Head and neck cancer: high‐risk population for COVID‐19

Dear Dr. Hanna, Since first identified in December of 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has disseminated from Wuhan, China rapidly across the globe. On March 11, 2020, the World Health Organization deemed Coronavirus Disease 2019 (COVID-19) a worldwide pandemic, sending the global community into a state of emergency. As of April 10, 2020, 1.6 million COVID-19 cases have been reported worldwide. Case-fatality rate have ranged from 2% to 7%. Clinically, COVID-19 is initially characterized by a constellation of nonspecific symptoms such as cough, fever, and dyspnea. However, this can escalate quickly, with the median time from symptom onset to severe hypoxemia, necessitating ICU admission, seen to be from 7 to 12 days. It is clear certain populations such as patients with coexisting conditions, older age, an immunocompromised state, and a smoking history are at a high risk for severe disease as well as poor outcomes. Head and neck cancer patients are placed in a vulnerable state and may equally be of high-risk to the consequences of COVID-19, given their immunosuppressed state from cancer and corresponding treatment as well as high prevalence of the aforementioned risk factors. In this correspondence, we aim to discuss sequelae of severe COVID-19 disease, in addition to describing head and neck cancer patients as a high-risk population. The majority of COVID-19 cases are of mild severity; however, 5% to 8% of COVID-19 patients may become critically ill, and experience respiratory failure, septic shock, and/or multi-organ failure. This necessitates admission into the intensive care unit (ICU). Two-thirds of these critically ill patients have met criteria for acute respiratory distress syndrome (ARDS) and require advanced respiratory support. The acute severity and rapid progression of COVID-19 is illustrated with over 63% patients requiring invasive mechanical ventilation in the first 24 hours of admission into the ICU. Mortality of COVID-19 patients in the ICU has been estimated to be 50%. Of these, patients of age > 70 years old and with severe comorbidities were seen to have mortality rates of 68% and 59%, respectively. As defined by the Center for Disease Control's weekly morbidity and mortality report regarding COVID-19, these comorbidities may include diabetes mellitus, chronic lung disease, cardiovascular disease, chronic renal disease, and other chronic disease, of which a history of cancer falls under. ARDS secondary to COVID-19 requires a longer time on mechanical ventilation than is usually required. Bhatraju et al reports a median of 10 days of time on mechanical ventilation before COVID-19 patients were extubated. This is in comparison to the 3 to 8 days seen on average for non-COVID related indications for mechanical ventilation. Even then, most patients are unable to wean off mechanical ventilation, as seen by a tragically high mortality rate of COVID-19 patients on mechanical ventilation (Table 1). The Intensive Care National Audit & Research Centre (ICNARC) demonstrated a 67.3% mortality rate of patients receiving advanced (ie, noninvasive or invasive ventilation, tracheostomy or extracorporeal respiratory support) respiratory support. Studies from China examining critically ill COVID-19 patients placed on mechanical ventilation have reported mortality rates of 81% to 97%. A Seattlebased analysis of critically ill patients on mechanical ventilation saw a comparatively lower mortality rate of 50%, however, at the time of this study three were still on mechanical ventilation without recovery from COVID19. These extraordinary high mortality rates of patients on mechanical ventilation, ranging from 50% to 97%, may reveal that full intensive care support and lifesustaining therapies still cannot overcome the poor prognosis of certain high-risk populations afflicted by Received: 11 April 2020 Accepted: 14 April 2020