key: cord-0720464-dvlhc1l9 authors: Lyons, A.; Mcdonald, C.; Kanatas, A.; Rogers, S.N. title: Early oral cancer management during the COVID-19 period date: 2020-08-13 journal: Br J Oral Maxillofac Surg DOI: 10.1016/j.bjoms.2020.06.043 sha: 6c4a2720d375664d612388599cd2a7e47e8f8d89 doc_id: 720464 cord_uid: dvlhc1l9 nan The standard of care for patients with oral squamous cell carcinoma (OSCC) is primary surgical resection with or without postoperative adjuvant therapy 8 and, depending on the nature of the defect, free-tissue transfer may be necessary. For the present (and at least in the medium term) during the treatment planning stage, clinicians will have to consider survival, morbidity, the need for tracheostomy (a high-risk procedure for the transmission of COVID-19), and available resources, including the number of hospital admissions and hospital stay. Patients who have free-flap reconstruction stay longer in hospital. It can be argued -taking into account the results of the COVIDSurg study 2 -that there is a measurable risk of COVID-19 transmission during the hospital stay, and a shorter stay with reduced healthcare contacts might reduce it. Free-flap reconstruction can have distinct advantages in terms of recovery. In addition to better function and a reduced risk of fistula and other complications, it can -by virtue of covering the resection defect -result in a rapid recovery, especially if there is no need for a tracheostomy. Neck metastasis in OSCC is a major prognostic variable in overall survival. While there is a general consensus that patients with T3 and T4 N0 primary OSCC or clinically-evident nodal metastases should have neck dissection, little consensus exists for patients with early-stage OSCC (T1N0/T2N0) and clinically and radiologically node-negative necks. 9 Sentinel node biopsy (SNB) is capable of detecting occult metastases in early oral cancer and is a safe technique for staging the clinically N0 neck, 10 although a proportion of patients will require readmission for a completion neck dissection (CND). The SEND trial concluded that for early oral cancer, elective neck dissection (END) resulted in better disease-free survival than wait and watch, 11 and can be completed during one hospital admission. This is in contrast to those who require completion neck dissection following SNB. Patients with early oral cancer are a heterogeneous group and this is often poorly reflected in the literature. Uncertainty arises because patients with larger tumours (when it has been decided that a free flap is not required) are likely to have a survival advantage with surgical staging of the neck, and this can be an END or SNB. On the other hand, thin tumours might have a lower risk of occult metastasis and END may not be necessary, although sentinel lymph node biopsy (SLNB) might be preferable to wait and watch. There is always a risk of ipsilateral or contralateral failure irrespective of which approach is used. Rates are low and SLNB has an advantage, especially when tumours encroach on the midline or have unexpected patterns of drainage. The concern about the added morbidity of CND compared with END is frequently raised. This is an important consideration and further investigation is warranted. In the current climate, SLNB has the disadvantage that when CND is indicated, two episodes of isolation, testing, and shielding may be required before the completion of surgery. These patient pathways differ from hospital to hospital and the impact of this will change over time. While the node-positive rates in the SEND trial for T1 and T2 cancers were 19.1% and 36.7%, respectively (with other trials of END and SLNB showing similar figures 11, 12 ) , it may be that advances in preoperative imaging could allow more node-positive patients to be identified during staging. Also, in the future it might be possible to improve the early detection of lymph node metastasis during follow up in the wait and watch group. In early oral cancer it is difficult to make valid comparisons, and interpretation is fraught with difficulty in the absence of randomised trials. HRQoL is better in those who have laser resection with END than it is in those who have free flaps. However, this is likely to be J o u r n a l P r e -p r o o f because the tumours are differentthat is, much larger in the free flap group -and of course the outcome is worse in those who also have postoperative radiotherapy (PORT). The patient's perspective needs to be considered for every treatment option. Even wellinformed patients can find it difficult to understand, in any meaningful way, the differences between SLNB, END, and watch and wait, and for most, the surgeon's preference and influence is the most important factor in decision making. At this moment in time, for patients with clinically and radiographically staged N0 neck oral cancer, there is a rationale for the simplification of surgery with primary resection, the avoidance of tracheostomy, and careful consideration of the optimal treatment of the neck. There is, however, a trade-off based on uncertainty. Simplifying surgical management may shorten the hospital stay, reduce the burden on services, and enable the backlog of cases to be treated quickly, without having a detrimental effect on crude survival or disease-specific survival. Not only will reduced surgical interventions result in shortened waiting times for cancer patients, they might also free up surgical lists when capacity is limited, for important but less urgent cases. This trade-off would probably be something that would resonate with patients, given the unprecedented situation. As COVID-19 will have an impact on surgical practice for the foreseeable future, any changes in practice need to be carefully audited. Balancing optimal cancer treatments with the risk of COVID-19 is an inexact science based on incomplete evidence and an evolving knowledge base. The risk will vary with time and location as the prevalence of COVID-19 changes. Individual multidisciplinary teams may find at times that national guidance does not J o u r n a l P r e -p r o o f 6 reflect the situation in their institution, and approaches to treatment need to be adaptable to account for this. Finally, every cancer patient requires careful clinical follow up to check for treatment failure, to aid rehabilitation, and identify unmet needs. 13 The COVID-19 crisis has resulted in reduced patient contact, and social distancing. Patient follow-up models will evolve, but patients still value the chance to discuss their concerns and seek reassurance. Technology will help shape the way consultations take place, but some patients will inevitably benefit from a face-to-face appointment. Although the prognosis for early oral cancer is good, one of their main concerns will be about recurrence, and the physical examination is very reassuring. Preoperative preparation and follow-up prompt lists have been developed and are in use in the UK. 14, 15 This model of care, resulting as a consequence of the COVID-19 pandemic, could support the foundation of a new more virtually based follow-up approach. J o u r n a l P r e -p r o o f British Association of Head & Neck Oncologists (BAHNO) Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study Head and neck oncology during the COVID-19 pandemic: reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks French consensus on management of head and neck cancer surgery during COVID-19 pandemic British Association of Oral and Maxillofacial Surgeons (BAOMS) Quality of life, cognitive, physical and emotional function at diagnosis predicts head and neck cancer survival: analysis of cases from the Head and Neck 5000 Study Precaution of 2019 novel coronavirus infection in department of oral and maxillofacial surgery Cancer of the oral cavity A decision analysis model for elective neck dissection in patients with cT1-2 cN0 oral squamous cell carcinoma Sentinel European Node Trial (SENT): 3-year results of sentinel node biopsy in oral cancer Nationwide randomised trial evaluating elective neck dissection for early stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort Head and Neck Disease Management Group. Elective versus therapeutic neck dissection in node-negative oral cancer Outpatient follow-up appointments for patients having curative treatment for cancer of the head and neck: are the current arrangements in need of change? The After-Diagnosis Head and Neck cancer-specific Patient Concerns Inventory (HaNC-AD) as a pre-treatment preparation aid during the COVID-19 pandemic The role of the Head and Neck cancer-specific Patient Concerns Inventory (PCI-HN) in telephone consultations during the COVID-19 pandemic We have no conflicts of interest.