Head and neck cancer cannot wait for this pandemic to end: Risks, challenges and perspectives of oral-maxillofacial surgeon during COVID-19.

To the Editor,

The SARS-CoV-2, or COVID-19 pandemic emergency has been affecting our country during the last weeks, influencing the Italian health system and economics. It emerged in the North above all in Lombardy region [1], [2]. It was anticipated that the need for ICU for COVID-19 patients would be greater than the actual capacity of the system to treat these patients. Due to the need for many ICU spots for COVID patients, the most elective surgical activities and procedures for patients potentially needing for postoperative intensive assistance have been postponed. The government promoted many restriction measures, hopefully effective for contagious spreading containment. From March 9, essential services are still available for the entire population, such as health assistance, food shops and pharmacies. The #iorestoacasa (#stayhome) legacy has been promptly accepted from everybody. Contagion prevention measures have so far proved to be efficient in preventing collapse of the Healthcare System in central-southern Italy [3], [4]. As of April 23, 2020, there have been more than 187.327 confirmed cases of COVID-19, and 54.543 patients have been cured. In the Lazio region, there are 5.975 affected patients and 4.257 of those are in Rome [4]. In terms of health assistance and hospital services, surgical procedures were authorized for emergencies and oncological cases classified as priority class A, which stands for “need for surgery no later than 30 days, according to the oncological prognosis”. The COVID-19 pandemic has significantly impacted the safe practice for all surgical specialists, as well oral-maxillofacial surgery [5]. Surgical procedures involving the nasal-oral-endotracheal mucosal region expose surgeons to an even higher risk for contagious, due to higher aerosolization of the virus in these areas [6]. Nonetheless, some of our patients cannot wait any longer, such as those suffering from cancer. In 2018, the International Agency for Research on Cancer (IARC) has reported, in the “Global Cancer Observatory (GCO)”, the presence of 354.864 newly diagnosed cases with oral and lip cancer worldwide and 3967 new oral cancer cases in Italy. The estimated number of death due to oral and lip cancer is 177,384 cases worldwide, and 1489 cases in Italy [7]. These account for most cancers in the district. In the case of Head and Neck tumors, the surgical treatment, consisting in resection and reconstruction, must be timely to eventually consider any adjuvant treatment [8]. Moreover, therapeutic outcome and morbidity hinge on the size and progression of disease. Timely intervention reduces tumor progression that could cause thus worsening the prognosis and making the complete surgical resection eventually impossible [8]. Therefore, we are taking care of our oncological patients who strictly need surgery within few weeks to hopefully increase their functional and oncological outcomes [9], [10]. Since March 10, 2020, 56 cases of head and neck cancer have been operated at our department. All the procedures were carried out in accordance with what is recommended in the literature and according to what is described by Zou et al. to reduce the risk for infection diffusion [6], [7], [8], [9]. The sample of patients consisted of 67.9% male and 32.1% female with a mean age of 64.96 (±15.16 SD). Different procedures were performed in general anesthesia: 34 tumor resections, of this sample 10 neck dissections, 2 sentinel lymph nodes were performed. Among the reconstruction procedures 20 patients received reconstruction with local flaps, 8 pedunculated flaps and 6 free flaps. Four trans-nasal endoscopic resections and 6 tracheostomies, 12 biopsies (2 endoscopic assisted) were performed. Going through the historical case series of our department, these data result as highlighted by the commitment of our Hospital to manage COVID patients. Swabs and telephone triage were performed on patients prior to hospitalization. One of the World Health Organization’s strategic priorities is to limit human-to-human transmission, including secondary infections among health care workers. Although restrictions have been first developed for patients’ safety, it is our opinion that medical and paramedical need to be protected too. As well as medical doctors, head and neck cancer do not take days off for COVID, and oral-maxillofacial surgeons need to deal with this emergency. We cannot stop despite the risks, as we must guarantee the best surgical treatment for these patients, and this is our contribution in these times of uncertainty.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.