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\begin{document}

\title{Disproportionate impact of COVID-19 Pandemic on Head and Neck
Cancer Survivors}



\author[1]{Eric Adjei Boakye et al.}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 06, 2024}


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\textbf{Full author list}

Eric Adjei Boakye, PhD, MA\textsuperscript{1,2}, Wiley Jenkins, PhD,
MPH\textsuperscript{1,2}, Arun Sharma, MD, MS\textsuperscript{2,3}

\textsuperscript{1}Department of Population Science and Policy, Southern
Illinois University School of Medicine, Springfield, Illinois

\textsuperscript{2}Simmons Cancer Institute at SIU, Southern Illinois
University School of Medicine, Springfield, Illinois

\textsuperscript{3}Department of Otolaryngology -- Head and Neck
Surgery, Southern Illinois University School of Medicine, Springfield,
Illinois

\textbf{Corresponding Author:}

Eric Adjei Boakye, PhD

Southern Illinois University School of Medicine

Department of Population Science and Policy

201 E. Madison Street, P. O. Box 19664

Springfield, IL 62794

Phone: 217-545-8511

Email: eadjeiboakye49@siumed.edu

\textbf{Word count:} 1,100

\textbf{Conflict of Interest:} None

\textbf{Funding Sources:} None

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause
of coronavirus disease 2019 (COVID-19), has been declared a pandemic by
the World Health Organization\textsuperscript{1} and is having
repercussions throughout our healthcare system and society. National
projections suggest that incidence and mortality of people with COVID-19
infection is going to significantly increase. Appropriately, much
attention has been paid to addressing the acute challenges associated
with caring for the surge of critically ill patients. This includes
shortages of testing and personal protective equipment (PPE) for
healthcare providers and inability of the healthcare system to handle
the influx of patients. The pandemic is placing strains on our
healthcare system and impacting patients who are seeking care for the
infection and other urgent and emergent medical conditions. However,
what has received less attention is the need for continuing, but perhaps
nonurgent, care for non-COVID-19 patients with chronic conditions such
as cancer. As our longer-term response to the pandemic evolves, we must
purposefully consider such patients.

The impact of pandemic response interventions across society are
significant, with social distancing becoming the norm, many states
entering a `lockdown' condition, and millions of people becoming
unemployed. This situation is particularly troubling for cancer
survivors and their caregivers as the survivors have continuing care
needs and both they and their caregivers already face burdens associated
with diminished income, reduced social contact and support, and
increased risk for anxiety and depression. A recent study in China by
Liang et al. indicated that patients with cancer may be at a higher risk
of both COVID-19 itself and subsequent adverse health
outcomes.\textsuperscript{2} These impacts may be particularly
disproportionate a) in rural areas, already experiencing paucities of
material, care, and financial resources, and b) among head and neck
cancer (HNC) survivors, who already face increased levels of isolation
and depression associated with their cancer and treatment outcomes (e.g.
disfigurement, increased daily care requirements). We urge purposeful
consideration of COVID-19 responses in view of the special circumstances
faced by HNC survivors, especially those residing in rural areas.

\emph{HNC survivors require continuing, but nonurgent, care}

HNC survivors typically experience continuing medical care, but many
non-urgent clinic appointments are already being postponed with an
unknown time frame for rescheduling. Much of cancer surveillance depends
on careful physical examination of the head and neck, including
examination of the pharynx and larynx, often by flexible fiberoptic
nasolaryngoscopy (FFNL). FFNL is an aerosol-generating procedure and the
current consensus is to avoid performing this unless imminently life
threatening in patients who are COVID-19-positive or those who have
unknown infection status.\textsuperscript{3} Therefore, many HNC
survivors will be unable to undergo complete cancer surveillance on
their routine timeline. Furthermore, elective procedures to improve
quality of life (such as esophageal dilation to improve swallowing) are
also being postponed. Possible outcomes of such delayed/deferred care
include delays in diagnosis of disease recurrence, increased anxiety,
and decreased quality of life.

\emph{Caregivers for HNC survivors are important}

Caregivers play a crucial role in the physical and emotional well-being
of people with cancer. This role is especially important for HNC as
survivors are more likely to lack familial and social support and
require more frequent and more detailed care while at home. HNC
survivors tend to be older; face increased social isolation; and need
help with feeding, communicating (speaking), and adhering to treatment.
These factors impede core aspects of daily life for HNC patients, thus
necessitating significant responsibilities for informal caregivers.
Caregivers often face challenges such as managing their emotional and
physical stress, balancing work and family responsibilities, and needing
help keeping the person they care for safe. To this mix in the current
crisis is the balance of keeping themselves safe from infection and
sustaining adequate survivor engagement to maintain health. Finally,
survivors in rural areas may lack access to an already-diminished pool
of caregivers, and perceived stigma or feelings of guilt in asking for
help among rural cancer survivors are additional barriers to obtaining
needed assistance.

\emph{There is new, and increased, burden on both survivor and caregiver
mental health}

The mandatory ``stay at home'' order in most states also could worsen
the financial burden cancer already faced by HNC survivors and their
caregivers as there are record rates of unemployment and numbers of new
unemployment claims in the country. HNC patients have higher rates of
depression, anxiety rates and suicide compared to the general
population. The COVID-19 pandemic has the potential to increase each of
these unless the healthcare system mobilizes to meet their needs. The
lack of continuing screening and access to other care is expected to be
a source of anxiety for HNC survivors. The physical distancing protocol
in place in most areas of the country also increases people's anxiety,
distress and depression. A phenomenon called ``infodemic'' --- an
overabundance of (mis)information on social media and elsewhere --- also
poses a major risk to patients' mental health.\textsuperscript{4} During
past disease outbreaks (e.g. 2003 SARS, 2014 Ebola), there were
significant negative impacts on public and individual mental health,
such as generalized fear and fear-induced overreactive behavior and
increased risk of depression and anxiety.\textsuperscript{5,6} This
issue may be compounded in rural areas; the majority of rural residents
live in mental health professional shortage areas since most mental
health professionals work exclusively in metropolitan areas.

\emph{Possible solutions to be explored}

There are possible solutions to the problems faced by HNC survivors and
their caregivers, and these may be disproportionately effective in rural
areas. Telemedicine is a scalable technology developed in large part to
meet the needs of rural providers. Telemedicine availability has been
expanded by the Centers for Medicare \& Medicaid Services (CMS) during
this pandemic to allow patients to access the health care system, even
if they are not able to physically go to physician
offices.\textsuperscript{7} This could be applied to many of the
possible risk described by allowing for continuing clinical care (to a
certain extent) and incorporating aspects of mental health and wellness.
Other solutions include the allocation of funding specific to survivors
and caregivers. As many of these individuals have a low or non-existent
income, the stimulus package approved by the US congress may not be
sufficient to offset increased costs and lost wages.

While patients with COVID-19 and other urgent and emergent conditions
take priority during the current pandemic, it remains important to
remember the care of head and neck cancer survivors, a vulnerable group.
Vigilance on our part could mitigate the effects of the pandemic on
their health and wellbeing. These patients will require extra care when
resources become available to care for their elective needs. Future
preparedness could help mitigate effects during future widespread events
that limit care.

\textbf{References}

1. Coronavirus (COVID-19) events as they happen. 2020;
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen.
Accessed March 26, 2020.

2. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2
infection: a nationwide analysis in China. \emph{The Lancet
Oncology.}2020;21(3):335-337.

3. Patel ZM, Fernandez-Miranda J, Hwang PH, et al. Precautions for
endoscopic transnasal skull base surgery during the COVID-19
pandemic.\emph{Neurosurgery.} 2020.

4. World Health Organization. 2019 Novel coronavirus (2019-nCoV):
Strategic preparedness and response plan. 2020;
https://www.who.int/docs/default-source/coronaviruse/srp-04022020.pdf.
Accessed 3/26/2020.

5. Person B, Sy F, Holton K, Govert B, Liang A. Fear and stigma: the
epidemic within the SARS outbreak. \emph{Emerging infectious
diseases.}2004;10(2):358-363.

6. Shultz JM, Cooper JL, Baingana F, et al. The Role of Fear-Related
Behaviors in the 2013-2016 West Africa Ebola Virus Disease
Outbreak.\emph{Current psychiatry reports.} 2016;18(11):104.

7. Medicare Telemedicine Health Care Provider Fact Sheet. 2020;
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.
Accessed March 26, 2020.

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