key: cord-0983724-4f6tchv7 authors: Meerwein, Christian M.; Stadler, Thomas M.; Balermpas, Panagiotis; Soyka, Michael B.; Holzmann, David title: Diagnostic pathway and stage migration of sinonasal malignancies in the era of the COVID‐19 pandemic date: 2021-09-04 journal: Laryngoscope Investig Otolaryngol DOI: 10.1002/lio2.640 sha: d18c06503a4a87cda0faa99063333a7b6916ae5e doc_id: 983724 cord_uid: 4f6tchv7 OBJECTIVES: The COVID‐19 pandemic bears the risk of delayed cancer diagnoses. METHODS: Study on the diagnostic pathway of sinonasal malignancies during the COVID‐19 pandemic. RESULTS: Median time from first symptom to treatment initiation was not increased during the pandemic: 137 days (interquartile range [IQR] 104‐193) vs 139 days (IQR 103‐219) (P = .60). Median time from first appointment at our institution to treatment initiation was even reduced in 2020: 18 days (IQR 11‐25) vs 11 days (IQR 7‐17) (P = .02). A trend toward advanced tumor stages during the pandemic was seen: 11/30 patients (36.7%) ≥ stage 4 in 2018 to 2019 vs 12/19 patients (63.2%) ≥ stage 4 in 2020 (P = .064). CONCLUSION: Both, time to diagnosis and time to treatment initiation were similar during the pandemic. However, a higher proportion of advanced tumors stages was observed. Despite the pandemic, we provided a swift diagnostic workflow, including a virtual tumor board decision and a prompt treatment initiation. Level of Evidence: 4. Among many other challenges in patient management, the recent COVID-2019 pandemic with months of national lockdowns in many countries worldwide bears a substantial risk of delayed cancer diagnosis. 1 Possible reasons for a delay in the oncological pathway are both, patient and health care system related. Screening, case identification, and referral in symptomatic cancer have all been affected by the pandemic. 2 Along with the call for social distancing, many patients have postponed their medical appointments, since they fear healthcare interactions or mistakenly believe, that health care systems are shut to all but COVID-19 patients. 3 With regard to three common cancers (a. breast, b. colorectal, and c. lung) recent data indicated a significant decline in newly diagnosed patients during the pandemic. 4, 5 For head and neck cancer, the sixth most common cancer worldwide, which typically reveals a short tumor volume doubling time, a delayed treatment initiation was shown to significantly impact overall survival (OS) for patients undergoing upfront surgery or radiotherapy (RT). 6, 7 For sinonasal Christian M. Meerwein and Thomas M. Stadler contributed equally to this work as first authors. Michael B. Soyka and David Holzmann contributed equally to this work as last authors. malignancies in particular, specific data on incidence and stage distribution during the pandemic is rare. 8 Owing to their growth pattern, characterized by locally aggressive expansion and close relationship to pivotal neuro-vascular structures, patients often present at an advanced T category, with involvement of dura, orbit, or brain. Based on these facts, most institutions advocate for initiation of head and neck cancer treatment within 4 to 6 weeks of diagnosis. 9 With this study on the diagnostic pathway and management of sinonasal malignancies during the COVID-19 pandemic in Switzerland, we aimed to compare the pandemic era (2020) to the prepandemic years (2018-2019). In particular, we wanted to investigate absolute numbers of newly diagnosed rhinologic tumors, time from first symptom to diagnosis and treatment initiation, time from first appointment at our institution to treatment initiation and a possible stage migration to more advanced tumors during the pandemic. This study received ethical approval from the ethics committee of the Canton of Zurich, Switzerland. Patients with documented denial to contribute personal health-related data to research were not included. We The following patient data and tumor data were collected: age, gender, risk factors, history of SARS-COV19-infection (patient, close social environment), symptoms at initial presentation, onset of first symptoms, first contact with family doctor, first contact with private ENT, first contact at University Hospital Zurich (tertiary referral center), date of biopsy, initial clinical classification (cT, cN, cM), tumor stage, time from first diagnosis to biopsy (days), time from first symptom to treatment initiation at our institution (days), time from first contact at our institution to treatment initiation (days), histopathological work-up, location of primary tumor, primary treatment protocols, duration of follow up (months), and state at last follow-up. Of note: Only patients with terminated initial treatment protocols were included for the follow up calculation (45/49 patients). The normality of distribution was checked using the Kolmogorov-Smirnov test. Data are either presented as median and interquartile range (IQR) or as mean ± standard deviation (SD), depending on the normality of data distribution. Differences between intervals (first symptom to biopsy, first symptom to treatment initiation, first appointment at our institution to treatment initiation) in the control group (2019-2019) and the index group (2020) were calculated using the Mann-Whitney U-test. Differences among the control and index group regarding the distribution of initial tumor stage were calculated using contingency tables and Fisher's exact test. Accordingly, symptoms at initial presentation among different tumor stages were compared. A post-hoc analysis for the given sample and alpha level of .05 using "clincalc.com" was performed. The end of follow-up was December 2020. A P-value less than .05 indicated significance. Statistics used SPSS version 22 (IBM, Armonk, New York). Table 1 : although we observed a trend toward an increased prevalence of manifest symptoms along with advanced tumor stage, there was no statistically significant association. Figure 2 ). 3.2 | Time to diagnosis, time to treatment initiation, and time to treatment initiation at tertiary referral center As indicated in Table 4 and Figure 3 , Initial treatment protocols consisted of surgery alone in 6/49 patients, neoadjuvant chemotherapy + definitive radiochemotherapy in 10/49 patients, surgery + adjuvant radio(chemo)therapy in 22/49 patients, primary radio(chemo)therapy in 10/49 patients, and best supportive care in one patient. The overall median follow up of the cohort was 15 months (IQR approximately 5% of all annual cancer diagnoses, have been suspended. 2 The Netherlands Cancer Registry reported declining cancer incidence rates up to 40% at the peak of the pandemic. 5 Additionally, data showed that patients with recently diagnosed cancer had significantly increased risk of COVID-19. 11 For head and neck cancer and sinonasal malignancies in particular, only limited data on the sequelae of the pandemic are available so far. 12 Data from the COVIDSurg collaborative estimated a 12-week cancellation rate of 38.9% for head and neck cancer surgery, while for benign head and neck procedures numbers were estimated even higher, with 81.5%. 13 Although it was shown that standard head and neck cancer therapy is safe and need not to be withheld during the pandemic, recent data on nasopharyngeal carcinomas indicated a pandemic-related delay in the diagnostic pathway and treatment initiation. 13, 14 For the entity of sinonasal malignancies, there is a lack of data concerning tumor stage migration in the pandemic era. Sinonasal malignancies represent 3% to 5% of all head and neck cancers and their growth is associated with potential affection of pivotal neurovascular structures, such as brain, dura, carotid artery, and optic nerve. 15 Besides its retrospective design, we acknowledge that our study has some noteworthy limitations. First, we included all newly diagnosed sinonasal tumors in 2020, a post-hoc power analysis at an alpha level of .05 revealed, that our study was underpowered (21.4%). Second, we included three different rhinologic tumor entities in our cohort, which exhibit a different biological behavior. However, distribution of those three tumor entities was similar between the prepandemic and the pandemic group. Third, the follow up, in particular of the pandemic group, is too short to provide reliable statements in terms of outcome. Fourth, the pandemic itself had its course of lockdowns, exertion, and loosened periods, which could bias our results. Thus, further studies on larger cohorts are necessary to better understand the impact of the COVID-19 pandemic on sinonasal malignancies and head and neck cancer care in general. Absolute time to diagnosis and time to treatment initiation were similar during the pandemic, when compared to prepandemic era. A trend toward an increased proportion of advanced tumors as an indirect indicator of a diagnostic delay was observed, bearing the risk of a poorer outcome. Despite the pandemic, we were able to provide a targeted and swift diagnostic workflow, including a virtual tumor board decision. This effort even resulted in a decreased time from first appointment to treatment initiation at our institution. 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