Fewer head and neck cancer diagnoses and faster treatment initiation during COVID-19 in 2020: A nationwide population-based analysis

The impact of the COVID-19 pandemic on time to treatment in head and neck cancer management: a systematic review

BACKGROUND AND PURPOSE

Coronavirus disease 2019 (COVID-19) caused a need for reorganization in the healthcare systems. First, we aimed to determine the impact of the COVID-19 pandemic on time to treatment in head and neck cancer (HNC) patients. Second, we aimed to determine the impact of COVID-19 on tumor stage and changes in treatment regimens used.

MATERIAL AND METHODS

A systematic search in PubMed and Embase was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were: (1) Studies including patients with head and neck squamous cell carcinomas; (2) Studies containing a comparison of time to treatment; (3) Studies containing a well-defined time interval with restrictions on health care due to COVID-19 and a well-defined time interval without restrictions.

RESULTS

A total of 19 studies were included comprising 24,898 patients treated for HNC cancer. Six studies (10.1% of the patients) reported an increase in waiting time within at least one interval, while seven studies reported a decrease (83.2% of the patients), and six studies found no significant effect. No changes in treatment modalities were observed. Seven of 15 studies (12.7% of the patients) observed an increase in either overall stage, size, or tumor node and metastasis classification during the COVID-19 pandemic. Among these, two studies reported increased waiting times as well.

INTERPRETATION

The impact of the COIVD-19 pandemic on time to treatment was heterogenous and subject to considerable intercountry and interregional variations. A tendency toward a higher T-classification was observed. In conclusion, otorhinolaryngology departments demonstrated resilience, as the pandemic led to only slight alterations in time to treatment.

Shorter Time to Biopsy of Patients with Head and Neck Squamous Cell Carcinoma During the COVID-19 Pandemic in Hungary

BACKGROUND/OBJECTIVES

The goal of this investigation was to compare the time to biopsy (TBI) and time to treatment (TTI) for head and neck squamous cell carcinoma (HNSCC) patients before and during the COVID-19 pandemic and to examine the effect of demographic and clinical characteristics on these intervals.

METHODS

Our retrospective study at a large regional Hungarian cancer center analyzed data from patients aged 18 or older diagnosed with HNSCC between 1 January 2017 and 15 March 2020 (pre-COVID-19 period) and 16 March 2020 to 13 May 2021 (COVID-19 period). We calculated the time from initial physician contact to biopsy (TBI) and from biopsy to treatment initiation (TTI) and performed descriptive and exploratory statistical analyses.

RESULTS

The median TBI decreased significantly (6 vs. 3 days; p = 0.008), while the median TTI was not affected significantly (28 vs. 29 days; p = 0.972) pre-pandemic and during the pandemic, respectively. Residence in a village was linked to a significant reduction in median TBI during the pandemic (p = 0.000), coinciding with a higher proportion of rural patients diagnosed with oral cavity/oropharyngeal cancers during the pandemic (50.3% pre-pandemic vs. 67.4% during pandemic, p = 0.044). Median TTI decreased significantly during the pandemic for patients with laryngeal tumors (27.5 vs. 18.5 days; p = 0.012).

CONCLUSIONS

Our study, one of a few from this region, provides insights into HNSCC patient waiting times. Improvement in TBI likely resulted from the availability of telemedicine, reduced diagnostic demands from non-cancer patients, and an increased incidence of oral cavity/oropharyngeal cancer among rural patients.

The global impact of the COVID-19 pandemic on delays and disruptions in cancer care services: a systematic review and meta-analysis

The coronavirus disease 2019 pandemic substantially impacted the delivery of cancer services and programs. Here we reviewed and synthesized the global scale and impact of pandemic-related delays and disruptions on cancer services, including diagnosis, diagnostic procedures, screening, treatment and supportive and palliative care. Based on data from 245 articles in 46 countries, we observed declines in the number of cancer screening participation (39.0%), diagnoses (23.0%), diagnostic procedures (24.0%) and treatment (28.0%), ranging from a 15.0% decline for radiotherapy to a 35.0% decline for systemic treatment during the pandemic compared to during the prepandemic period. Medium-human development index (HDI) category countries experienced greater reductions than high- and very-high-HDI countries. Missing data from low-HDI countries emphasize the need for increased investments in cancer surveillance and research in these settings. PROSPERO registration: CRD42022301816.

Treatment of oropharyngeal cancer during the COVID-19 lockdown - outcomes for patients treated during the pandemic

Background

The onset of the coronavirus disease 2019 (COVID-19) outbreak caused major interruptions to the entire healthcare network affecting referral, diagnosis and treatment pathways with the potential to affect cancer treatment outcomes. In Ireland a national lockdown was initiated in March 2020 involving a stay-at-home order with a limitation on travel, social interactions and closure of schools, universities and childcare facilities. We designed a retrospective study comparing treatment outcomes for patients with oropharyngeal cancer treated before and during the COVID pandemic.

Materials and methods

All patients receiving radical radiotherapy for oropharyngeal cancer pre-COVID (July 17 - July 18) and during COVID (Mar 20 - Mar 21) were included. Patient and disease characteristics, diagnostic timelines, treatment delays and disease outcomes were extracted from the patient record. Disease free survival and overall survival were calculated for both groups.

Results

159 oropharynx patients were included, 76 in the pre-COVID group (Group 1) and 83 in the pandemic group (Group 2). When comparing Group 1 and 2, respectively: There were no differences in human papilloma virus (HPV) status (74% vs. 71% p = 0.795) or Tumour-Node-Metastasis (TNM) overall stage [American Joint Committee on Cancer (AJCC) ed. 8]: (Stage 1: 25% vs. 45.8%, Stage 2: 28.9% vs. 18.1%, Stage 3: 21% vs. 15.7%, Stage 4: 25% vs. 20.5%, p = 0.268). Use of moderate hypofractionated regime increased during the pandemic (2.6% to 10.8%) and one patient omitted chemotherapy due to COVID-related reasons. There was no change in overall treatment times between groups with COVID-related sepsis accounting for one significant delay and one death during treatment. Overall survival at 2 years via Kaplan-Meier analysis; Group 1 cumulative proportion surviving at 2 years was 77% [95% confidence interval (CI): 67-86%] vs. 85% in Group 2 (95% CI: 77-93%, p = 0.35). The disease free survival at 2 years was 69% in Group 1 (95% CI: 59-80%) vs. 76% in Group 2 (95% CI: 67-85%, p = 0.567).

Conclusion

In spite of challenges related to the COVID-19 pandemic, we have demonstrated that oropharyngeal cancer patients treatment standards and outcomes were maintained. We did not demonstrate any significant difference in overall survival and disease free survival at 2 years when compared to a similar group prior to the pandemic.

[Impact of the coronavirus pandemic on the diagnosis and treatment of head and neck cancer]

BACKGROUND

After the first appearance of COVID-19 cases, the virus spread worldwide within a few months. This led to a decrease in medical consultations. The present study investigates whether this effect had an impact on the diagnosis and treatment of head and neck cancer during the period from 2018 to 2022.

MATERIALS AND METHODS

Data from the clinical cancer registration center (KKR) of Mecklenburg-Vorpommern from the 2020-2022 period were compared to those from the two previous years (2018, 2019). Demographic data, case numbers, diagnosis data, International Classification of Diseases (ICD) codes, and TNM classifications were recorded. COVID-19 case numbers were obtained from the Robert Koch Institute (RKI). Data were analyzed using the Mann-Whitney U test and Pearson's correlation.

RESULTS

A total of 2332 patient cases could be included in this study. During the lockdown there was neither a significant reduction in tumor diagnoses registered at the KKR nor a correlation between COVID-19 case numbers and tumor diagnoses. Significant differences were found in terms of T category in the year 2022 compared to the pre-COVID years 2018 and 2019. Furthermore, there was a shift in the relative frequencies of some ICD-10 codes.

CONCLUSION

During the COVID-19 pandemic, no significant differences in tumor diagnoses were observed upon comparing the years 2018 to 2022. Contrary to the expectation of a decrease in case numbers during the pandemic due to the lockdown with an increase in tumor stages, a reduction of the T category could be found in 2022, and a shift in the relative frequencies of some ICD-10 codes in the pandemic period was observed.

Nationwide clinical practice variation for reconstructive surgery following oral cavity cancer from the Dutch Head and Neck Audit: are we all doing the same?

Quality registries provide real-world data that can drive quality improvement, which often starts with reducing inter-hospital variation. We explored outcomes and the extent of nationwide inter-hospital variation for patients undergoing reconstructive surgery after oral cavity cancer (OCC) using the Dutch Head and Neck Audit (DHNA). Within the DHNA, we selected all OCC patients who underwent curative reconstructive surgery between 2018 and 2022. Patient, tumour, and treatment characteristics were compared, including reconstruction strategies (skin grafting, local transposition, and pedicled and free flaps). Of those treated with free flap reconstruction, postoperative complications were scored according to the Clavien-Dindo (CD) classification and labelled minor (CD 1-2) or major (CD ≥3). A total of 1383 patients were included in the analysis. Especially in the case of patients with stage I tumours (10.1%) there was a wide variation in reconstructive surgery between centres, with a preference for local transposition (42.6%). Free flaps (n = 974) were used most often in patients with a more extensive tumour load (65.4-89.2%), with the radial forearm flap the preferred technique (54.7%, range range 37.1-80.8%). Thirty-four per cent of patients treated with a free flap had postoperative complications, with 38 cases of total flap loss (overall 3.9% complications). Strategies and percentages varied widely across centres, showing high inter-hospital variation in applied techniques and outcomes, and the need for national data improvement. Level of evidence: II.

Impact of the 2nd, 3rd and 4th waves of the COVID-19 pandemic on wait times in head and neck cancer: A retrospective study in a French expert center

BACKGROUND

Treatment delay in head and neck cancer is a major problem, with impact on survival. The COVID-19 (coronavirus disease 2019) pandemic, evolving in waves around the world, caused diagnostic and therapeutic delays in certain cancers. The main objective of the present study was to analyze whether there was a change in wait times during three successive waves in our center.

METHOD

This was a single-center retrospective study of patients with a first diagnosis of head and neck cancer. Three groups, corresponding to waves 2, 3 and 4, were compared to a control group corresponding to a pre-pandemic period. Study data comprised median times between first consultation and tumor board meeting (C1-TB) and between tumor board meeting and treatment (TB-T). The significance threshold was set at P<0.005.

RESULTS

Ninety-six patients were included in the control group, and 154 in the "waves 2-3-4" group. There was no increase in C1-TB interval (respectively 35 and 26days, P=0.046) or TB-T interval (respectively 27 and 28days, P=0.723).

CONCLUSION

Intervals between first consultation and tumor board meeting and between tumor board meeting and treatment did not increase during the 2nd, 3rd and 4th waves of COVID-19 in our center.

Impact of the COVID-19 pandemic on the severity of newly diagnosed cases of head and neck cancer in southern Brazil

This observational study aimed retrospectively assess the impact of the COVID-19 pandemic on the head and neck squamous cell carcinoma (HNSCC) diagnosis and severity of the disease in southern Brazil. All new cases diagnosed with HNSCC from March 11, 2019 to March 10, 2020 (pre-COVID-19) and from March 11, 2020 to March 10, 2021 (COVID-19) were included. The data collected were: date of the histopathological diagnosis, sociodemographic data, place of residence, data related to the tumor (location of the primary tumor, lymph node involvement, distant metastasis and TNM clinical staging), time elapsed between the diagnosis and treatment initiation. There was no significant difference in the number of new diagnoses in the COVID-19 group (n=45) compared to the pre-COVID-19 group (n=47). There was also no statistical difference regarding patients' sociodemographic profile, time between diagnosis and treatment, and overall TNM staging. However, the clinical N classification was more severe in the COVID-19 group (p=0.021). Patients diagnosed during the COVID-19 pandemic were 4.05 times more likely to have the N-stage more advanced (95% CI:1.62 - 10.12). Although there was no reduction in the number of new diagnosis of HNSCC during COVID-19 pandemic, the diagnosed cases showed lymph node metastasis in more advanced stages.

Changes in Time to Initial Physician Contact and Cancer Stage Distribution during the COVID-19 Pandemic in Patients with Head and Neck Squamous Cell Carcinoma at a Large Hungarian Cancer Center

The aim of our study was to compare the characteristics and time to initial physician contact in patients with head and neck squamous cell carcinoma (HNSCC) before and during the COVID-19 pandemic at a large Hungarian cancer center. This was a retrospective study of patients 18 years or older presenting at the regional cancer center of Pécs Clinical Center with HNSCC between 1 January 2017, and 15 March 2020 (the pre-COVID-19 period) and between 16 March 2020, and 13 May 2021 (the COVID-19 period). Demographic and clinical data were collected, and the time between initial symptom onset and initial physician contact (TTP) was determined. Descriptive and exploratory statistical analyses were performed. On average, the number of patients diagnosed with HNSCC per month during the pandemic decreased by 12.4% compared with the pre-COVID-19 period. There was a significant increase in stage I and stage II cancers (from 15.9% to 20.3% and from 12.2% to 13.8%, respectively; p < 0.001); a decrease in stage III and IVa,c cancers; and a significant increase in stage IVb cancers (from 6% to 19.9%; p < 0.001) during the pandemic. The median TTP increased during the pandemic from 43 to 61 days (p = 0.032). To our knowledge, this is the first study investigating the effect of COVID-19 on patients with HNSCC in the Central-Eastern European region. We found a bidirectional shift in cancer stages and increased TTP during the pandemic. Our findings highlight the necessity for more nuanced analyses of the effects of COVID-19.

Laryngeal cancer incidence trends in the United States over 2000-2020: a population-based analysis

INTRODUCTION

Laryngeal cancers account for one-third of all head and neck cancers. We aimed to report the incidence trends of laryngeal cancer over 2000-2020 in the United States (US), by age, sex, race/ethnicity, and histological subtypes.

METHODS

Data from the Surveillance, Epidemiology, and End Results 22 database were used to identify patients with laryngeal cancer based on the International Classification of Diseases for Oncology, version 3. Age-standardized incidence rates (ASIRs) for laryngeal cancer, adjusted for reporting delays, were calculated. The Joinpoint Regression Program was then utilized to determine annual percent changes (APCs) and average annual percent changes (AAPCs) in the trends. The analysis excluded data from 2020 to prevent potential bias related to the COVID-19 pandemic.

RESULTS

A total of 104,991 cases of laryngeal cancer were identified in the US from 2000 to 2019. Squamous cell carcinoma was the predominant subtype, accounting for 94.53% of cases. Above 73.20% occurred among non-Hispanic whites, with the highest incidence observed among individuals aged 55-69 years (46.71%). The ASIRs were 5.98 and 1.25 per 100,000 population for men and women, respectively. Over 2000-2019, there was a significant reduction in ASIRs for laryngeal cancer in both sexes. Non-Hispanic black men exhibited the highest ASIR (9.13 per 100,000) and the largest decline in the ASIRs over 2000-2019 (AAPC: -3.26%).

CONCLUSIONS

Laryngeal cancer incidence rates showed a decline from 2000 to 2019, in addition to 2020, during the COVID-19 pandemic. Additional research is required to investigate risk factors and their influence on incidence rates of laryngeal cancer.

Impact of the COVID-19 pandemic on stage and incidence of head and neck cancer: A rapid review and meta-analysis

OBJECTIVES

This rapid review aims to evaluate the impact of the COVID-19 pandemic on incidence of head and neck cancer (HNC) and stage distribution at diagnosis.

DESIGN

Rapid review and meta-analysis.

PARTICIPANTS

Comparative data for new HNC patients between a pre-pandemic cohort (before March 2020) and a pandemic cohort (after March 2020 during the lockdown period).

MAIN OUTCOMES MEASURED

Data on tumour stage, incidence, referral pathway (number of new patient referrals), or workload levels (number of HNC treatments). Data on stage were summarised as odds ratios (OR) with 95% confidence intervals (CI), and data related to changes in numbers of diagnoses, referrals, and workload levels were summarised as a narrative synthesis.

RESULTS

A total of 31 reports were included in this review. Individually 16 out of 23 studies did not show a significant impact on stage relative to the pre-pandemic period. However, the meta-analysis revealed that patients diagnosed with HNC during the pandemic were 16% more likely to have nodal involvement (OR = 1.16; 95% CI 1.00-1.35), 17% more likely to have a late overall stage (OR = 1.17; 95% CI 1.01-1.36), and 32% more likely to present with advanced tumour extent (T3 and T4 stage) (OR = 1.32; 95% CI 1.08-1.62). Data on incidence was extremely limited and not currently sufficient to assess trends in burden of disease.

CONCLUSIONS

This review indicates that during the COVID-19 pandemic, there was upstaging of HNC at diagnosis, suggesting the provision of care to HNC patients was significantly affected.

Continuity of care for patients with de novo metastatic cancer during the COVID-19 pandemic: A population-based observational study

During the COVID-19 pandemic recommendations were made to adapt cancer care. This population-based study aimed to investigate possible differences between the treatment of patients with metastatic cancer before and during the pandemic by comparing the initial treatments in five COVID-19 periods (weeks 1-12 2020: pre-COVID-19, weeks 12-20 2020: 1st peak, weeks 21-41 2020: recovery, weeks 42-53 2020: 2nd peak, weeks 1-20 2021: prolonged 2nd peak) with reference data from 2017 to 2019. The proportion of patients receiving different treatment modalities (chemotherapy, hormonal therapy, immunotherapy or targeted therapy, radiotherapy primary tumor, resection primary tumor, resection metastases) within 6 weeks of diagnosis and the time between diagnosis and first treatment were compared by period. In total, 74,208 patients were included. Overall, patients were more likely to receive treatments in the COVID-19 periods than in previous years. This mainly holds for hormone therapy, immunotherapy or targeted therapy and resection of metastases. Lower odds were observed for resection of the primary tumor during the recovery period (OR 0.87; 95% CI 0.77-0.99) and for radiotherapy on the primary tumor during the prolonged 2nd peak (OR 0.84; 95% CI 0.72-0.98). The time from diagnosis to the start of first treatment was shorter, mainly during the 1st peak (average 5 days, p < .001). These findings show that during the first 1.5 years of the COVID-19 pandemic, there were only minor changes in the initial treatment of metastatic cancer. Remarkably, time from diagnosis to first treatment was shorter. Overall, the results suggest continuity of care for patients with metastatic cancer during the pandemic.

The Impact of the COVID-19 Pandemic on Time to Treatment in Surgical Oncology: A National Registry Study in The Netherlands

To avoid delay in oncological treatment, a 6-weeks norm for time to treatment has been agreed on in The Netherlands. However, the impact of the COVID-19 pandemic on health systems resulted in reduced capacity for regular surgical care. In this study, we investigated the impact of the COVID-19 pandemic on time to treatment in surgical oncology in The Netherlands.

METHODS

A population-based analysis of data derived from five surgical audits, including patients who underwent surgery for lung cancer, colorectal cancer, upper gastro-intestinal, and hepato-pancreato-biliary (HPB) malignancies, was performed. The COVID-19 cohort of 2020 was compared to the historic cohorts of 2018 and 2019. Primary endpoints were time to treatment initiation and the proportion of patients whose treatment started within 6 weeks. The secondary objective was to evaluate the differences in characteristics and tumour stage distribution between patients treated before and during the COVID-19 pandemic.

RESULTS

A total of 14,567 surgical cancer patients were included in this study, of these 3292 treatments were started during the COVID-19 pandemic. The median time to treatment decreased during the pandemic (26 vs. 27 days, p < 0.001) and the proportion of patients whose treatment started within 6 weeks increased (76% vs. 73%, p < 0.001). In a multivariate logistic regression analysis, adjusting for patient characteristics, no significant difference in post-operative outcomes between patients who started treatment before or after 6 weeks was found. Overall, the number of procedures performed per week decreased by 8.1% during the pandemic. This reduction was most profound for patients with stage I lung carcinoma and colorectal carcinoma. There were fewer patients with pulmonary comorbidities in the pandemic cohort (11% vs. 13%, p = 0.003).

CONCLUSIONS

Despite pressure on the capacity of the healthcare system during the COVID-19 pandemic, a larger proportion of surgical oncological patients started treatment within six weeks, possibly due to prioritisation of cancer care and reductions in elective procedures. However, during the pandemic, a decrease in the number of surgical oncological procedures performed in The Netherlands was observed, especially for patients with stage I disease.

Faster surgery initiation in oral cancer patients during the COVID-19 pandemic in Osaka, Japan

BACKGROUND

We investigated the impact of the COVID-19 pandemic on oral cancer (OC), comparing diagnosis and number of pre-operative days in the diagnosis of OC in 2019 (pre-COVID-19) and that in 2020 (during the COVID-19 pandemic).

METHODS

Using data from a cancer registry-based study on the impact of COVID-19 on cancer care in Osaka (CanReCO), we collected details of sex, age, residential area, cancer site, date of diagnosis, clinical stage at first treatment and number of pre-operative days in OC patients.

RESULTS

A total of 1470 OC cases were registered. Incidence of OC before and during COVID-19 was 814 and 656 cases, respectively. During the first wave of the pandemic (March to May 2020), incidence was about half that in the same period in 2019 (2019; n = 271, 2020; n = 145). Number of pre-operative days (median number of days between the first hospital visit and surgery date) was significantly shorter during the COVID-19 year (24.5 days) than in the pre-COVID-19 year (28 days, p = 0.0015).

CONCLUSIONS

Incidence of OC during the COVID-19 pandemic was lower than in pre-COVID-19. Despite disruption in the healthcare system, the number of pre-operative days for OC cases was shorter during the pandemic.

Differences in the association of time to treatment initiation and survival according to various head and neck cancer sites in a nationwide cohort

OBJECTIVES

To assess whether there are differences in the effects of time to treatment interval (TTI) on patient survival for head and neck cancer (HNC) sites in order to provide evidence that can support decision-making regarding prioritizing treatment.

MATERIALS AND METHODS

Patients in the Netherlands with a first primary HNC without distant metastasis between 2010 and 2014 were included for analysis (N = 10,486). TTI was defined as the time from pathologic diagnosis to the start of initial treatment. Overall survival (OS), cox regression analyses and cubic spline hazard models were calculated and visualized.

RESULTS

Overall, the hazard of dying was higher (HR = 1.003; 95 % CI 1.001-1.005) with each additional day until treatment initiation. The pattern, as visualized in cubic spline graphs, differed by site the hazard increased more steeply with increasing TTI for oral cavity cancer. For oropharyngeal and laryngeal cancer, a slight increase commenced after a longer TTI than for oral cavity cancer, while there was hardly an increase in hazard with increasing TTI for hypopharyngeal cancer.

CONCLUSION

The relationship between longer TTI and decreased survival was confirmed, but slight variations in the pattern of the hazard of dying by TTI by tumour site were observed. These findings could support decisions on prioritizing treatment. However, other aspects such as extent of treatment and quality of life should be investigated further so this can also be included.

National Improvement of Waiting Times: First Results From the Dutch Head and Neck Audit

OBJECTIVE

Timely treatment initiation in head and neck cancer (HNC) care is of great importance regarding survival, oncological, functional, and psychological outcomes. Therefore, waiting times are assessed in the Dutch Head and Neck Audit (DHNA). This audit aims to assess and improve the quality of care through feedback and benchmarking. For this study, we examined how waiting times evolved since the start of the DHNA.

STUDY DESIGN

Prospective cohort study.

SETTING

National multicentre study.

METHODS

The DHNA was established in 2014 and reached national coverage of all patients treated for primary HNC in 2019. DHNA data on curative patients from 2015 to 2021 was extracted on national (benchmark) and hospital level. We determined 3 measures for waiting time: (1) the care pathway interval (CPI, first visit to start treatment), (2) the time to treatment interval (TTI, biopsy to start treatment), and (3) CPI-/TTI-indicators (percentage of patients starting treatment ≤30 days). The Dutch national quality norm for the CPI-indicator is 80%.

RESULTS

The benchmark median CPI and TTI improved between 2015 and 2021 from 37 to 26 days and 37 to 33 days, respectively. Correspondingly, the CPI- and TTI-indicators, respectively, increased from 39% to 64% and 35% to 40% in 2015 to 2021. Outcomes for all hospitals improved and dispersion between hospitals declined. Four hospitals exceeded the 80% quality norm in 2021.

CONCLUSION

Waiting times improved gradually over time, with 4 hospitals exceeding the quality standard in 2021. On the hospital-level, process improvement plans have been initiated. Systematic registration, auditing, and feedback of data support the improvement of quality of care.

[Impact of the COVID-19 pandemic on the diagnosis and treatment of patients with head and neck cancer in Brandenburg and Berlin]

BACKGROUND

The impact of the COVID-19 pandemic on potential limitations to the diagnosis and treatment of patients with head and neck tumours has not yet been adequately investigated. There are contradictory data on this subject. Data from larger patient collectives do not exist for Germany so far.

OBJECTIVE

The aim of the survey was to clarify in a large cohort whether the COVID-19 pandemic had an influence on the diagnosis and treatment of patients with head and neck tumours.

METHODS

A retrospective data analysis of the reporting data of the Clinical and Epidemiological Cancer Registry of Brandenburg and Berlin (Klinisch-epidemiologischen Krebsregisters Brandenburg-Berlin, KKRBB) of 4831 cases with head and neck tumours from 2018 to 2020 was performed. The period before April 01, 2020, was evaluated as a prepandemic cohort and compared with the cases of the pandemic cohort from April 1, 2020, until December 31, 2020, in terms of patient-related baseline data, tumour location, tumour stage, tumour board and treatments administered.

RESULTS

No differences were observed between the prepandemic and pandemic cohorts with regard to patient-related baseline data, tumour localisation and tumour stage. Likewise, no temporal delay in diagnosis, tumour board and treatment was evident during the pandemic period. On the contrary, the time interval between diagnosis and start of therapy was shortened by an average of 2.7 days in the pandemic phase. Tumours with T4 stage were more frequently treated surgically during the pandemic compared to the period before (20.8% vs. 29.6%), whereas primary radio(chemo)therapy decreased during the pandemic (53.3% vs. 40.4%). For all other tumour stages and entities, there were no differences in treatment.

CONCLUSION

Contrary to initial speculation that the COVID-19 pandemic may have led to a decrease in tumour cases, larger tumour stages at initial presentation and a delay in diagnosis and treatment, the cohort studied for Brandenburg and Berlin showed neither a delay in tumour treatment nor an increase in tumour size and stage at initial presentation. The treatments performed, however, were subject to a change in favour of surgery and it remains to be seen whether this trend will be maintained in the long term.

Impact of the Sars-Cov-2 outbreak on the initial clinical presentation of new solid cancer diagnoses: a systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic might have delayed cancer diagnosis and management. The aim of this systematic review was to compare the initial tumor stage of new cancer diagnoses before and after the pandemic.

METHODS

We systematically reviewed articles that compared the tumor stage of new solid cancer diagnoses before and after the initial pandemic waves. We conducted a random-effects meta-analysis to compare the rate of metastatic tumors and the distribution of stages at diagnosis. Subgroup analyses were performed by primary tumor site and by country.

RESULTS

From 2,013 studies published between January 2020 and April 2022, we included 58 studies with 109,996 patients. The rate of metastatic tumors was higher after the COVID-19 outbreak than before (pooled OR: 1.29 (95% CI, 1.06-1.57), I2: 89% (95% CI, 86-91)). For specific cancers, common ORs reached statistical significance for breast (OR: 1.51 (95% CI 1.07-2.12)) and gynecologic (OR: 1.51 (95% CI 1.04-2.18)) cancers, but not for other cancer types. According to countries, common OR (95% CI) reached statistical significance only for Italy: 1.55 (1.01-2.39) and Spain:1.14 (1.02-1.29). Rates were comparable for stage I-II versus III-IV in studies for which that information was available, and for stages I-II versus stage III in studies that did not include metastatic patients.

CONCLUSIONS

Despite inter-study heterogeneity, our meta-analysis showed a higher rate of metastatic tumors at diagnosis after the pandemic. The burden of social distancing policies might explain those results, as patients may have delayed seeking care.

Effects of COVID-19 pandemic on hospital visit of head and neck cancer patients

OBJECTIVE

Head and neck cancer (HNC) often causes respiratory symptoms, so diagnostic delays due to COVID-19 are anticipated. Especially, our institute is a designated medical institute for Class 1 specified infectious diseases, and most of the severe COVID-19 patients in this region were preferentially admitted or transferred. Hereby, we evaluated the trends of the numbers, primary sites and clinical stages of HNC patients before and after COVID-19 pandemic.

METHODS

A retrospective analysis of all patients diagnosed and treated for HNC from 2015 to 2021 was performed. Especially, 309 cases between 2018 and 2021 were extracted in order to examine a direct impact of COVID-19 pandemic, which were dichotomized into "Pre" group in 2018-2019 and "COVID" group in 2020-2021. They were compared about the distribution of clinical stage, the period between onset of symptom and hospital visit.

RESULTS

HNC patients decreased by 38% in 2020 and by 18% in 2021 compared to average number of patients from 2015 to 2019. Patients of stage 0 and 1 in "COVID" group significantly decreased compared to that in "Pre" group. Cases performed emergent tracheostomy in hypopharyngeal cancer and laryngeal cancer increased in "COVID" group (10.5% vs 1.3%).

CONCLUSION

Patients with slight symptoms would hesitated to visit hospital after COVID-19, and only a few delays of HNC diagnosis could have increased tumor burden and caused narrowed airway, especially in advanced HPC and LC.

Stage shift and relative survival for head and neck cancer during the 2020 COVID-19 pandemic: a population-based study of temporal trends

Objective

During the first wave of the COVID-19 pandemic in 2020, non-essential health services were suspended in Belgium, and the public was ordered to socially isolate. Underdiagnosis of cancer during this period was reported worldwide. Certain risk factors for head and neck cancer (HNC) overlap with those for COVID-19 incidence and mortality, making underdiagnosis and subsequent stage shift of this potentially rapidly progressing cancer a major concern. We aimed to analyze incidence, clinical stage at presentation, and survival of patients diagnosed with HNC in 2020 in Belgium, considering recent temporal trends.

Methods

Using population-based data from the Belgian Cancer Registry (BCR), we extrapolated 2017-2019 trends in incidence, clinical stage, and 1-year relative survival (1yRS) of HNC to create an expected value for 2020 and compared this to the observed value.

Results

There were 9.5% fewer HNCs diagnosed in 2020, compared to the predicted incidence. Underdiagnosis was larger for males (-11.8%), patients aged 50-64 (-11.2%) and 65-79 (-11.1%), and for oral cavity cancer (-17.6%). Shifts to more advanced stages were observed in larynx and oropharynx tumors and for (male) patients aged 80+. A 2.4 percentage point decline in 1yRS was observed, relative to the increasing trends in 1yRS (2017-2019).

Conclusion

The COVID-19 pandemic led to underdiagnosis of HNC, resulting in shifts to more advanced stage at presentation in certain subgroups. A stage shift can be expected for the 9.5% of tumors not yet diagnosed at the end of 2020. HNC patients diagnosed in 2020 suffered higher than expected mortality.

The COVID-19 pandemic has not changed stage at presentation nor treatment patterns of head and neck cancer: A retrospective cohort study

OBJECTIVES

To evaluate the impact of the COVID-19 lockdown measures on HNC, by comparing the stage at presentation and treatment of HNC before and after the most severe COVID-19 restrictions.

DESIGN

A retrospective cohort study.

SETTING

A regional cancer network serving a patient population of 2.4 million.

PARTICIPANTS

Newly diagnosed patients with HNC between June and October 2019 (pre-pandemic) and June and October 2021 (post-pandemic).

MAIN OUTCOME MEASURES

Symptom duration before diagnosis, stage at diagnosis, patient performance status (PS) and intent of treatment delivered (palliative vs. curative).

RESULTS

Five hundred forty-five patients were evaluated-250 in the 2019 and 295 in the 2021 cohort. There were no significant differences in symptom duration between the cohorts (p = .359) or patient PS (p = .821). There were no increased odds of presenting with a late (Stage III or IV) AJCC cancer stage in 2021 compared with 2019 (odds ratio [OR] = 0.90; 95% confidence interval [CI]: 0.76-1.08); nor increased odds of receiving palliative rather than curative treatment in 2021 compared with 2019 (OR = 0.68; 95% CI: 0.45-1.03).

CONCLUSION

The predicted stage shift to more advanced disease at the time of diagnosis of HNC due to the COVID-19 pandemic has not been realised in the longer term. In keeping with this, there was no difference in symptom duration, patient PS, or treatment patterns between the 2019 and 2021 cohorts.

Association between the COVID-19 pandemic and first cancer treatment modality: a population-based cohort study

BACKGROUND

Physicians were directed to prioritize using nonsurgical cancer treatment at the beginning of the COVID-19 pandemic. We sought to quantify the impact of this policy on the modality of first cancer treatment (surgery, chemotherapy, radiotherapy or no treatment).

METHODS

In this population-based study using Ontario data from linked administrative databases, we identified adults diagnosed with cancer from January 2016 to November 2020 and their first cancer treatment received within 1 year postdiagnosis. Segmented Poisson regressions were applied to each modality to estimate the change in mean 1-year recipient volume per thousand patients (rate) at the start of the pandemic (the week of Mar. 15, 2020) and change in the weekly trend in rate during the pandemic (Mar. 15, 2020, to Nov. 7, 2020) relative to before the pandemic (Jan. 3, 2016, to Mar. 14, 2020).

RESULTS

We included 321 535 people diagnosed with cancer. During the first week of the COVID-19 pandemic, the mean rate of receiving upfront surgery over the next year declined by 9% (rate ratio 0.91, 95% confidence interval [CI] 0.88-0.95), and chemotherapy and radiotherapy rates rose by 30% (rate ratio 1.30, 95% CI 1.23-1.36) and 13% (rate ratio 1.13, 95% CI 1.07-1.19), respectively. Subsequently, the 1-year rate of upfront surgery increased at 0.4% for each week (rate ratio 1.004, 95% CI 1.002-1.006), and chemotherapy and radiotherapy rates decreased by 0.9% (rate ratio 0.991, 95% CI 0.989-0.994) and 0.4% (rate ratio 0.996, 95% CI 0.994-0.998), respectively, per week. Rates of each modality resumed to prepandemic levels at 24-31 weeks into the pandemic.

INTERPRETATION

An immediate and sustained increase in use of nonsurgical therapy as the first cancer treatment occurred during the first 8 months of the COVID-19 pandemic in Ontario. Further research is needed to understand the consequences.

Prioritization of head and neck cancer patient care during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

The COVID-19 pandemic placed considerable strain on the healthcare system, leading to the re-allocation of resources and implementation of new practice guidelines. The objective of this study is to assess the impact of COVID-19 guideline modifications on head and neck cancer (HNC) care at two tertiary care centers in Canada.

METHODS

A retrospective cohort study was conducted. HNC patients seen at two tertiary care centers before and after the onset of the COVID-19 pandemic (pre-pandemic: July 1st, 2019, to February 29th, 2020; pandemic: March 1st, 2020, to October 31st, 2020) were included. The pre-pandemic and pandemic cohorts were compared according to patient and tumor characteristics, duration of HNC workup, and treatment type and duration. Mean differences in cancer care wait times, including time to diagnosis, tumor board, and treatment as well as total treatment package time and postoperative hospital stay were compared between cohorts. Univariate and multivariate analyses were used to compare characteristics and outcomes between cohorts.

RESULTS

Pre-pandemic (n = 132) and pandemic (n = 133) patients did not differ significantly in sex, age, habits, or tumor characteristics. The percentage of patients who received surgery only, chemo/radiotherapy (CXRT) only, and surgery plus adjuvant CXRT did not differ significantly between cohorts. Pandemic patients experienced a significant time reduction compared to pre-pandemic patients with regards to the date first seen by a HNC service until start of treatment ([Formula: see text] = 48.7 and 76.6 days respectively; p = .0001), the date first seen by a HNC service until first presentation at tumor board ([Formula: see text] = 25.1 and 38 days respectively; p = .001), mean total package time for patients who received surgery only ([Formula: see text] = 3.7 and 9.0 days respectively; p = .017), and mean total package time for patients who received surgery plus adjuvant CXRT ([Formula: see text] = 80.2 and 112.7 days respectively; p = .035).

CONCLUSION

The time to treatment was significantly reduced during the COVID-19 pandemic as compared to pre-pandemic. This transparent model of patient-centered operative-room prioritization can serve as a model for improving resource allocation and efficiency of HNC care during emergency and non-emergency scenarios.

Timeliness and Modality of Treatment for New Cancer Diagnoses During the COVID-19 Pandemic in Canada

Importance

The impact of COVID-19 on the modality and timeliness of first-line cancer treatment is unclear yet critical to the planning of subsequent care.

Objective

To explore the association of the COVID-19 pandemic with modalities of and wait times for first cancer treatment.

Design, Setting, and Participants

This retrospective population-based cohort study using administrative data was conducted in Ontario, Canada, among adults newly diagnosed with cancer between January 3, 2016, and November 7, 2020. Participants were followed up from date of diagnosis for 1 year, until death, or until June 26, 2021, whichever occurred first, to ensure a minimum of 6-month follow-up time.

Exposures

Receiving a cancer diagnosis in the pandemic vs prepandemic period, using March 15, 2020, the date when elective hospital procedures were halted.

Main Outcomes and Measures

The main outcome was a time-to-event variable describing number of days from date of diagnosis to date of receiving first cancer treatment (surgery, chemotherapy, or radiation) or to being censored. For each treatment modality, a multivariable competing-risk regression model was used to assess the association between time to treatment and COVID-19 period. A secondary continuous outcome was defined for patients who were treated 6 months after diagnosis as the waiting time from date of diagnosis to date of treatment.

Results

Among 313 499 patients, the mean (SD) age was 66.4 (14.1) years and 153 679 (49.0%) were male patients. Those who were diagnosed during the pandemic were less likely to receive surgery first (subdistribution hazard ratio [sHR], 0.97; 95% CI, 0.95-0.99) but were more likely to receive chemotherapy (sHR, 1.26; 95% CI, 1.23-1.30) or radiotherapy (sHR, 1.16; 95% CI, 1.13-1.20) first. Among patients who received treatment within 6 months from diagnosis (228 755 [73.0%]), their mean (SD) waiting time decreased from 35.1 (37.2) days to 29.5 (33.6) days for surgery, from 43.7 (34.1) days to 38.4 (30.6) days for chemotherapy, and from 55.8 (41.8) days to 49.0 (40.1) days for radiotherapy.

Conclusions and Relevance

In this cohort study, the pandemic was significantly associated with greater use of nonsurgical therapy as initial cancer treatment. Wait times were shorter in the pandemic period for those treated within 6 months of diagnosis. Future work needs to examine how these changes may have affected patient outcomes to inform future pandemic guideline development.

The impact of COVID-19 on presentation and diagnosis of head and neck squamous cell carcinoma

Objective

To analyze how the COVID-19 pandemic has influenced trends in head and neck squamous cell carcinoma (HNSCC) presentation and diagnosis-including referral patterns, stage at presentation, and time to diagnosis-over a longitudinal time course.

Setting

Multicenter tertiary care academic institution.

Methods

A retrospective review of patients with HNSCC presenting between January 1, 2019 and December 31, 2020 was performed. Patients were stratified into pre-COVID and COVID cohorts based upon presentation date either before or after the COVID pandemic was declared a national emergency. Data was collected on demographics, referral site, symptoms, tumor characteristics, and time to diagnosis.

Results

Of 203 patients with HNSCC identified, 77.3% (157/203) were in the pre-COVID cohort and 22.7% (46/203) were in the COVID cohort. Patients in the COVID cohort were more likely to present through inpatient or ER consultation (26% vs. 11%) than outpatient setting. There was a greater than 50% decrease in new tumor board case presentations per month in the COVID cohort (4.8) relative to the pre-COVID (10.9) cohort. Cancer stage at presentation was similar between cohorts. Time from presentation to diagnosis was similar between the cohorts at approximately 30 days.

Conclusions

These results suggest that patients presenting during the COVID pandemic may have unique referral patterns. A significant decrease in tumor board presentations was noted, which may contribute to more delayed presentations that have yet to be observed. Further investigation with a larger sample size is warranted.

Lay Summary

The COVID-19 pandemic may have changed where and how patients with head and neck cancer initially seek care. We found that patients with newly diagnosed head and neck cancer more often were initially seen in urgent settings than before the pandemic.

Level of Evidence

3.

Prospective assessment of stress and health concerns of radiation oncology staff during the COVID-19 pandemic

•

The COVID-19 pandemic required continuous adjustment of radiotherapy practice.

•

Global stress levels and health concerns of staff followed COVID-19 infection waves.

•

Frontline workers with direct patient contact were most affected by the pandemic.

•

Beyond COVID-19, weekly regular online surveys can help to monitor staff well-being.

Introduction and background

The COVID-19 pandemic has required rapid and repetitive adjustment of radiotherapy practice, hospital-level and department-level organization and hygiene measures. To prospectively monitor and manage stress levels and health concerns, employees of a radiation oncology department were invited to participate in weekly online surveys during the first year of the pandemic.

Materials and methods

Starting March 31st, 2020, cross-sectional online surveys were distributed to all employees of the Department of Radiation Oncology, University Hospital Zurich. The survey included questions about the profession, the work setting, the global stress level as well as the health concerns during the past work week. Stress levels and health concerns were assessed on a 10-point scale. SurveyMonkey® was used to conduct the survey. Distribution was performed via email. Participation was anonymous and voluntary.

Results

Between March 2020 and February 2021, 50 weekly surveys were distributed to 127 employees on average and resulted in 1,877 individual responses. The average response rate was 30%. The mean global stress level varied significantly by profession, ranging from 2.7 (±2.5) points for administrative staff to 6.9 (±2.3) points for radiation therapy technicians (p < 0.001). The mean global stress level was highest with 4.8 (±2.9) points for in-hospital work with direct patient contact. Health concerns were highest regarding family and friends with 4.0 (±3.1) points on average. Changes of the stress level varied in correlation with infection waves.

Conclusion

Weekly online surveys for prospective assessment of stress levels and health concerns were successfully conducted during the first year of the COVID-19 pandemic, indicating their feasibility and value to monitor profession and workplace specific stress patterns and to allowed for tailored interventions. The physical and mental health of frontline healthcare workers in radiation oncology should remain a top priority for departmental leadership beyond the COVID-19 pandemic.

COVID-19 and head and neck cancer management. Experience of an oncological hub comprehensive cancer centre and literature review

COVID-19 severely impacted the healthcare system in most industrialised countries and contributed to the postponement of many elective healthcare services. As most national and international surgical associations promptly drew up guidelines to preserve time-dependent surgery, the Lombardy Region, the epicentre of the outbreak of COVID-19 in Italy, also created differentiated pathways for COVID-19 and non-COVID-19-related health services based on a hub/spoke design. At the Department of Otorhinolaryngology and Head and Neck Surgery of the European Institute of Oncology (IEO), we needed to rearrange our assistance pathways, as a designated oncological hub, to guarantee gold-standard treatments to cancer patients. Specific protocols were developed for the management of regional patients and extra-regional patients confined to self-isolation due to the lockdown and stay-at-home policy. Specific assistance trajectories were created for cancer patients coming from other hospitals needing life-saving procedures. Herein, we report the outcomes of patients undergoing head and neck treatments at the IEO Department of Otorhinolaryngology and Head and Neck Surgery, with the aim to evaluate the efficacy of all the measures adopted as an oncological hub during the COVID-19 pandemic and compare our data with that in the international peer-reviewed published medical literature regarding the consequences of COVID-19 on the management of head and neck cancer patients.