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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

 

Cyrus Kerawala                                                                               

President BAHNO