The COVID-19 pandemic had a profound impact on healthcare system guidelines worldwide. In particular, the early stages of the pandemic required a considerable proportion of healthcare personnel and equipment to be reallocated towards relieving the growing burden of caring for COVID-19 patients. A 2021 study on one tertiary-care center showed that during the first two months of the pandemic, there was approximately a 50% reduction in hospital activity compared to pre-pandemic practice [18]. Furthermore, healthcare workers needed to cope with the added challenge of protecting themselves while providing the highest possible standard of care for patients [19, 20]. Guideline alterations recommended managing all patients as though they are potentially COVID infected, and therefore adhering to universal safety precautions [21]. Regarding surgical specialties, certain centers prioritized surgeries with a high chance of cure while those with uncertain benefit and poor prognosis were avoided [18]. Nevertheless, healthcare systems needed to balance managing COVID-19 risk with other critical illnesses requiring medical attention for diseases such as malignancies [22]. The management of HNC was no exception and faced similar burdens during the pandemic. With respect to COVID-19 outcomes, HNC patients are typically of higher risk due to their age, comorbidities, and male predominance [18].

The interpretation of our study necessitates an understanding of the guideline modifications that were specifically undertaken for HNC patient care at our two tertiary care centers. At our first tertiary care center, henceforth known as Center A, all elective surgeries were stopped at the peak of pandemic waves, allowing only prioritized and emergency surgeries, including oncologic cases, to take place. Accordingly, the limited OR time was managed adequately based on a patient-centered approach. An OR Prioritization Committee was formed and met on a weekly basis to review all surgical requests based on priority: P0 was designated for cases requiring surgery within two weeks, and P1 was designated for cases requiring surgery within four weeks. Priority was determined through a transparent discussion of every case, and the limited OR time was allocated to prioritized patients instead of being allocated to surgeons with block operative time to fill. OTL-HNS clinics were often downsized to 50% capacity and telemedicine was promoted when possible. Furthermore, the clinical activities of non-oncological OTL-HNS physicians were significantly reduced to the point that some of these physicians stopped seeing patients entirely during peaks of pandemic waves. At our second tertiary care center, henceforth known as Center B, OR prioritization was handled in a similar fashion to Center A, including the prioritization of HNC cases throughout the peak of pandemic waves. However, it is worth noting that during the first six weeks of the first pandemic wave, essentially all surgery came to a halt in Center B. Accordingly, several patients were directed towards radiotherapy and/or chemotherapy during this period whereas in a non-pandemic situation, they would not have. Another difference is that the OR prioritization committee in Center B met daily, as opposed to weekly in Center A, to decide which patient cases would be operated the following day.

The results of our study show a significant decrease in the periods between date first seen by OTL-HNS until date first presented at tumor board and the date first seen by OTL-HNS until the start date of treatment, indicating an accelerated HNC cancer workup during the pandemic. As per our covariate analysis, these results were not impacted by tumor site, tumor type, and tumor staging. These results were also not impacted by the total HNC case volume during the pandemic, which remained similar to the pre-pandemic total case volume. We postulate that as hospital care became limited towards routine clinical visits and non-urgent or elective operations, care was diverted to cancer patients whose workups and treatments could not be delayed. Accordingly, the mean total treatment package time for patients receiving surgery only, which was defined as the duration of the hospital stay, was significantly reduced to less than 4 days. The total package time for patients receiving surgery plus adjuvant CXRT, defined from the date of first surgery to end of adjuvant treatment, was also reduced to less than 81 days. The opposite was found for those receiving CXRT only, despite there being no significant changes in the number of patients in the CXRT only and other treatment categories. For this group, total package time was defined from start to end date of CXRT, which increased to over 53 days. The significant differences in total package time for those receiving surgery only, CXRT only and surgery plus adjuvant CXRT were highlighted when adjusting for pertinent covariates, namely all tumor characteristics, all tumor characteristics except for metastasis, and all tumor characteristics except for metastasis and tumor size respectively. The gain in the efficiency of HNC cancer care or cancer care in general in our institutions surely has come at the expense of many patients with non-urgent health care needs and delayed elective surgeries with increasing number of patients in surgical wait list as had been documented by provincial statistics.

Our results show a reduction trend in the periods between symptom onset until start date of treatment, first visit to any doctor until start date of treatment, and the date first biopsied until date of histopathological diagnosis. Other studies have acknowledged the cancellation of non-urgent elective surgeries during the first phase of the pandemic—due to a reduction in the number of available spots in intensive care units—resulting in a reduced waitlist for more urgent procedures [23]. Similarly, the decreased wait time from first biopsy to histopathological diagnosis may have resulted from an overall decreased burden on the pathology departments during the pandemic period. Although many elective operations were delayed or canceled, the treatment of HNC patients could not be safely postponed, as it may be associated with increased morbidity and mortality [24]. Thus, while it was initially thought that cancer patient care would be delayed by the pandemic, the cancellation of non-urgent elective clinics and surgeries by OTL-HNS, as well as other disciplines, at our tertiary care centers had the opposite effect. Consequently, our study suggests that the most influential factor for accelerated HNC patientcare at our centers during the pandemic was likely the transparent model of patient-centered OR prioritization among all medical disciplines involved in the workup of these patients.

Another possible, yet less influential, factor for the reduced wait times in HNC treatment could be the initial reluctance of patients to present at the hospital due to the pandemic. Subsequently, they would present at a more advanced stage of their cancer and require faster and more urgent treatment. Although not significant, our results reflect a trend towards more advanced cancer staging at the time of diagnosis. Other studies have shown that in 2020, patients were more reluctant to go to hospitals despite the severity of their condition, showing significant delays in diagnosis, admission and treatment [22, 25]. A study by Tevetoğlu et al. showed that overall rates of T3/T4 tumors were significantly increased in 2020 [22]. These results are consistent with our study showing an upward trend in advanced cancer presentations, including T3/T4, N1, N2, and those with metastatic disease. It is worth noting that tumor board meetings were never rescheduled or canceled at either of our tertiary care centers, which other studies have suggested as a possible cause for delays in HNC workup and more advanced staging at diagnosis at other hospitals during pandemic waves [25].

As expected, our results show a significant increase in patients who had their first encounter with OTL-HNS through telemedicine during the pandemic. Furthermore, there was a greater tendency for patients to be seen by telemedicine during their first visit with any doctor, including primary care, for index symptoms during the pandemic. With respect to patient preferences, a 2021 study showed that the majority of HNC patients at a tertiary care center preferred in-person surveillance of their condition with a physical exam; however, those who preferred telemedicine cited convenience and the desire to avoid infection [26]. With respect to patient satisfaction, another 2021 study showed that OTL-HNS patients at two tertiary care centers were overall highly satisfied with teleconsultations and believed that its main advantages were earlier care and faster service [10]. Other notable advantages include increased availability of in-person care, decreased travel time/cost for patients, and group decision making with family members and other healthcare providers. At our tertiary care centers, telemedicine allowed OTL-HNS physicians to conduct simple interactions such as revision of test results through virtual appointments, hence freeing up clinic time for in-person appointments that required more active interventions. Although these advantages support the continued implementation of telemedicine, disadvantages such as lack of physical exam, potentially missed diagnoses, and lack of patient access/comfort with technology must be dealt with to increase the long-term efficacy of telemedicine in HNC patient care [10, 26].

Regarding HNC treatment, our study shows no significant changes in the proportion of HNC cases that were treated by surgical versus non-surgical means during the pandemic. Similarly, there were no significant changes in the proportion of cases that were treated with curative versus palliative intent during the pandemic. This indicates that HNC treatment algorithms at our tertiary care centers were not significantly affected by guideline alterations that aimed to re-allocate healthcare workers and equipment, reduce the number of elective surgeries, and increase the availability of hospital beds. A non-significant trend towards decreased treatments of curative intent was observed which can be related to the upward trend in advanced cancer presentations previously discussed. Additionally, the halting of surgeries during the first six weeks of the pandemic by Center B may have played a role in results demonstrating a non-significant downward trend in the number of patients receiving surgery only. It is worth noting that the length of hospitalizations following major HNC surgeries are usually prolonged, which potentially puts HNC patients at risk of coronavirus infection [18]. Accordingly, it was thought that HNC postoperative care would be significantly shortened by pandemic guideline alterations. However, our study demonstrates that there was no significant difference in the length of postoperative hospitalization during the pandemic, meaning that postoperative care of HNC patients was not jeopardized.

There are several limitations to this study that limit interpretation of the results. It is worth noting that HNC workup was affected by the variability of multiple factors: primary care center or physician on presentation, telemedicine consults, past medical history, tertiary care center for OTL-HNS workup, and supervising OTL-HNS surgeon for each patient. In particular, it is worth noting that each of the two tertiary care centers in this study had minor differences in OR prioritization that dictated changes in HNC patient care during the pandemic. Our conclusions are limited by the timing of our pandemic cohort during the early phase of the COVID-19 pandemic, particularly the first and second waves. Further investigation into later waves of the pandemic may yield differing results as the general population and healthcare system gradually adapted, and their daily practices returned closer to normalcy.

Although multiple worldwide COVID-19 waves have passed at the time of this writing, it is evident that healthcare systems across the globe still face the threat of emerging variants and new potential pandemics in the future. This study only investigated two centers in the same city, thereby limiting the external validity as it relates to other cities and provinces within Canada which may have implemented different triage policies during this time [27]. Further exploration of HNC patient care in other Canadian centers during the pandemic, along with a prospective evaluation of this transparent model for patient-centered OR prioritization in those different settings, would help determine its role on the national level moving forward. The results are also limited in their comparison to other countries which utilize healthcare systems unlike the publicly funded single-payer system in Canada (Medicare), especially in terms of wait times and access to services [28,29,30]. For example, a study by Schoonbeek et al. in the Netherlands, also found a decrease in the mean time to treat interval during the first wave of the pandemic, which they attributed in part to a decline in overall patient volume and national quality indicators for HNC patient care [31]. The decrease from 37 days in the pre-pandemic to 30 days in the pandemic was smaller, however, as were the mean wait times for both groups when compared to those found in the present study [31]. Together, results of this study along with similar work in different parts of the world have enduring global significance and will inform practice for future outbreaks and for regions with a rising incidence of COVID-19.