COVID-19 Causes Major Treatment Modifications in Head and Neck Cancer

Nabil F. Saba, MD, FACP

The coronavirus disease 2019 (COVID-19) has created a unique set of challenges in the head and neck cancer paradigm, as related to the age and fitness of patients, the increased susceptibility to viral transmission through oral cavity examination, and the need for multidisciplinary treatment, according to Nabil F. Saba, MD, FACP.

Such challenges have led to the rapid implementation of telehealth, rotation schedule modifications for physicians, and new surgical guidance.

"We are adapting," said Saba. "As more time progresses, the more we are able to adapt to the situation. We are making changes that I believe will last even after the pandemic is gone. Sometimes it takes a crisis to induce people, including health care workers, to make the necessary changes to improve care for patients."

In an interview with OncLive, Saba, director of the Head and Neck Medical Oncology Program at Winship Cancer Institute of Emory University, professor in the Department of Hematology and Medical Oncology and Department of Otolaryngology at Emory University School of Medicine, discussed how the COVID-19 pandemic has impacted treatment in head and neck cancer and the health care system at large.

OncLive: How has the COVID-19 pandemic altered your practice?

Saba: Things have been drastically changing since the COVID-19 pandemic [started]. This has affected our day-to-day life in the cancer center and the way we practice. My schedule has completely changed. In regard to the clinic schedule, the rotation of physicians who are covering the clinic has changed. As you can imagine, it has really had a drastic effect on our patients.

At the cancer center, each of us spend a long time, every day, reviewing information, going over ways to implement new methods to try to overcome this [virus], and trying to cope with the current situation.

How has the virus impacted treatment plans for patients?

At the cancer center, we are trying to rely on telehealth. We are trying to structure the clinics so that patients who are healthy enough to be treated and managed remotely can take advantage of this possibility.

Regarding head and neck cancer, we really have 2 groups of patients. One group consists of patients who have relatively good disease. They may be in a follow-up period after definitive therapy or have advanced disease that is under control. [Those patients] are not getting high-dose cytotoxic chemotherapy that would put them at high-risk [of COVID-19]. Those patients are likely the best candidates for remote visits and telehealth.

The problem arises with patients who present with an acute illness that requires immediate care. We know that cancer in general is a dreadful disease and an inherently life-threatening condition. Therefore, when you add another life-threatening situation, such as COVID-19, it complicates matters for our patients who need acute intervention and care.

Patients with head and neck cancer need to be seen by multiple specialists. It's unlike other cancers. The blessing, but also the curse, of head and neck cancer is that it requires a multidisciplinary approach to treatment. We have the blessing of having multiple specialists taking care of patients. During this crisis, the surgical aspect has been affected to a great extent. Because of our multidisciplinary approach to treatment, many of these patients [have been] offered alternative modalities to surgery until a surgical approach can be offered.

In this period of time where social distancing is important, it becomes challenging to limit the health care team that is [allowed] in the clinic. We typically have multiple people in the same location trying to manage patients with acute problems.

This [issue] is compounded by the fact that head and neck cancer is inherently a disease where you need to examine the patient's oral cavity to look into the airway. We rely on that to be able to diagnose the disease and monitor patients.

If the patient's disease is relatively under control, it likely makes sense to follow them through telehealth. Additionally, there may be some ways to remotely examine patients' lesions.

However, when you are dealing with a newly diagnosed patient who has a life-threatening disease and requires immediate intervention, it becomes difficult to manage these patients through telehealth. Those patients need to be in the clinic for the initial evaluation and endure treatments that are already harsh for them in a normal situation. Now we are adding COVID-19 to the mix.

Surgery is taxing on the patient's day-to-day life, and the recovery period is slow and difficult. Daily radiation or chemoradiation for 6 weeks is also taxing.

In head and neck cancer, we don't have the luxury of de-intensifying therapy because our ultimate goal is to cure patients. When you have a patient who requires immediate intervention, deintensification is not really an option.

Have there been situations where you have been able to delay surgery or radiation in patients?

In general, we don't want to delay [treatment] because many of these patients need immediate care. However, we've been forced to delay interventions in many cases. Our surgical colleagues have been greatly affected by [COVID-19]. In the operating room, the nature of their work is to utilize the equipment [we need] to ration for the potential surge of patients who [present with] COVID-19.

In addition, there is a high risk when you manipulate and examine the patient's airway as we have seen from China and other countries. When you look into a patient's oral cavity during intubation, the chance of transmitting COVID-19 becomes high. This poses a major problem to those patients who require surgery.

We've created a sort of emergency mini-tumor conference where usually 3 of us representing surgery, medical oncology, and radiation oncology meet remotely on very short notice to briefly go over the cases that are scheduled for surgery or definitive therapy. Those are the most acute cases; we aren't talking about follow-ups or patients who are in progress.

We make decisions based on different factors, such as what is happening in the operating room and whether surgeries are allowed to happen that week. For example, this week has been better than 2 weeks ago when our operating rooms [limited patients from having] elective surgeries. This week, [surgeries] have been somewhat easier to schedule. Another factor is how acutely ill the patient is. When we look at different factors in a normal situation like the patient's age, and whether they are likely to tolerate the [proposed regimen], we need to see the patient.

We have been very busy not just dealing with COVID-19, but dealing with the ramifications of the virus on our patients.

Are you limiting the use of immunotherapy?

This is a very good question that we still need to learn more about. In head and neck cancer, we tend to use high-dose chemotherapy. However, high-dose chemotherapy, even though it is fairly toxic when you combine it with radiation, is not usually as immunosuppressive as the chemotherapy you would use in a patient with leukemia or breast cancer. We typically use cisplatin combined with radiation. The main toxicities include kidney toxicity, which we take care of by making sure the patient is well hydrated. Other common toxicities include neuropathy and hearing loss. Cisplatin in general is not very immunosuppressive because of these other limiting toxicities. In that sense, we are still somewhat blessed compared with some of our other colleagues.

However, I would say that we also deal with a patient population that has smoking-related cancers and patients who tend to have comorbidities linked to smoking. Of course, we have our HPV-positive patient population that is usually healthier and younger.

Additionally, because head and neck cancer tends to occur in an older patient population, these patients are at a higher risk of developing complications from COVID-19. They may have comorbidities that increase that risk as well.

Therefore, even though our treatment may not be as immunosuppressive, we are not dealing with a young, relatively healthy patient population. A large portion of patients with head and neck cancer tend to be older, frail, and at a high-risk of developing complications.

Your practice is based in Atlanta, Georgia. How has this city responded to the crisis?

Thus far in the Atlanta health care system, including our academic center at Emory University, it has been able to manage well, despite the fact that we have had a surge of patients with COVID-19. This surge has not broken the health care system or put us in a dire situation where we are not able to cope. We've been able to cope well.

I am hoping that because of the aggressive social distancing we've observing that things will continue to improve over the next few weeks.

The world is rapidly changing, and the world of communication is rapidly changing. We're able to at least communicate and keep in connection with our patients and colleagues. If it were not for [technology], we would be in a very different situation.

Additionally, health care and the treatment of patients with cancer is evolving. Those 2 worlds have to take advantage of what is happening in the world and implement these new tools to improve patient care and patient satisfaction. We've been forced to do that at some level [because of the current situation]. It is a good, healthy step for many cancer centers and for health care in general [to evolve with the times].

Is there anything else you would like to share?

It is important to remember different aspects of what we do in general. [The COVID-19 pandemic] has had an effect on our trainees, residents, and fellows. They are in a period of time where they need to [have as much hands-on learning] as possible. They need to see patients and be with the attending physicians to learn how to manage patients on a day-to-day basis.

I think we may have forgotten about this aspect, but it is an important aspect [of the conversation]. We're training the future physicians while we are dealing with this crisis. Our fellows and residents are stepping up to the plate to manage the situation, but because we are all under so much stress, we tend to not pay much attention to this.