Head and neck surgery recommendations during the COVID-19 pandemic.

We read the recent international consensus recommendations from Hisham Mehanna and colleagues in The Lancet Oncology regarding head and neck surgical practice in the setting of resource constraint due to the COVID-19 pandemic with great interest. However, the sections dedicated to the prioritisation of treatment should be considered controversial, even though the methodology employed is well regarded. The monograph characterised treatment of advanced head and neck cancer with “do not delay surgery; operate within 4 weeks of diagnosis”, while adopting a more permissive policy toward T1–T2 N0 oral cancer and T1 N0 laryngeal cancer: “do not delay surgery beyond 8 or 12 weeks”. Although it seems logical to assign high treatment priority to advanced tumours in a setting of resource constraint, the limited data testing the precept do not fully support these recommendations.

Head and neck squamous cancers progress at a rate that can be measured in the course of typical clinical practice. Node progression due to prolonged time to treatment initiation replaces stage I–II with stage III–IV cancer. The survival impact of such progression is reflected in the staging system. In a setting of resource constraint the crucial issue should be consideration of which outcome is most affected by prolonged time to begin treatment. Which is more detrimental to survival: T1 N0 progressing to T1 N1 or T3 N2b developing greater node burden?

Murphy and colleagues addressed this question for squamous cancers. A treatment delay of 31–60 days adversely affects survival for stage I–II head and neck cancer (HR 1·17; 95% CI 1·12–1·23), but not stage III-IV (1·02; 0·99–1·07). A similar relation exists for longer delays of 61–90 days for early stage (HR 1·54; 95% CI 1·41–1·68) and advanced stage (1·08; 1·02–1·14) squamous cancer. Delay in treatment more significantly affects survival of stage I–II head and neck cancer than stage III–IV. Although it seems logical to operate on a patient soon to become formally unresectable or develop more advanced nodal disease, the data suggest that stage I–II patients (with a more favourable prognosis before progression) will derive greater benefit.

The COVID-19 pandemic creates challenges in the management of patients with head and neck cancer. Allocation of scarce resources will be difficult. Available data, not solely expert opinion, should be employed when assigning priorities.