The Multidisciplinary Approach in Head and Neck Oncology During COVID-19 Pandemic.

To the Editor: As everyone is aware, oncologic patients need a multidisciplinary team of highly qualified physicians in order to handle not only the base pathology but also the multitude of complications that may supervene during the course of the treatment whether they are due to surgery, radio, or chemiotherapy.[1]

A multidisciplinary team needs the presence of a surgeon, an oncologist, a radiologist, and a pathologist. Moreover, the presence of a pain therapist (whether we refer to an oncologist or an anesthesiologist specialized in antalgic therapy), nutritionist, and psycho-oncologist are required. Dealing with head and neck cancer, our Oncologic Multidisciplinary Group foresees the collaboration of all the aforementioned figures. Both maxillofacial and ear-nose-throat specialists address the surgical aspect, whereas a radiotherapist assists the radiologists and oncologists. Moreover, in order to guarantee the beginning of every treatment in highly debilitated patients, a gastroenterologist deals with the management of the nutrition status of the patient if in need of nasogastric tube feeding or the placement of endoscopic percutaneous gastrostomy. This 360-degree management of the head and neck cancer patients, already considered as the gold standard of treatment, has become of pivotal importance during the delicate historical moment we are living in.

Although cancer treatments were not completely suspended, the severe acute respiratory syndrome coronavirus 2 pandemic has indeed created more obstacles for our patients. Prolonged required time for diagnostic or stadiative exams, the need of molecular nasal swabs to admit the patient in wards, reduced hospital beds and operating room availability, lack of oxygen and continuous positive airways pressure masks are just few of the problems we all had to deal with.[2,3] Physical and chemical treatments of operating rooms and medical offices had to be constantly performed due to virus persistence on surfaces and surgical plans had to be adapted in order to find the best cost-benefit ratio, balancing the hospital and patient needs favoring less invasive, more conservative procedures delaying reconstructions in select cases and using local or regional flaps rather than complex free flap to minimize surgery time and hospitalization.[4-6] Furthermore, the patients refrained from being visited in an outpatient setting or admitted inside the hospital in fear of contagion. This hesitation has increased the already unfavorable effects of diagnostic and therapeutic delay on oncologic, functional, and psychosocial outcomes in head and neck cancer patients, being timing one of the most important prognostic factors. Longer delay between onset of symptoms and diagnosis associates with staging progression, which in turn leads to more aggressive surgical and/or chemoradiation therapies, higher morbidity and loss of function, lower quality of life, and lower survival rate overall.

In order to respect social distancing rules and avoid any unnecessary contact and aggregation, we had to tackle these problems on multiple fronts. First, we converted de visu meetings in online meetings through the video conferencing platforms available. Then, we modified our approach on ward and outpatient's management, making the most of telephonic and e-mail communications in order to guarantee continuity of care. Obviously, the use of e-mails and instant messaging services as contact tools has not been an easy task: if we consider that head and neck cancer is a prerogative of old age and low sociocultural level patients, the doctor-patient relationship is often held by the caregivers. This approach has also been particularly complicated in more than one occasion.

Nonetheless, the well-rehearsed weekly online meetings has improved patient management limiting the aforementioned discomforts, reducing to the minimum the waiting times and allowing each specialist to be constantly updated on the clinical conditions of his patient. Recently, we have created a joint outpatient department in order to better follow the patient on each step of his/her treatment plan: from the diagnosis and therapeutic plan, to the surgical, radiotherapy, and oncological follow-up. Both in short and long term, the patients feel more involved and at the same time, it is easier for the specialists to guarantee continuity in follow-ups. The continuity we pursue becomes of crucial importance in spotting possible recurrence of disease if we consider the low follow-up adherence of head and neck patients, and allows us to promptly intervene accordingly.[7]

If we then take into account the patient's fear in hospital admission, when they are informed of simultaneous visits in the same location, it is perceived as a reassurance in reducing the contagion risk. The feedbacks we are collecting from our patients are extremely positive both on avoiding multiple hospital trips and the feeling of commitment on the personal case. From May 2020 to April 2021, our multidisciplinary oncologic group discussed and treated 128 patients: 60% by the surgical team and 36% by the medical oncology team. Specifically, Maxillofacial Surgeons operated 38% of patients, ENT surgeons 22%; 6% of patients received chemotherapy treatment, 17% both chemo and radiotherapy treatment, 13% received radiotherapy treatment only. 4% of patients were unfortunately lost at follow-up.

Besides the benefits in patient care, the resident's formation has also improved. Although the practical training is partially crippled by the pandemic, residents have the opportunity to learn and exchange knowledge from a different yet complementary branch of medicine. Although clinics are learning specific physical examinations and posttherapy treatments, surgeons widen their knowledge in daily oncologic therapies, including support and palliative therapies, therefore exchanging knowledge peculiar of each specialization. In an era where the medical discipline has gradually compartmentalized in specialized and ultra-specialized branches, the chance to have an early multidisciplinary approach becomes fundamental. Patient management is in fact at its best and at the same time, the single specialist can benefit from the colleague's competences, cooperating toward a “continuum of care” for the good of the patient. Willing to find a bright side of the situation we are dealing with, we believe, beyond any doubt, that the spirit of cooperation that join us all in our daily practice is to be found again, more and more every day.