The COVID‐19 pandemic has not changed stage at presentation nor treatment patterns of head and neck cancer: A retrospective cohort study

Abstract Objectives To evaluate the impact of the COVID‐19 lockdown measures on HNC, by comparing the stage at presentation and treatment of HNC before and after the most severe COVID‐19 restrictions. Design A retrospective cohort study. Setting A regional cancer network serving a patient population of 2.4 million. Participants Newly diagnosed patients with HNC between June and October 2019 (pre‐pandemic) and June and October 2021 (post‐pandemic). Main outcome measures Symptom duration before diagnosis, stage at diagnosis, patient performance status (PS) and intent of treatment delivered (palliative vs. curative). Results Five hundred forty‐five patients were evaluated—250 in the 2019 and 295 in the 2021 cohort. There were no significant differences in symptom duration between the cohorts (p = .359) or patient PS (p = .821). There were no increased odds of presenting with a late (Stage III or IV) AJCC cancer stage in 2021 compared with 2019 (odds ratio [OR] = 0.90; 95% confidence interval [CI]: 0.76–1.08); nor increased odds of receiving palliative rather than curative treatment in 2021 compared with 2019 (OR = 0.68; 95% CI: 0.45–1.03). Conclusion The predicted stage shift to more advanced disease at the time of diagnosis of HNC due to the COVID‐19 pandemic has not been realised in the longer term. In keeping with this, there was no difference in symptom duration, patient PS, or treatment patterns between the 2019 and 2021 cohorts.

the National Health Service (NHS) was put on an emergency footing in March 2020 to deal with an expected surge in  patients. In keeping with measures in several other countries, all non-urgent surgery and outpatient clinic activity were suspended along with public health messaging for the population not to attend the health services unless absolutely necessary. 1 This was accompanied with a rapid reduction in 'urgent suspicion of cancer' referrals from primary to secondary care. 2 The suspended elective services are essential to the early detection of cancer. Globally, COVID-19 public health measures were used to limit the transmission of coronavirus, the most severe of which resulted in national 'lockdowns'. These measures are also associated with a reduction in healthcare service use. Both these factors risked the timely diagnoses of head and neck cancer (HNC) 3 being made, with modelling predicting a stage shift to more advanced disease when eventually diagnosed. 4 While studies published to date have compared the pre-lockdown period to cohorts during the first 2020 national lockdown, 5 one might expect the full impact of the restrictions described above to be observed at a later time point. This is yet to be evaluated.
The aim of this study is to investigate the impact of the COVID-19 public health measures on stage at diagnosis and treatment patterns of HNC after the most severe restrictions were lifted.

| Eligibility criteria
The time periods sampled were 'pre-pandemic' (1 June to 31 October 2019) and 'post-pandemic' (1 June to 31 October 2021). These dates were chosen to be after the rollout of the vaccination programme permitting the gradual lifting of national COVID-19 public health measures (except social distancing and mask wearing).

| Data collection
Patients were identified from the regional multidisciplinary team (MDT) database, which includes all patients newly diagnosed with HNC in the West of Scotland serving a patient population of 2.4 million. Data were collected from electronic clinical records.
Demographic data included: age at diagnosis, sex, history of smoking (current/former-smoker or never smoker) or excess alcohol consumption (current/former alcohol excess or never alcohol excess) defined by UK government guidance as more than 14 units per week; symptom duration which was estimated by the clinician at time of referral as the number of weeks of red flag symptoms and categorised arbitrarily into <6 weeks, 6-12 weeks and >12 weeks; whether the type of referral was emergency or non-emergency.

Performance status (PS) was recorded via the Eastern Cooperative
Oncology Group (ECOG) PS scale.
Patients' home postcodes were linked to the Scottish Index of Multiple Deprivation (SIMD) 2020 scores. SIMD 2020-an areabased measure of socioeconomic deprivation-categorises geographical areas of Scotland using information from seven domains: income; employment; education; health; access to services; crime and housing. The SIMD 2020 score has five levels with each quintile containing 20% of Scotland's population, with SIMD 1 representing the most deprived areas and SIMD 5 the least deprived areas. 7

Key points
• The public health emergency caused by the coronavirus pandemic created major disruption to the National Health Service (NHS).
• The public health message was to not use the NHS, it is unknown how this has impacted on head and neck cancer (HNC).
• There is a lack of evidence as to the impact of the pandemic on HNC stage presentation, symptom duration and treatment intent.
• This retrospective study did not demonstrate a difference in symptom duration, stage, performance status or treatment intent pre-and post-pandemic in a large cohort of HNC patients.   Changes in treatment intent patterns were evaluated in a similar way to stage using a univariate analysis and a multivariate analysis with a binary logistic regression model. All analyses were performed using SPSSv24 (IBM).

| Patient characteristics
Patient characteristics are shown in Table 1, they did not differ significantly between the two cohorts. Most of the patients with HNC lived in deprived communities, with 43% of patients being from the 20% most deprived areas. 78% had a history of smoking and 96% had a non-emergency presentation. There were no significant differences in symptom duration between the cohorts ( p = .359).
However, there were significantly more patients with a history of excessive alcohol consumption in the 2021 cohort compared with 2019 ( p = .023).

| Treatment patterns and treatment intent
A summary of the treatments received by patients in both cohorts is listed in Table 4  It is likely therefore, that our study, the first to evaluate the impact of the pandemic on HNC diagnosis and treatment patterns at this later time point, is reflective of the situation internationally.
While these initial findings are reassuring, the true impact of the COVID-19 pandemic on patients with HNC will remain unclear for many years until long-term trends are available and survival outcomes are known. More nuanced effects on quality of life and morbidity may be more difficult to evaluate but also warrant further investigation.

| CONCLUSION
For the first time, we demonstrate that the predicted stage shift because of the COVID-19 pandemic, to more advanced disease at the time of diagnosis of HNC has not been realised in the longer term. In keeping with this, there was no difference in symptom duration, patient PS or treatment patterns between the 2019 and 2021 cohorts.