Vincent Wu MD1*, Christopher W. Noel MD1,2*, David Forner MD2,3*, Zhi-Jian Zhang MD PhD 4 , Kevin M. Higgins MD MSc 1 , Danny J. Enepekides MD MPH 1 , John M. Lee MD MSc 1 , Ian J. Witterick MD MSc 1 , John J. Kim MD 5 , John N. Waldron MD MSc 5 , Jonathan C. Irish MD MSc 1 , Qing-Quan Hua MD PhD 4 , Antoine Eskander MD ScM1,2 1
Department of Otolaryngology – Head and Neck Surgery, University of Toronto, Toronto, Canada; 2 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; 3Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, Canada; 4Department of Otolaryngology – Head and Neck Surgery, Renmin Hospital of Wuhan University, Wuhan, China 5Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network and Department of Radiation Oncology, University of Toronto, Toronto, Canada *equal contribution
Corresponding Author:
Dr. Antoine Eskander
Sunnybrook Health Sciences Centre
2075 Bayview Ave., Room M1 102
Toronto, Ontario M4N 3M5, Canada
Conflict of Interest and Funding: None
Disclosures: None
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Introduction
Coronavirus Disease 2019 (COVID-19), caused by the SARS-CoV-2 virus,
emerged in December 2019 with an initial epicentre focused in Wuhan,
China. As of April 9, 2020, the COVID-19 pandemic has infected over
1,500,000 people worldwide and resulted in nearly 90,000
deaths1. The COVID-19 pandemic carried profound
implications on the head and neck oncology practice in Wuhan and is a
rapidly emerging concern in Canada. Projections vary, though the
Canadian federal government estimates that between 30 and 70 percent of
Canadians could become infected with coronavirus2.
Toronto’s experience with severe acute respiratory syndrome (SARS) in
2003 highlighted the dangers of inadequate preparation and protocols
when faced with a novel and dangerous coronavirus3,4.
Rapid nosocomial spread of SARS led Toronto to become one of the most
impacted regions in the world3,4. Fortunately, from
this experience, significant institutional memory exists within the
University of Toronto partner hospitals5. Our
healthcare systems are better prepared for, and are uniquely positioned
to comment on, the challenges faced with COVID-19.
In order to meet the unprecedented needs facing healthcare systems
across the world, head and neck surgeons must evolve and modify the care
provided to patients in the midst of this pandemic. The Canadian
Association of Head & Neck Surgical Oncology (CAHNSO) has recently
published thoughtful guidelines for the management of patients with head
and neck cancer during COVID-19 6. In combination with
other guidelines and expert opinions, suggestions on how to proceed with
our patients are accumulating for COVID-19 7-9.
Ontario Health (Cancer Care Ontario) developed pandemic clinical
practice guidelines in 2009 which have been recently updated to reflect
the province’s strategy for COVID-19 10,11. A priority
classification system is currently used to triage resources to oncology
patients with the greatest needs. Most head and neck cancer care remains
at the highest level of priority, and the need to provide ongoing head
and neck oncology care remains clear. However, application and
operationalization of these various guidelines can differ across
institutions and real-world experience is needed. This paper describes
the regional institutional practices in Toronto, Canada and Wuhan,
China, and how we have operationalized such guidelines. We outline key
practice considerations for personal protective equipment (PPE),
triaging and decision-making for new referrals, ongoing surgical care,
and follow-up practices from the perspective of two large cancer
institutions with experiences in pandemic management.