Discussion
Cancer is the second leading cause of death globally, accounting for an estimated 24.5 million incident cancer cases and 9.6 million deaths, or one in six deaths, in 2018.8 Head and neck cancer in India has a distinct demographic profile, risks factors, food habits, and personal and family history. HNC is a major public health problem in India, mainly due to the widespread use of tobacco. In contrast to the west, where it is the 6th most common cancer, HNC in India is the commonest cancer of males in India.3Already burdened with the high patient load and high percentage of late-stage HNC patients, the spread of COVID-19 has further deteriorated the situation.
As of April 14, 2020, corona virus disease 2019 (COVID-19) has affected 1,914,916 persons worldwide. The death toll in the highest affected countries like Italy is approaching 12 000 people, with Spain not far behind. The USA has reported more than 164 000 cases of the disease, including more than 38 000 cases in New York City alone.9 India, a country of 1.35 billion people, has also come in the grasp of this highly contagious disease with its first case reported on 30 January in the state of Kerala.10Now the footprint of COVID-19 has spread in almost all states, affecting more than 11000 people and with the death of more than 370 people as on 14thApril 2020.9
Due to the rising number of COVID-19 patients in India, almost all government hospitals and teaching health care institutions are on high alert and doctors are the main task force for managing this pandemic. After the announcement of 21 days lock down throughout the whole India on the 24th march 2020 midnight by the Indian government, all elective surgeries and outpatient services at majority of hospitals were withheld to control this menace and vacating the facilities in stage wise manner to harness the resources. Only emergency services were continued for the management of life threatening problems.11 Most of the major government hospitals were aligned to assess their resources and convey the present status of the availability of ICU beds, ventilators and beds availability. Gradually, beds in the wards were vacated by discharging stable patients and only critical patients were kept in hospitals. Beds of each department catering emergency patients were asked to join hands and combine their beds in a limited area on a sharing basis so that other areas can be made available as isolation wards with sufficient number of beds for the growing number of COVID-19 patients.
Recently to contain the spread of disease, the Indian government has earmarked selected facilities which will be dedicated for COVID-19 management. They have proposed three types of COVID dedicated facilities as COVID care centre (CCC), Dedicated COVID Health Centre (DCHC) and Dedicated COVID Hospitals (DCH). All these facilities will have separate ear marked areas for suspected and confirmed cases. Suspected and confirmed cases will not be allowed to mix under any circumstances. Out of these both DCHC and DCH would be the existing hospitals and most of them are secondary to tertiary care government hospitals.12 HNC surgeries together with other cancer surgeries are majorly affected after major health care institutions were converted into dedicated COVID-19 centres. Meanwhile, few dedicated cancer centres are able to continue doing HNC surgeries but in limited numbers by following their own institutional guidelines. But this situation is dynamic and an expected exponential increase in the number of COVID-19 patients and probable community spread may lead to overburdened health care facilities and more stringent policies to take up new cases.
India, which has a high burden of head and neck cancer, is compounded with long waiting lists in all hospitals of India. A problem that is particularly worse in government funded hospitals, which cater to the poorest of society. With further delays in surgery during the pandemic of COVID-19, the burden will exponentially increase. The biggest problem will be to manage such a high load of these malignancies after the situation is normalized. The patients may become inoperable and deemed only for palliative treatment. The Government of India is taking a lot of measures to contain this disease and purchasing a large number of ventilators to cater the expected increase of COVID-19 patients in the near future. But we also need guidelines and a mechanism to surgically treat at least those head and neck cancer patients which are in dire need of surgery for a reasonable survival.
The practice in other countries where the infection is more severe than in India has been to create new and innovative care pathways. In the United Kingdom, NHS England has rapidly supported the creation of ‘cancer hubs’, where cancer patients from multiple tumour groups are fast tracked on priority basis. To ensure full stakeholder participation, the hubs have suspended conventional regulatory requirements to referring surgical teams to operate at the hub. The hub is maintained as COVID-19 free by requiring patients to self-isolate when they have been accepted for intervention and regular testing for COVID-19 in the pre-treatment period. Patients needing urgent cancer surgeries are referred to such dedicated centres and are scheduled for treatment as decided by the tumour board. Their tumour boards conduct virtual multidisciplinary team (MDT) meetings and decisions are taken accordingly.13 The American College of Surgeons (ACS) has given guidelines for triage of cancer surgeries during this pandemic and recommended the decision to be taken by the MDT team based on the available resources and situation pertaining in their region.14
During the current pandemic, the important points to consider are that all head and neck procedures including simple clinical examinations are potentially aerosol generating and should be considered high risk. Testing of COVID-19 is limited and cannot be performed in all patients. Protective supplies, such as N95 masks, PPE gowns, gloves and other protective materials are in short supply or unavailable in many institutions. As the illness progresses our systems may be burdened with potential shortage of beds and health care manpower. Also there will be difficulty and uncertainty in mobility of patients due to lockdowns and quarantine. Availability of blood and blood products may become a challenge. ICU Bed/ ventilators may be at a premium and scarce. Cancer patients are likely to be more vulnerable in India during COVID-19, so decisions to treat the patient should be taken on the basis of risk benefit ratio during this epidemic period.
At present there are no national guidelines for cancer patients from the government of India, so we have to either depend on institutional, state or association guidelines. The foundation for head and neck oncology (FHNO) has given guidelines which covers diagnosis, treatment and follow up of HNC patients and is described in Table 3.15