Head and neck cancer in times of COVID-19: Emotion-based medicine

We are living in uncertain times. Right now, with the first peak of the pandemic over, where massive efforts were made to salvage the structure and prevent the collapse of the healthcare system, we find ourselves with the consequences of events and a setting filled with unresolved doubts. We have to admit here, we are not good at this type of situation. The medical profession is used to working within an environment of supposed certainties, the fruit of a scientific method, and the least inexact we know. Evidence-based medicine is proudly practised and we are forever emphasizing this praxis, creating a sensation of certainty which has now, more than ever, been demonstrated not to exist. The medical community needs to work by basing its decisions on the highest evidence available and this inevitably means that it is a sector which poorly tolerates and handles uncertainty.¹

Just 6 months after notification of the existence of the first SARS-CoV-2 infection case, it is easy to understand that there is no solid evidence regarding any aspect related to the virus. The lack of data forces us to take decisions based on the precarious and dubious method of trial and error. This leads to precipitated decisions and the use of patterns of behaviour prior to those which method allows, with rapid conclusions being reached which are based on scarce scientific evidence. To sum up, we can fight uncertainty by sacrificing our inflexibility. Although it is obvious that one is forced to act, we must not forget that the first of our aims should always be not to harm our patients. The physician is above all a person, exposed to multiple biases, and must be aware of his or her condition and accept it, so as to fight against them.

We are also experiencing an unprecedented biopsychosocial crisis. In addition to the absence of consistent scientific data due to the novelty of the infection we are undergoing a state of social, political, economic and healthcare emergency which has roughly shaken us up. Inevitably, this even further conditions our perception of reality in highly diverse ways and obstructs appropriate decision-making. Public health is being mixed with individual health, with the macro economy and social pressure from the magnitude of the tragedy. No university taught anyone to be prepared for this. However, we must take a stand. In fact we have to guide by example and become the voice of reason.

Head and neck cancer is an aggressive disease and its prognosis is directly dependent upon time of response. Without any active treatment, half of the patients are destined to a fatal end within 4 months.² All clinicians know that its impact is extremely high in terms of survival but also in terms of the quality of life of these people and their families. Although we are aware that we cannot refuse them the healthcare they deserve, we must not forget that neither should we offer them suboptimal care, except in the event of force majeure and for the briefest possible period.

During these weeks there have been many publications in highly prestigious international journals (The Lancet, New England Journal of Medicine [NEJM], Oral Oncology, Head and Neck, etc.)^3–5 from different scientific societies and workgroups in the form of recommendations, protocols or clinical guidelines for the management of patients with head and neck cancer during the COVID-19 pandemic. These documents are essential, because in view of the lack of clinical trials to provide reliable data, they are of greatest aid to the medical community for patient management. In contrast, one has to know how to interpret them and be aware of their tremendous limitations, due to the context in which they have been written. It is important to underline that most of them either focus on decision-making in the context of extreme scarcity of healthcare resources, or are limited to preventing and combating virus expansion.

However, little is yet known yet about the impact these measures are having and will have in the vital prognosis of the population with head and neck tumours. There are already several publications which speak of a foreseeable increase in the mortality of these patients of between 10% and 35%, due to the measures adopted to combat COVID-19. Since the duration of the “new normality” has not yet been defined, and in view of possible new future waves of infection, it is crucial to consider to what extent we should change the way in which we care for patients. The suspension of surgical activity, the suspension and/or modification of surgical treatments, delay in diagnosis, scarcity of access to the healthcare system, fear of going into hospitals, the reduction in number of oncological reviews, the establishment of non face-to-face attendance, the absence or limitation of professional multidisciplinary meetings, the prohibition of attendance at scientific reunions, the impossibility of access to training for students and interns, etc., are all realities which we have not just all experienced but which we have also recommended, in the interest of avoiding a greater evil. Given this situation, the burning and simple question is: when will these measures stop preventing a greater evil and actually cause one? Obviously the answer is uncertain and highly complex.

We are thus living through a time which is full of opportunities to learn, to improve and to correct the errors now deeply rooted in our everyday practice. To do so we must leave emotions to one side, and be ever more controlled, rational, prudent and committed to our profession. Good will and effort are insufficient. We have to be professionals in the widest sense of the word. Cooperative work, free access to scientific evidence and embracing uncertainty to generate hypothesis which will lead us to research and provide answers is more necessary now than ever. Cancer will wait for no one.