BAHNO Statement on Covid-19

Initial guidance for head and neck cancer management during Covid-19 pandemic in consultation with ENT UK. BAOMS endorsement awaited.

Issued 17 March 2020

To: UK head and neck multidisciplinary teams

BAHNO position:

Healthcare services internationally are seeking to meet and manage the unprecedented impact of the Covid-19 pandemic.

The following is guidance for the provisioning of head and neck (H&N) cancer services during this period. It is intended to guide and support decisions made locally/regionally within H&N MDTs. These should not be viewed as being prescriptive, rather as a support for local decision making and should be used alongside Department of Health guidance. They will be updated as priorities and understanding of the situation evolves.

1. Referrals

Immediate referral triage strengthening (both two-week wait and urgent cancer referrals) with prioritisation of cases highly likely to represent malignancy
Referrals less likely to represent H&N cancer should be delayed/deferred but a record retained for future recall. Consider telephone consultations to ascertain severity where referral urgency is unclear
Non-cancer or benign cases should be deferred/rejected
Patients over 70 years of age (and/or with high risk co-morbidities, frailty) who fulfil urgent cancer criteria should be prioritised in such a way as to minimise time in hospital environment.

2. Diagnostic/ staging workup

Limit diagnostic workup for low risk cases or those where there is a low clinical suspicion of malignancy
Ensure personal protective equipment is available when needed
Follow ENT-UK advice for nasendoscopy
Consider best utilisation of available diagnostic capacity. Where necessary, limit investigations to those modalities that are necessary for safe treatment decision making
Expedite one-stop investigations if possible
AHP input remains essential but should be targeted to those in most need
Additional procedures (e.g., dental assessment/extractions, PEG provision) should be restricted to absolute need.

3. MDT working

Maintain normal MDT frequency (where service allows) but minimise its duration
Quorate MDT constitutes (minimum)

MDT co-ordinator, 1x surgeon (depending on case mix ENT/OMFS/Plastics), 1x clinical oncologist, 1x radiologist (with H&N specialist interest) and 1x pathologist

Specific AHP guidance/input should sought where treatment decisions are likely to be influenced
All MDTs should expedite/encourage steps to facilitate dial-in options for core MDT membership.
Immediate steps should be taken locally to plan prioritisation of treatment plans for H&N cancer (as below) with appropriate discussion in the MDT setting (with clearly documented decisions)
Consider limited discussion/protocolisation of common clinical scenarios with well-recognised treatments (e.g. early cancers of oral cavity and glottic larynx).

4. Treatment

Local contingency plans should be made immediately for prioritisation of surgical and non-surgical treatment

Surgical examples - cessation of all but the most urgent thyroid cancer surgery, prioritise day case surgery where feasible (e.g. wide local excision without reconstruction), restriction/cessation of surgical procedures requiring post-operative HDU/ITU care. Given consideration to reducing the length of surgery when possible e.g. use of local/pedicled flaps rather than free flaps. Restrict non-essential personnel in theatre environment i.e. medical students, additional trainees, medical reps. Ensure personal protective equipment are worn by all staff.

Non-surgical examples - restriction/cessation of chemoradiotherapy in favour of radiotherapy alone, consideration of hypo-fractionated radiotherapy courses in appropriate patients. Delay commencement of palliative chemotherapy in asymptomatic individuals.

5. Follow up

Minimise all follow up appointments.
Immediate attempt to minimise patient contact by postponed appointing (6-9 months) for patients beyond the period of highest risk for recurrence (e.g. 18-24 months post treatment). Prioritise patients in immediate (4/52) post-treatment phase and consider longer intervals between follow ups as soon as suitable. Instigate telephone follow up where possible/appropriate immediately

6. Research/Clinical trials

Prioritise support of patients who are on clinical trials
Consider immediate cessation of trial recruitment if issues exist with capacity or safety
Additional guidance should be available from local R&D guidance (supported by MHRA and clinical trials unit/centres). https://mhrainspectorate.blog.gov.uk/2020/03/12/advice-for-management-of-clinical-trials-in-relation-to-coronavirus/

Cyrus Kerawala

President BAHNO