list]

https://www.annalsofoncology.org/article/S0923-7534(20)36383-3/fulltext

www.bccancer.bc.ca/about/news-stories/news/2020/covid-19-and-cancer-treatments

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www.cancer.org.au/cancer-and-covid-19.html

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https://www.guidelines.co.uk/infection/covid-19-rapid-guideline-delivery-of-systemic-anticancer-treatments/455238.article

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www.esmo.org/newsroom/covid-19-and-cancer?hit=ehp

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www.rcr.ac.uk/college/coronavirus-covid-19-what-rcr-doing/coronavirus-covid-19-resources/coronavirus-covid-19-1

[PubMed] [Ref list]

www.fiercebiotech.com/biotech/dana-farber-md-anderson-ban-all-business-travel-over-covid-19

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www.facs.org/covid-19/ethics

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Correspondence

www.thelancet.com/oncology Vol 21 April 2020 e180

Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine (YX, RJ, WL, HS) and Department of Medical Oncology (JZ), Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310052, China

1 Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020; published online Feb 14. http://dx.doi.org/10.1016/ S1470-2045(20)30096-6.

2 Xu Z, Shi L, Wang Y, Zhang J, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020; published online Feb 18. https://doi.org/10.1016/ S2213-2600(20)30076-X.

3 Schreiber RD, Old LJ, Smyth MJ. Cancer immunoediting: integrating immunity’s roles in cancer suppression and promotion. Science 2011; 331: 1565–70.

4 Cai G. Bulk and single-cell transcriptomics identify tobacco-use disparity in lung gene expression of ACE2, the receptor of 2019-nCov. medRxiv 2020; DOI:10.1101/2020.02.05.20020107 (preprint).

5 Guan W-J, Ni Z-Y, Hu Y, et al. Clinical characteristics of 2019 novel coronavirus infection in China. medRxiv 2020; DOI:10.1101/2020.02.06.20020974 (preprint).

Risk of COVID-19 for patients with cancer We read the excellent Comment by Wenhua Liang and colleagues1 in The Lancet Oncology with great interest. Of 1590 cases with confirmed coronavirus disease 2019 (COVID-19), 18 patients had a history of cancer. The authors concluded that patients with cancer had a higher risk of COVID-19 and with a poorer prognosis than those without cancer.

First, the data in the Comment by Liang and colleagues1 showed a higher percentage of patients with cancer in the COVID-19 cohort than in the overall population. However, this observation is not sufficient to conclude that patients with cancer had a higher risk of COVID-19. The incidence of COVID-19 in patients with cancer would be more informative in assessing whether or not patients with cancer have an increased risk of COVID-19. Second, we reviewed the cancer history of the 18 individuals discussed in Liang and colleagues’ Comment.1 We are concerned that such a small sample size with a large amount of heterogeneity, presenting as various cancer types with different biological behaviours, highly variable disease courses (from 0–16 years), and diverse treatment strategies, might be filled with contingency and thus not ideally representative of the whole population with cancer. Notably, half of the patients with cancer had a disease course of more than 4 years, indicating that a substantial proportion of these patients might be clinically cured. Therefore, any conclusions that generalise to all patients with cancer should be interpreted with caution. Third, 13 (72%) of 18 patients with cancer had a history of surgical resection; the prolonged effects induced by surgery including immunosuppression should not be neglected. Comparison of patients with COVID-19 and surgical history

with and without cancer would be of interest.

Additionally, the authors reported that patients with cancer were prone to severe events (admission to the intensive care unit requiring invasive ventilation, or death) from COVID-19. Evidence indicates that overwhelming inflammation and cytokine-associated lung injury could be important in instigating these severe events in patients with COVID-19.2 However, accumulated evidence has shown that development of cancer is usually associated with a blunted immune status3 characterised by overexpressed immunosuppressive cytokines, suppressed induction o f p r o i n f l a m m a t o r y d a n g e r signals, impaired dendritic cell maturation, and enhanced functional immunosuppressive leukocyte populations, which is contradictory to the events believed to result in severe events in patients with COVID-19. Indeed, one of the potential explanations for differing susceptibility and prognosis is the higher rate of smoking history in the 18 patients with cancer. Data have shown that tobacco use significantly increases the gene expression of angiotensin- converting enzyme 2, the binding receptor for severe acute respiratory syndrome coronavirus 2, which could explain the elevated susceptibility to COVID-19 in smokers.4 Furthermore, cigarette smoking is the leading cause of chronic obstructive pulmonary disease, which has been identified as an independent risk factor in severe COVID-19 cases.5

Overall, current evidence remains insufficient to explain a conclusive association between cancer and COVID-19. We declare no competing interests.

Yang Xia†, Rui Jin†, Jing Zhao†, Wen Li, *Huahao Shen huahaoshen@zju.edu.cn

†Joint first authors

Published Online March 3, 2020 https://doi.org/10.1016/ S1470-2045(20)30150-9

Risk of COVID-19 for patients with cancer
- References

S P E C I A L I S S U E

Surge after the surge: Anticipating the increased volume and needs of patients with head and neck cancer after the peak in COVID-19

Ryan Bowman MS | Dana L. Crosby MD MPH | Arun Sharma MD MS

Department of Otolaryngology – Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA

Correspondence Arun Sharma, Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, 720N Bond Street, Springfield, IL 62794. Email: asharma74@siumed.edu

Abstract

The novel coronavirus disease 2019 (COVID-19) pandemic continues to have

extensive effects on public health as it spreads rapidly across the globe.

Patients with head and neck cancer are a particularly susceptible population to

these effects, and we expect there to be a potential surge in patients presenting

with head and neck cancers after the surge in COVID-19. Furthermore, the

impact of social distancing measures could result in a shift toward more

advanced disease at presentation. With appropriate anticipation, multi-

disciplinary head and cancer teams could potentially minimize the impact of

this surge and plan for strategies to provide optimal care for patients with head

and neck cancer.

KEYWORD S

COVID-19, head and neck cancer, novel coronavirus, SARS-CoV-2

1 | INTRODUCTION

Severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2), which causes the novel coronavirus disease 2019 (COVID-19), has had an unprecedented effect on the world and the medical community. The World Health Organization declared it a pandemic on March 11, 2019, and, as of April 25, 2020, more than 2.8 million people have been infected, resulting in over 200 000 deaths worldwide.1,2 COVID-19 has already had extraordinary effects on how multi- disciplinary head and neck cancer (HNC) teams provide HNC patients in initial hotspots such as Wuhan, China and in Italy as well as the United States and throughout the world.3-5 Following previous regional disasters such as Hurricane Katrina in 2008, there was an increase in incidence of patients pre- senting with advanced head and neck cancers.6 We should be prepared for a similar surge in this patient

population with the current pandemic after we pass the COVID-19 incidence peak. Although estimates of peak hospital resource use of the COVID-19 surge vary between models and geographic locations, estimates from the Institute of Health Metrics and Evaluation (IHME) estimate that the national peak was on April 17, 2020. However, estimated peaks from all states cur- rently range from April 4, 2020 to May 14, 2020 with the possibility of another surge in the coming months.7 The peak time of deaths from COVID-19 are roughly similar but include an even broader range of dates.

Multidisciplinary HNC teams need to be proactive in anticipating and preparing for the potential influx of HNC patients as public health guidelines shift from social distancing to containment strategies. By implementing tactics to mitigate and ultimately deal with this surge, patients with HNC can receive quality and prompt care without increased adverse outcomes.

Received: 26 April 2020 Accepted: 28 April 2020

DOI: 10.1002/hed.26260

2 | REASONS FOR THE SURGE AND WAYS TO PREVENT IT

Post-Hurricane Katrina, reduced access to cancer care was significantly associated with difficulty obtaining treatment.6 We believe that lack of timely access to care could lead to a similar post-COVID-19 surge of advanced stage HNC across the country. During these unprece- dented times, there are many reasons for which a patient may be evaluated later than usual. Patients themselves may fear visiting their doctor at the risk of potentially contracting COVID-19, while physicians have limited their schedules and a patient could be given a later appointment time. Clinics have limited their schedules in order to optimize the safety of their staff and their patients. Reasons for these restricted schedules include but are not limited to, lack of personal protective equip- ment (PPE), lack of rapid COVID-19 testing, lack of transportation, social distancing and shelter-in-place orders, limiting office visits for patients deemed high risk of contracting COVID-19, lack of access to telemedicine services, and staffing concerns. Fear of contracting COVID-19 has been shown to play a significant role in patients not seeking medical care. In Italy, hospital statis- tics from the period of March 1 to 27, 2020, showed sub- stantial decreases (ranging from 73% to 88%) in pediatric emergency department visits compared with the same time periods in 2018 and 2019. All parents who were sur- veyed reported avoiding hospitals for fear of infection with COVID-19.8 In light of this, patients and their pri- mary care physicians should be reminded that Otolaryn- gology – Head and Neck Surgery clinics are still open and consider patient safety the highest priority. This can be done through a variety of platforms such as social media, phone calls, emails, virtual town halls, and online patient portals just to name a few. Patients who are concerned about coming to clinic should be made aware that adequate precautions are in place to decrease the risk of contracting COVID-19 and when appropriate, can be offered telemedicine services.

3 | STRATEGIES TO MITIGATE THE HNC SURGE

Patients with HNC, along with otolaryngologists, are high- risk populations for contracting COVID-19, primarily because high viral loads of SARS-CoV-2 are located in the upper aerodigestive tract and procedures in this area (eg, endoscopy, tracheostomy, surgery, etc.) lead to aerosoliza- tion of viral particles.9 In addition to this, patients with HNC in particular may be susceptible to rapid deterioration and worse outcomes (eg, admission to an intensive care

unit, mechanical ventilation, and death) if they do contract COVID-19 due to coexisting comorbidites.10,11 Therefore, in order to manage the surge of patients with HNC, certain precautions and strategies must be implemented by otolar- yngologists to effectively treat these patients.12 First and foremost, ample PPE should be available before seeing any patients or doing any procedures. In association with this, preappointment screening should be done on all patients and (rapid) COVID testing should be utilized when avail- able and appropriate.13

Scheduling should be streamlined to allow for timely care. Telemedicine has been shown to be a valuable tool in this era, and although it comes with its’ own limita- tions, it can be optimized in order to provide care for patients with HNC.14,15 Visits that are expected to pre- dominantly involve reviewing results and counseling can be performed with telemedicine. One strategy would be to schedule all patients for telemedicine visits, except for those which require an in-office procedure (such as a biopsy or laryngoscopy) or for whom in-person physical examination is critical for decision-making (such as palpation of an oral tongue cancer).

Multidisciplinary care through a head and neck tumor board has been clearly shown to improve outcomes in patients with head and neck cancer.16-18 During the COVID-19 pandemic, utilization of a multidisciplinary decision-making is of critical importance, especially when there is an influx of many patients during a time of limited resources and high risk of COVID-19 transmission. In some situations, surgical and nonsurgical treatment options may have similar outcomes. In such situations, the preferred option is the one which allows for timely initia- tion of treatment while conserving resources and minimiz- ing risks to patients and healthcare workers. Given the complexity of such decisions and influence by evolving local and regional factors, multidisciplinary consensus is critical. Since many otolaryngologists whose practices do not focus on HNC may not be experiencing the clinical volume that they normally have, their clinical skills could be of critical importance in managing an influx of patients with HNC. Having these providers available to provide care for patients during the HNC surge could facilitate timely diagnosis, workup, and treatment. However, close monitoring of out- comes is necessary, as is always the case, to ensure that patients are receiving the highest level of care.

4 | CONCLUSION

COVID-19 continues to have widespread effects on the field of Otolaryngology – Head and Neck Surgery. In the coming weeks and months, there will very likely be a surge of patients with HNC with delayed presentations

BOWMAN ET AL. 1421

due to a host of reasons. By incorporating preventative measures and strategies aimed at addressing this post- COVID-19 surge, multidisciplinary HNC teams can provide these patients with the appropriate care they need.

ORCID Arun Sharma https://orcid.org/0000-0001-8038-7783

REFERENCES 1. Coronavirus (COVID-19) events as they happen. World Health

Organization. 2. COVID-19 Dashboard by the Center for Systems Science and

Engineering (CSSE) at Johns Hopkins University (JHU). https:// gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/ bda7594740fd40299423467b48e9ecf6 Accessed April 24, 2020.

3. Wu V, Noel CW, Forner D, et al. Considerations for head and neck oncology practices during the coronavirus disease 2019 (COVID-19) pandemic: The Wuhan and Toronto Experience. Head Neck. 2020. https://doi.org/10.1002/hed.26205.

4. De Felice F, Polimeni A, Valentini V. The impact of coronavi- rus (COVID-19) on head and neck cancer patients’ care. Radio- ther Oncol. 2020;147:84-85.

5. Brody R, Albergotti W, Shimunov D, Nicolli E, Harris B, Bur A. Changes in head and neck oncologic practice during the COVID- 19 pandemic. Head Neck. 2020. https://doi.org/10.1002/hed.26233.

6. Loehn B, Pou AM, Nuss DW, et al. Factors affecting access to head and neck cancer care after a natural disaster: a post- Hurricane Katrina survey. Head Neck. 2011;33(1):37-44.

7. COVID-19 Projections. https://covid19.healthdata.org/united- states-of-america Accessed April 25, 2020.

8. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adole Health. 2020;4(5):e10-e11.

9. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020;382(12):1177-1179.

10. Yan F, Nguyen SA. Head and neck cancer: a high-risk popula- tion for COVID-19. Head Neck. 2020. https://doi.org/10.1002/ hed.26209.

11. Guan WJ, Liang WH, Zhao Y, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: a nationwide analy- sis. Eur Respir J. 2020;2000547. https://doi.org/10.1183/ 13993003.00547-2020.

12. Crosby DL, Sharma A. Evidence-based guidelines for manage- ment of head and neck mucosal malignancies during the COVID-19 pandemic. Otolaryngol Head Neck Surg. 2020. https://doi.org/10.1177/0194599820923623.

13. Patel RJ, Kejner A, McMullen C. Early Institutional head and neck oncologic and microvascular surgery practice patterns across the United States during the SARS-CoV-2(COVID19) pandemic. Head Neck. 2020. https://doi.org/10.1002/hed.26189.

14. Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020.382:1679–1681. https://doi.org/ 10.1056/NEJMp2003539.

15. Prasad A. Optimizing your telemedicine visit during the covid- 19 pandemic: practice guidelines for head and neck cancer patients. Head Neck. 2020. https://doi.org/10.1002/hed.26197.

16. Liu JC, Kaplon A, Blackman E, Miyamoto C, Savior D, Ragin C. The impact of the multidisciplinary tumor board on head and neck cancer outcomes. Laryngoscope. 2020;130(4): 946-950.

17. Shah BA, Qureshi MM, Jalisi S, et al. Analysis of decision making at a multidisciplinary head and neck tumor board incorporating evidence-based National Cancer Comprehensive Network (NCCN) guidelines. Pract Radiat Oncol. 2016;6(4):248-254.

18. Lewis CM, Nurgalieva Z, Sturgis EM, Lai SY, Weber RS. Improv- ing patient outcomes through multidisciplinary treatment plan- ning conference. Head Neck. 2016;38(S1):E1820-E1825.

How to cite this article: Bowman R, Crosby DL, Sharma A. Surge after the surge: Anticipating the increased volume and needs of patients with head and neck cancer after the peak in COVID-19. Head & Neck. 2020;42:1420–1422. https://doi.org/10. 1002/hed.26260

1422 BOWMAN ET AL.

S P E C I A L I S S U E

Management of dysphagia in the patient with head and neck cancer during COVID-19 pandemic: Practical strategy

Peter K. M. Ku MD1,2 | Floyd Christopher Holsinger MD3 |

Jason Y. K. Chan MD2 | Zenon W. C. Yeung MD1 | Becky Y. T. Chan MSc4 |

Michael C. F. Tong MD2 | Heather M. Starmer MA, CCC-SLP, BCS-S3

1Department of Otorhinolaryngology— Head and Neck Surgery, United Christian Hospital and Tseung Kwan O Hospital, Tseung Kwan O, Hong Kong 2Department of Otorhinolaryngology— Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong 3Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University, Palo Alto, California 4Department of Speech Therapy, Prince of Wales Hospital, Shatin, Hong Kong

Correspondence Peter K. M. Ku, MD, Department of Otorhinolaryngology—Head and Neck Surgery, United Christian Hospital and Tseung Kwan O Hospital, 2 Po Ning Lane, Han Hou, Tseung Kwan O, Hong Kong. Email: pkukm@yahoo.com

Abstract

The global pandemic of 2019 novel coronavirus disease (COVID-19) has tremen-

dously altered routine medical service provision and imposed unprecedented

challenges to the health care system. This impacts patients with dysphagia com-

plications caused by head and neck cancers. As this pandemic of COVID-19

may last longer than severe acute respiratory syndrome (SARS) in 2003, a practi-

cal workflow for managing dysphagia is crucial to ensure a safe and efficient

practice to patients and health care personnel. This document provides clinical

practice guidelines based on available evidence to date to balance the risks of

SARS-CoV-2 exposure with the risks associated with dysphagia. Critical consid-

erations include reserving instrumental assessments for urgent cases only, opti-

mizing the noninstrumental swallowing evaluation, appropriate use of personal

protective equipment (PPE), and use of telehealth when appropriate. Despite

significant limitations in clinical service provision during the pandemic of

COVID-19, a safe and reasonable dysphagia care pathway can still be

implemented with modifications of setup and application of newer technologies.

KEYWORD S

coronavirus, COVID-19, dysphagia, head and neck, management

1 | INTRODUCTION

The worldwide health care system has been inundated by a sudden surge of suspected and confirmed cases of the novel coronavirus disease (COVID-19) since the World Health Organization declared the global pandemic of this viral ill- ness on March 11, 2020. In just over a month, 1 914 916 confirmed cases of COVID-19 were reported globally with 123 010 deaths by April 14, 2020.1 This represents a 10-fold increase in confirmed cases and 15-fold increase in deaths since the declaration of pandemic. Although this global pandemic has flooded and imposed unprecedented

challenges to the health care system, the global shortage of personal protective equipment (PPE) has created extra burden to frontline health care personnel.

There are 550 000 new cases of head and neck cancer (HNC) registered worldwide per year.2 The incidence of HNC is not anticipated to be affected by pandemic of COVID-19. Dysphagia is one of the most common com- plaints for HNC patients before, during, and after treat- ment. These patients often require multidisciplinary care by speech-language pathologists (SLPs) and otolar- yngologists in dedicated swallowing disorders clinics. A detailed symptom inventory, oromotor examination,

Received: 15 April 2020 Accepted: 20 April 2020

DOI: 10.1002/hed.26224

clinical swallowing assessment, objective instrumental swallowing studies, swallowing intervention, and moni- toring of progress are still essential for these patients during the COVID-19 pandemic. However, given the significant challenges involving transmission risk and limited PPE, alteration to the typical provision of swallowing services must be considered during this out- break. As this pandemic of COVID-19 may last longer than severe acute respiratory syndrome (SARS) in 2003, a practical workflow for managing dysphagia is of utmost importance. In these clinical guidelines, we propose a strategic plan to facilitate safe practice in dys- phagia management for health care personnel and patients with dysphagia, without jeopardizing the stan- dard of care.

2 | SELECTION OF SWALLOWING STUDIES

Fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing studies (VFSS; also sometimes called modified barium swallow) are two com- mon instrumental swallowing studies. During FEES examination, a fiberoptic endoscope is passed by the cli- nician through the nose of the patient into the pharynx, which allows observation of anatomy of the pharynx/ larynx, management of saliva and food/liquid boluses, coordination of the pharynx, tongue, and larynx during swallowing, and presence of laryngeal penetration or aspiration into the airway. It is commonly performed by SLPs and otolaryngologists. VFSS utilizes real-time X-ray to assess the different phases of swallowing and swallowing physiology as the bolus passes through the oral cavity, pharynx, and upper cervical esophagus using barium impregnated food materials of different consis- tencies. It allows for observation of swallowing biome- chanics and any consequences of dysfunction including penetration and aspiration of food materials into the airway. VFSS is typically performed by radiologists and SLPs. Although FEES and VFSS have their own merits and limitations, both can be used to assess patients with HNCs.

Although both VFSS and FEES are appropriate tests to utilize in assessment of swallowing, in the context of the COVID-19 outbreak, clinicians need to consider relative risk with these procedures. The higher risk of aerosolization of matter from the nasal passage and nasopharynx with FEES may suggest that VFSS may be the safer option in the current climate. In addition, some centers may still practice testing of laryngeal sensation by air-pulse stimulator that fires air-pulses in 50 millisec- onds duration with pressure from 2 to 10 mmHg to elicit

the reflexive twitching of vocal cords before endoscopic evaluation of swallowing.3,4 These air-pulses may either create air current in the pharynx or induce cough if the air pressure is high, which may generate droplets and aerosol. In light of the pandemic of COVID-19, suspen- sion of laryngeal sensory testing and FEES examinations should be seriously considered to minimize aerosol generation.

3 | SELECTION OF PERSONAL PROTECTIVE EQUIPMENT

Recent studies reported the R0 of SARS-CoV-2 ranged from 5.71 to 7.23,5 which is higher than SARS-CoV (2-4) in 2003.6 Therefore, the virulence of COVID-19 is far higher than SARS and may well explain the seemingly uncontrolled pandemic of COVID-19 in many countries. There has been some confusion throughout the health care community with regard to droplet vs aerosol trans- mission of COVID-19, and subsequently the different levels of PPE required to minimize transmission risk. Aerosol is formed by droplets of smaller sizes, usually smaller than 5 μm in diameter, allowing them to remain suspended in the air, to travel longer distances, and to penetrate face masks with larger pore sizes. High-level PPE such as N95 respirators are mandatory with any aerosol generating procedures (AGPs). The recent find- ings of hyposmia, anosmia, and dysgeusia in a sizable proportion of confirmed COVID-19 cases may suggest a higher viral load in the nasal cavity/nasopharynx.7 Based on the observation of high viral shredding of coronavirus in the nasal passage/nasopharynx8 and anecdotal evidence of increased risk of transmission in the otolar- yngology community, use of positive airway power respirators (PAPRs) has been advocated for any nasal procedures which generate aerosol. This recommenda- tion would thus apply to FEES exams.

Evidence shows coughing can generate droplets of size from 0.1 to 100 μm, which lie in the range of aerosol generation.9 Therefore, we can categorize pro- cedures that may induce coughing, such as FEES and VFSS, as AGP and recommend adoption of the highest level of PPE with face shield or goggles, N95 respira- tor, and isolation gown when undertaking these procedures. Face shield can practically provide more coverage to the eyes and face and prevent contamina- tion of the facial skin which is commonly overlooked by most health care personnel during doffing of PPE leading to later transmission of virus through the nose and eyes through hand spread. Careful donning and doffing of isolation gowns is critical to minimize potential contamination.

1492 KU ET AL.

FIGURE 2 Workflow for swallowing studies in head and

neck patients during COVID-19

pandemic. NPS, nasopharyngeal

swab; PAPR, positive airway

pressure respirator; PCR,

polymerase chain reaction; PPE,

personal protective equipment;

SAR-CoV-2, novel coronavirus

FIGURE 1 Audiovisual facilities for fiberoptic endoscopic

evaluation of swallowing with

IQAir air filter in a room [Color

figure can be viewed at

wileyonlinelibrary.com]

KU ET AL. 1493

4 | SCREENING AND TIMING OF EXAMINATION

FEES and VFSS can trigger sneezing and/or coughing, leading to aerosolization during the procedure. The unpublished data of 982 patients attending the combined dysphagia clinic in Prince of Wales Hospital showed that of those with dysphagia following HNC treatment, nearly 80% had impaired laryngeal protective reflex. Thus, the incidence of intense coughing during FEES and VFSS may be low in patients with HNC as their nose and phar- ynx are less sensitive to instrumentation and penetra- tion/aspiration. However, as evidence shows speaking can generate a sufficient amount of droplets to transmit SARS-CoV-2,10 and patients are generally not able to wear a face mask during the swallowing evaluation, we should be more conservative when considering these instrumental swallowing procedures. If the condition is not urgent, we suggest postponing any FEES or VFSS for 14 days, as suggested according to the incubation period of COVID-19 in any high-risk patients based on history (travel, occupation, contact, and clustering phenomenon as TOCC) and symptomatology such as fever, cough, shortness of breath, and expectorant. It must also be con- sidered that the patient must self-isolate for that 14-day period in order for the health care team to be confident of low risk for completion of the swallowing assessment. In addition, olfactory disturbance has been noticed to occur in high proportion of confirmed cases of COVID-19 (15%-60%) globally, and can be an early or solitary symp- tom of infection.11 With more supporting evidence in our unpublished data on smell loss (47%) and taste loss (45%) in COVID-19 confirmed patients, smell and taste distur- bance may serve as markers for potential COVID-19 to enhance surveillance in clinic. For patients who require urgent swallowing evaluation in extenuating circum- stances (such as acute status change or newly diagnosed aspiration pneumonia), SARS-CoV-2 testing or full aero- sol PPE are recommended to minimize transmission risk.

4.1 | Setup of examination environment for dysphagia evaluation

VFSS is preferable to FEES in the current situation of COVID-19 as it does not involve invasive instrumentation during the procedure and the administering clinician (SLPs, radiologists, or otolaryngologists) can maintain a greater distance from the patient while the examination is undertaken. However, it does require patients to be trans- ferred to radiology department. As most radiology depart- ments do not have negative pressure rooms for containment of any airborne particulates during VFSS, the

use of IQAir HealthPro (Incen AG, Thal, Switzerland) air- filter with high-efficiency particulate air (HEPA) class H13 filtration system is recommended. The filter is capable of screening 99.97% of all particles >0.3 μm and would be able to filter any micro-droplets and aerosol generated dur- ing VFSS during coughing events. In contrast to VFSS, FEES is more portable and can be moved into negative pressure ventilation rooms. Thus, it may be the preferred option for SARS-CoV-2 positive patients or those under investigation if assessment must be performed in an urgent manner. Preferably, FEES would also be performed in a room with setup of IQAir air-filter for all patients to reduce environmental contamination by respiratory droplets dur- ing the COVID-19 pandemic (Figure 1). Figure 2 summa- rizes the workflow for instrumental swallowing evaluation in patients with HNC during the COVID-19 pandemic.

5 | ROLE OF SLPs AND DYSPHAGIA CLINICIANS IN PATIENTS WITH HNC DURING COVID-19 PANDEMIC

Although instrumental assessment of swallowing should be limited during the COVID-19 pandemic, SLPs and dysphagia clinicians (DCs) must still find ways to appro- priately evaluate and manage patients with suspected dysphagia. Various tools may be implemented to obtain the most objective, comprehensive evaluation possible. The clinical swallowing assessment should include a thorough case history, evaluation of oral motor and laryngeal function, and oral trials of food and liquid. The Mann Assessment of Swallowing Ability—Cancer12 may be utilized to quantify the degree of swallowing impair- ment, though multiple items may be difficult to capture if conducted through telehealth. When the clinical evalua- tion is conducted through telehealth, advanced prepara- tion is necessary to ensure the patient has appropriate food and liquid boluses available. Providing the patient with the International Dysphagia Diet Standardization Initiative13 diet-level descriptions in advance will allow the clinician to better understand the complexity of the boluses administered. Additional considerations for per- formance of a clinical evaluation through telehealth is use of clear feeding instruments to allow the clinician to best gauge the size of bolus presented, use of food color- ing in boluses to increase visibility, and application of colored tape at the level of the thyroid cartilage to aid in visualization of laryngeal elevation during the swallow.14

A clinical swallowing evaluation, whether in person or via telehealth should be combined with quantitative swallowing measures to minimize the potential for bias. A number of patient-reported outcome (PRO) measures

1494 KU ET AL.

and clinician-rated scales have been validated for use in the population with HNC. The MD Anderson Dysphagia Inventory is a 20-item PRO that can be used to capture the patient’s perception of their swallowing difficulties and has been broadly used in the population with HNC and adapted and validated in many languages.15,16 Other swallowing-specific PROs include the Eating Assessment Tool-10,17 the Sydney Swallow Questionnaire,18,19 and the Royal Brisbane Hospital Outcome Measure for Swallowing.20 In addition to PROs, there are several clinician-related tools that can be utilized to quantify dys- phagia and its outcomes. The Performance Status Scale Head and Neck21 has two items that are routinely admin- istered to quantify dysphagia impact: the normalcy of diet subscale and the eating in public subscale. Furthermore, the Functional Oral Intake Scale22 and Food Intake Level Scale23 can provide additional information about diet level with regard to tube feeding use. This combination of thorough case history, clinical observation, PROs, and clinician rating scales can provide the clinician with needed information to guide recommendations and treat- ment planning until instrumental assessment becomes more readily available.

It is important for the SLPs and DCs to recognize the limitations of noninstrumental methods of swallowing evaluation. Although agreement between telehealth and in-person clinical swallowing evaluations is good, there are limitations to clinical evaluations, particularly in patients with more severe dysphagia.24 Thus, clinicians may need to adopt a more conservative approach to dys- phagia management with close attention to potential markers of complications such as increased cough, fever, and weight loss. In those circumstances, the benefits of completing an instrumental evaluation may outweigh the disadvantages. Given higher risks associated with aero- solization and close proximity during FEES exams, the modified barium swallow would be the preferred tool during the COVID-19 outbreak.

In addition to dysphagia diagnostics, swallowing ther- apy also may need to be adapted during the pandemic. In general, swallowing therapy should be reserved for telehealth whenever possible to minimize transmission risk. There is a paucity of evidence on the benefits of telehealth in dysphagia therapy, but there is some sugges- tion of improved treatment adherence in patients receiv- ing telehealth in comparison with patient-lead home treatment.25 In addition to telehealth, other technology- driven options such as mobile applications may play a role when available.26,27 Swallowing therapists should strive to adapt their virtual visits to provide the highest level of care possible. Postirradiated patients with history of virally mediated nasopharyngeal and oropharyngeal cancer may find these mobile app and telehealth options

very beneficial because they are relatively young, inde- pendent, knowledgeable, and receptive to the use of technology. Engaging home caregivers and advanced planning of materials needed may help to facilitate treat- ment sessions. Table 1 summarizes the guidelines for telehealth in swallowing management.

6 | CONCLUSIONS

In the global pandemic of COVID-19 disease when the health care system is under unprecedented pressure, any implementation of medical care should be prioritized according to urgency and safety. Dysphagia can be poten- tially life threatening if left unattended as it may cause aspiration pneumonia or airway obstruction. Although we suggest deferring any nonurgent instrumental swallowing studies, particularly in patients considered at high risk for COVID-19 based on TOCC and acute respiratory symp- toms, screening and assessment of swallowing function can still be possible through telehealth using various non- instrumental methods. Such assessments can help to miti- gate risks associated with dysphagia and to triage those patients most in need of instrumental evaluation. Telehealth can also be used to implement swallowing training, for monitoring, and to review progress as well as to engage home caregivers and plan future services. In cases where instrumental assessment is deemed neces- sary, we advocate for adoption of conservative, high-level PPE use to minimize risk to patients and health care providers.

TABLE 1 Guidelines for telehealth in swallowing therapy

Type of patients 1. Inpatient • Active cases

2. Outpatient/day hospital/community speech therapy cases • Active cases • New cases with history known to

the clinicians

Selection criteria 1. Patients/carers receptive to telehealth with needed equipment

2. Problems that can be tackled by education, advice, monitoring, and indirect training. For example, monitoring of diet tolerance, meal observation, swallowing exercises, oromotor exercises, education on feeding techniques, and diet modification

Intervention Patient and carer education and advice, home exercise program prescription, home program delivery and monitoring, communication for discharge planning

KU ET AL. 1495

ORCID Floyd Christopher Holsinger https://orcid.org/0000- 0002-9594-1414 Jason Y. K. Chan https://orcid.org/0000-0002-9480- 4637 Zenon W. C. Yeung https://orcid.org/0000-0003-4643- 6240 Heather M. Starmer https://orcid.org/0000-0002-1716- 9852

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How to cite this article: Ku PKM, Holsinger FC, Chan JYK, et al. Management of dysphagia in the patient with head and neck cancer during COVID-19 pandemic: Practical strategy. Head & Neck. 2020;42: 1491–1496. https://doi.org/10.1002/hed.26224

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