Special considerations for elderly patients with head and neck cancer during the COVID-19 pandemic.

Elderly patients with head and neck cancer are at increased risk of adverse outcomes during and after treatment of head and neck cancer. COVID-19 severity and mortality can be expected to be significantly greater in elderly patients with head and neck cancer, given that increased age, comorbidities, and presence of malignancy are known risk factors for disease severity and mortality in patients with COVID-19. Therefore, their management requires multidisciplinary consensus and patient input. A thorough geriatric assessment, which has been shown to be beneficial prior to the COVID-19 pandemic, could be particularly helpful in this patient population with the added dimension of COVID-19 risk. In many cases, prudent treatment plan modification may allow for overall best outcomes. Furthermore, recruitment of social services and, when appropriate, palliative care, may allow for optimal management of these patients.

Coronavirus disease 2019 (COVID‐19), caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), has been designated as a pandemic by the World Health Organization.1, 2 There remain many uncertainties about the disease and its optimal management ; even greater uncertainties are present in management of diseases not directly related to COVID‐19 during the pandemic. Since initial reports suggest high viral load in the pharynx and respiratory secretions, there are important ramifications for optimal management of patients with head and neck cancer. This is especially true of patients with mucosal malignancies and those who require tracheotomy or laryngectomy.4, 5, 6 As is standard for management of head and neck cancers, multidisciplinary tumor board and conferences are critical for ensuring the safety of patients, caregivers, family members, health care providers, and the greater community.6, 7, 8 Elderly patients with head and neck cancer are a unique subset as they are at increased risks of adverse outcomes; 70% of deaths from head and neck cancer occur in patients over the age of 70. Therefore, their management deserves close attention, multidisciplinary consensus, and shared decision making.

The National Institute on Aging and US Census Bureau define elderly patients as those over the age of 65. However, much of the oncology literature uses cutoffs ranging from 70 to 80 years for classifying patients as elderly or geriatric.9, 11 Regardless of the age cutoff to define “elderliness,” age is best thought of a continuous variable, with increased risks occurring as a continuum rather than after a certain chronological age. Furthermore, the impacts of age on survival and functional outcomes are modified by comorbidities, frailty, and functional status.9, 12, 13, 14 Increasing age, presence of malignancy, and comorbidity are associated with increased disease severity in COVID‐19,1, 15, 16, 17 which puts elderly patients with head and neck cancer at risk of poor outcomes from both diseases.

Treatment of head and neck cancer can involve surgery, radiation therapy, systemic therapy, or a combination of these. Advanced cancers generally require multimodality therapy. Whether and how the current COVID‐19 pandemic should modify treatment modalities is currently unclear, especially for elderly patients. However, patients with COVID‐19 who are 80 years or older have a mortality risk of 13%. Furthermore, 95% of deaths from COVID‐19 occur in patients over 60; 50% of deaths occur in patients over 80. Given concerns about hospital‐acquired COVID‐19, surgery should certainly be reconsidered for elderly patients as it can result in exposure to COVID‐19, which is particularly concerning given the risk of disease severity and mortality. However, administration of both radiation therapy and systemic therapy requires repeated visits, although inpatient settings can sometimes be avoided. Therefore, until more robust data becomes available, treatment decisions will need to be individualized and take into account patient disease and status, local COVID‐19 burden, and resource availability.

The International Society of Geriatric Oncology consensus is to recommend a geriatric assessment (GA) in older patients with cancer. GA includes assessment of functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and presence of geriatric syndromes. The benefits of such an assessment include more accurate prediction of adverse outcomes, detection of unidentified problems, improved estimation of residual life expectancy, appropriate employment of geriatric interventions, and appropriate cancer treatment selection. The potential impact of COVID‐19 infection could be assessed within this GA framework to allow for optimal shared decision making. Therefore, an 85 year old patient with head and neck cancer with multiple comorbidities and limited social support may be best served by delaying or altering the treatment plan given the potential harm that could occur with COVID‐19 infection. However, a 70 year old patient with a similar cancer but no comorbidities and strong social support may be able to proceed with treatment, with appropriate precautions for both the patient and health care providers. Certainly, such decisions would need to be made after multidisciplinary discussion, extensive counseling, and shared decision making.

Early involvement of comprehensive palliative care and social services are often an integral part of management of elderly patients with head and neck cancer, especially in the setting of recurrent or metastatic disease. Such services are likely to be particularly helpful during the current COVID‐19 pandemic.

The current COVID‐19 pandemic is altering how we manage head and neck cancer in a multitude of ways. This is particularly evident in elderly patients with head and neck cancer. This particularly vulnerable population is even more susceptible to adverse outcomes during the COVID‐19 pandemic. For those reasons, we have a responsibility to provide multidisciplinary care, thorough assessment of risks and benefits of any possible interventions, shared decision making, social resources, and, when appropriate, comprehensive palliative care for elderly patients with head and neck cancer.