The impact of Coronavirus (COVID-19) on head and neck cancer patients' care.

To monitor and defeat further progression of the novel Coronavirus (COVID-19) infection, a strong public health vigilance has been adopted in Italy [1]. By March 18, 31,772 cases were confirmed, with 2390 deaths [2]. The median age of patients who are infected is 63 years and more than two-thirds of deaths have occurred in elderly patients (aged ≥70 years) [2]. Hospitals’ work regimes have been re-prioritized, but Coronavirus does not really affect the cancer clinics. Although radiation oncologists are not fighting on the front line, they have to guarantee treatment – radiotherapy with or without concomitant chemotherapy ((C)RT) – and, in the meantime, protect patients from the COVID-19 infection.

In this scenario, (C)RT has a crucial role in head and neck cancer (HNC) management. It is the mainstay of treatment for most of the HNC sites, because of its proven curative intent assuring an organ preservation strategy [3], [4]. HNC is a relatively rare cancer in Italy, with 9300 new cases and 3216 deaths described per year [5]. Most of the patients are diagnosed in a locally advanced stage disease and should receive treatment as soon as possible. Therefore, during this pandemic period, HNC patients represent a major clinical problem with treatment decision-making process. Due to the complexity in optimal strategy plan and patients’ support care through treatment, the multidisciplinary team should weigh the risks and the benefits to patients in deciding whether to modify patients’ work-up and treatment approach. We cannot provide specific guidance on any other protocol of therapy – at this time, no clinical HNC-specific data on COVID-19 are available – but we can state that each decision requires an individualized risk/benefit assessment. The aim should be to protect HNC patients without compromising their oncologic outcome. It is paramount to stress open channels of communication between administrators, clinicians, patients and caregivers [6]. In order to assist shared decision-making, multidisciplinary team meetings should be promoted using web-platforms. A reasonable treatment strategy between anticancer therapy and epidemic prevention should be selected. It should be considered to: i) omit systemic therapy for patients ≥70 years or younger with co-morbidities, such as diabetes and cardiovascular diseases. On the one hand, the updated meta-analysis of chemotherapy in head and neck cancer (MACH-NC) did not show any survival benefit resulting from the addition of chemotherapy for elderly patients [3]. On the other hand, these relevant co-morbidities are linked to a higher risk of death in case of COVID-19 infection [7]. ii) omit cisplatin-based induction chemotherapy. A definitive benefit in overall survival with the incorporation of induction chemotherapy compared to standard (C)RT has not been proven in randomized studies [8]. iii) short overall treatment time. Definitive (C)RT should be limited to simultaneous integrated boost (SIB) techniques in the standard (5 fractions per week) or accelerated schedule (6 fractions per week), in order to achieve a 1-week reduction compared to sequential technique. SIB technique represents an optimum balance between tumor control and prevention of late toxicity excess [9]. iv) delay post-operative RT in patients with salivary gland tumors until 12 weeks after surgery. Time factor is not strictly linked to adverse effect in these cases [10]. v) develop an online surveillance plan. At present HNC patients deal with the double ordeals of disease and pandemic situation. Patients should be educated to properly identify those symptoms and signs that potentially signify a recurrence (increased local pain and difficulty in swallowing, unexplained weight loss and development of new lump in the head and neck region). For sure, patients should be informed regarding the Coronavirus symptoms (mainly fever, dyspnea and cough) and educated in proper hand washing and all other measures to limit viral transmission (avoid touching your eyes, nose and mouth; cover your nose and mouth with a tissue when you cough or sneeze; clean and disinfect high touch surfaces regularly; stop shaking hands or kissing as a greeting; reduce exposure to sick contacts and large crowds). Psychological counseling should be paid attention to through seeking alternative schemes.

It must be appreciated that this document is an attempt to provide practical suggestions on how to define a reasonable treatment strategy and mitigate the COVID-19 impact on HNC patients under the current pandemic conditions. It is necessary to offer adequate individualized treatment recommendations based on both the epidemic situation and the patient's own condition. We significantly hope to help HNC patients to survive this difficult period.