Covid-19 pandemic and head and neck cancers, what should we expect?

To the Editor,

One year after the first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Italy, the COVID-19 emergency has been affecting our country; however, it is early to really understand the social implications of the pandemic. Instead, what we can try to predict is what has already happened in the field of head and neck (HN) oncology and, above all, what we should expect in the coming months. Since February 21, 2020, when the first case of COVID-19 was reported in Italy [1], [2], the Italian Health System’s ability to respond to the COVID-19 emergency has been severely tested in terms of human and economic resources [3]. It is neither known nor foreseeable what effects the pandemic has had on the diagnosis and treatment of these patients [4]. The lockdown has caused a blockage of outpatient visits to general practitioners, dentists, and specialists such as maxillofacial or ENT surgeons, thus significantly limiting access to screening visits for oral cancer patients. The effects of COVID-19 on the population of patients potentially suffering from HN cancer are manifold. Patients suffering from this pathology are often socially marginalized – smokers, alcohol abusers – and unlikely to access private care facilities. Onset symptoms, such as dental or mucous membrane pain and neck swelling, can be confused with the symptoms of an infection of the oral cavity or dental abscess. If these patients are not visited, it is easy to underestimate these symptoms and treat them with antibiotic or corticosteroid therapy. The difficulties in treating patients with HN cancer during this pandemic [5], [6] have been faced and overcome by putting into practice the prevention strategies suggested by the international literature [7]. What has recently been highlighted, both in literature and our clinical practice, is how the diagnostic and therapeutic delay affects the patients’ outcomes [8], [9]. This delay is partly due to patient-related factors (social distancing and travel restrictions during the pandemic makes it challenging to attend the hospital for treatment) and partly to healthcare-related factors. The pandemic is affecting both treatment-naive patients, as it worsens survival and quality of life and aggravates psychological impact, and follow-up patients, as it delays their visits [10]. What caught our attention in these months is the number of outpatient biopsies and new cancer diagnoses, compared to the same period of the previous year. A comparison between the outpatient biopsies performed in our Department from March to December 2019 and those performed in 2020 shows a significant reduction in their number (Table 1 ). In 2019, 268 biopsies were performed, while only 93 in 2020 –a difference of 175 procedures. The decrement is due to the lockdown in the first place, but also to the limited number of procedures that can be performed daily in the clinic to comply with the preventive measures, i.e., by rigorously scheduling appointments. The percentage of malignant tumors diagnosed in 2019 is 34.4% on 268 procedures (92 patients) and 34.5% (32 patients) in 2020; considering this data, the question is: out of all the patients who did not undergo the biopsy, how many are affected by a malignant tumor?

Table 1

Sample characteristics. OLSCC: oral and lip squamous cell carcinoma; MSG: minors salivary glands; ITAC: Intestinal-type adenocarcinoma; SNUC: Sinonasal undifferentiated carcinoma.

Biopsies (March-December) 2019	268
Benign	176 (65.7%)
Malignant	92 (34.3%)
###OLSCC	82 (89%)
###Lymphoma	3
###Melanoma	2
###Adenocarcinoma of the MSG	2
###Ameloblastic carcinoma	1
###ITAC	1
###SNUC	1
Biopsies (March - December) 2020	93
Benign	61 (65.6%)
Malignant	32 (34.4%)
###OLSCC	27 (84.4%)
###Lymphoma	2
###Carcinosarcoma	1
###ITAC	1
###Metastasis	1

Furthermore, patients treated in recent months were frequently at very advanced stages, but further studies are needed to confirm this suggestion. Considering that the incidence of HN cancer cannot be decreased, how many diagnostic delays will be caused by the pandemic? How many patients will undergo less thorough treatments or, even worse, will not be treated surgically and will be referred to palliative care for the extreme stage of the disease?

Two admonishments we must learn from the lesson that COVID19 taught us. First, prevention and screening services must always be guaranteed, especially for the weaker social classes. Second, the health-care systems’ capacity and financing need to be increased in order to face this new reality, wherein we must live with the virus and all the maneuvers essential to its confinement. To date, we have suffered the short-term effects of this pandemic, but the long-term repercussions are foreseeable and cannot be underestimated.

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.