CONFLICT OF INTEREST
None declared.
ETHICAL APPROVAL
As per institutional policy, this project was registered with local hospital's clinical effectiveness register. Project number was 10787.
AUTHOR CONTRIBUTIONS
Study concept and design: All. Data acquisition: LU. Data analysis and interpretation: LU and MSI. Statistical analysis: SM. Manuscript preparation and finalisation: All.
Dear Editor,
During the COVID‐19 pandemic, it was postulated that there might be a delay in cancer patients' presentation, stage migration and changes in management leading to excess cancer mortality. 1 However, there is a paucity of real‐time objective data to support this, particularly in HNC. In our HNC multidisciplinary team (MDT), approximately 300 new patients present annually. The purpose of this observational study was to assess the impact of COVID‐19 on the presentation, stage and management pattern on newly presented HNC patients during the pandemic era.
The data on all newly diagnosed HNC patients at our centre during April–December 2020 (COVID‐19 cohort) were collected, and it was compared against the baseline pre‐COVID‐19 cohort (all new HNC patients diagnosed between April and December 2019). The comparative variables included patients' demographics, TNM/overall stage, primary site of disease, treatment intention (radical versus palliative) and detail of treatment modality. Chi‐squared and Fisher's exact test was used for categorical variables, and Student's t‐test was used for continuous variables.
There was 33% decrease in new confirmed HNC cases during COVID‐19 (150 vs. 223 patients). There was significant reduction in T1 stage (25.0% vs. 36.3%; p 0.003) and significant increase in T4 stage at presentation during the COVID‐19 period (36.5% vs. 25.0%; p 0.022). This T‐stage up‐migration led to reduction in overall stage I (14.0% vs. 25.1%; p 0.009) and increase in overall stage IVb (13.3% vs. 5.8%; p 0.012). Reviewing management intent, there appeared to be almost 7% increase in palliative intent between cohorts, although this difference was not statistically significant; however, there was a significant reduction in radical surgery as the only treatment modality (20.0% vs. 30.9%; p 0.023). These results are summarised in Table 1. Our MDT took a pragmatic approach to surgical treatment throughout the pandemic. Theatre capacity was significantly reduced, but we were able to maintain therapeutic and diagnostic capacity for cancer patients where required. Treatment with curative intent was still offered to all appropriate patients. For a brief period in the first wave of the pandemic (March/April 2020), transoral robotic surgery was suspended for patients who had radiotherapy as an alternative, offering an equal chance of cure. Subsequent to this initial pause, surgical treatment has continued to be offered as per pre‐pandemic decision‐making. Throughout the pandemic, cases requiring surgery with reconstruction (e.g., laryngectomy, laryngopharyngectomy and oral cavity resection) continued as per pre‐pandemic practice.
TABLE 1.
A comparative table of patients' characteristics with significance in differences
| Characteristic | 2019 (n = 223) | 2020 (n = 150) | Significance |
|---|---|---|---|
| Mean age (SD) | 67.2 (11.4) | 66.0 (11.1) | 0.313 |
| Gender (% of cohort) | 0.770 | ||
| Male | 165 (74%) | 113 (75.3%) | |
| Female | 58 (26%) | 37 (24.7%) | |
| Primary malignancy (% of cohort) | |||
| Oropharynx | 87 (39.0%) | 44 (29.3%) | 0.055 |
| Oral cavity | 57 (25.6%) | 35 (23.3%) | 0.625 |
| Larynx | 47 (21.1%) | 29 (19.3%) | 0.697 |
| Hypopharynx | 15 (6.7%) | 25 (16.7%) | 0.003 |
| Nasopharynx | 3 (1.3%) | 2 (1.3%) | 1.000 |
| Others | 14 (5.2%) | 14 (9.3%) | 0.210 |
| TNM staging, AJCC seventh edition (% of cohort) | |||
| T0 | 4 (1.8%) | 5 (3.4%) | 0.493 |
| T1 | 81 (36.3%) | 37 (25.0%) | 0.022 |
| T2 | 57 (25.6%) | 27 (18.2%) | 0.099 |
| T3 | 32 (14.3%) | 25 (16.9%) | 0.506 |
| T4 | 49 (22.0%) | 54 (36.5%) | 0.002 |
| N0 | 100 (44.8%) | 58 (38.9%) | 0.258 |
| N1 | 12 (5.4%) | 10 (6.7%) | 0.594 |
| N2 | 105 (47.1%) | 74 (49.7%) | 0.626 |
| N3 | 6 (2.7%) | 7 (4.7%) | 0.302 |
| M | 0.296 | ||
| 0 | 217 (97.3%) | 141 (95.3%) | |
| 1 | 6 (2.7%) | 7 (4.7%) | |
| Overall staging, AJCC seventh edition (% of cohort) | |||
| I | 26 (25.1%) | 21 (14.0%) | 0.009 |
| II | 18 (8.1%) | 9 (6.0%) | 0.449 |
| III | 21 (9.4%) | 18 (12.0%) | 0.424 |
| IV | 128 (57.4%) | 101 (67.3%) | 0.053 |
| IVa | 109 (48.9%) | 76 (50.7%) | 0.735 |
| IVb | 13 (5.8%) | 20 (13.3%) | 0.012 |
| IVc | 6 (2.7%) | 5 (3.3%) | 0.761 |
| Treatment intent | |||
| Radical | 190 (85.2%) | 118 (78.7%) | |
| Palliative | 33 (14.8%) | 32 (21.3%) | |
| Treatment modality | |||
| Radical surgery only | 69 (30.9%) | 30 (20.0%) | 0.023 |
| Surgery + adjuvant (chemo)radiotherapy | 48 (23.5%) | 40 (26.7%) | 0.752 |
| Radical (chemo)radiotherapy | 67 (30.0%) | 47 (31.3%) | 0.876 |
| Palliative radiotherapy | 19 (8.5%) | 15 (10.0%) | 0.626 |
| Palliative chemotherapy | 0 | 1 (0.7%) | 0.402 |
| Best supportive care | 16 (7.2%) | 13 (8.7%) | 0.598 |
Bold values indicate significant differences (p < 0.05).
The COVID‐19 pandemic, associated national lockdown with a reduction in diagnostic services and disruption in care delivery, is leading to unintended consequences in long‐term morbidity. 2 There have been reports of a decrease in referrals with suspected HNC, 3 but there is lack of published numerical data on any actual reduction in confirmed cases and if this has impacted on the patterns of care.
To the best of authors' knowledge, this is first such report confirming the relative change in T‐stage and overall upstage migration in patients with HNC. Our study also showed that there was a trend towards an increased use of palliative treatment and significant reduction in use of radical surgery as sole treatment modality, suggesting that the pandemic is likely to impact long‐term survival of HNC patients.
1. ACKNOWLEDGEMENT
The authors acknowledge Sam Morrison for providing patient's list.
DATA AVAILABILITY STATEMENT
Anonymised data will be shared on individual's request.
REFERENCES
- 1. Maringe C, Spicer J, Morris M, et al. The impact of the COVID‐19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population‐based, modelling study. Lancet Oncol. 2020;21(8):1023‐1034. Erratum in: Lancet Oncol. 2021;22(1):e5. 10.1016/S1470-2045(20)30388-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Patt D, Gordan L, Diaz M, et al. Impact of COVID‐19 on cancer care: how the pandemic is delaying cancer diagnosis and treatment for American seniors. JCO Clin Cancer Inform. 2020;4:1059‐1071. 10.1200/CCI.20.00134 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Taylor R, Omakobia E, Sood S, Glore RJ. The impact of coronavirus disease 2019 on head and neck cancer services: a UK tertiary centre study. J Laryngol Otol. 2020;134(8):684‐687. 10.1017/S0022215120001735 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Anonymised data will be shared on individual's request.