10.14639/0392-100X-N1604
Objective. The COVID-19 pandemic emergency forced the health system in Italy to implement an immediate reorganisation to support the care of tens of thousands of patients and to maintain the quality of care for patients with other pathologies, such as oncologic diseases. The main goal of this study was to evaluate the impact of COVID-19 restrictions on the hospitalisation and post-operative rehabilitation of head and neck oncologic patients and to determine whether the introduction of new technologies such as video-communication may be useful to mitigate social distancing by close family members. Methods. Fifty-one consecutive patients underwent surgery for head and neck cancer during the period of lockdown caused by the COVID-19 pandemic. The data collected (postoperative pain, post-operative complications, duration of hospitalisation) were compared with those of 51 consecutive patients treated for head and neck cancer in the period immediately preceding lockdown. Results. The average duration of hospitalisation was longer in patients operated on in the COVID-19 period, and, in particular, among patients who underwent a more demanding rehabilitation protocol. Despite this, our study did not show a significant difference in psychological aspects during hospitalisation. Conclusions. The greatest difficulties that occurred in the COVID-19 period were met by a greater commitment from medical staff, allowing the quality of life of head and neck cancer patients during post-operative rehabilitation to be maintained at a similar level to that before the pandemic. In the future, there will be a need for technological solutions to bring the patient closer to family members.
text/xml
1827-675X
1604
en
Giovanni Succo
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
rehabilitation
Impact of COVID-19 restrictions on hospitalisation and post-operative rehabilitation of head and neck cancer patients
Text.Serial.Journal
https://www.actaitalica.it/
41
COVID-19
2021-12-21
2021-04-07
2021-12-22
2021-12-22
489-495
1
Giovanni Succo
2021/12/21
10.14639/0392-100X-N1604
489
Head and Neck Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy; Department of Oncology, University of Turin, Orbassano (TO), Italy
1827-675X
rehabilitation
495
Impact of COVID-19 restrictions on hospitalisation and post-operative rehabilitation of head and neck cancer patients
https://www.actaitalica.it/article/download/1604/707
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:489-495; doi: 10.14639/0392-100X-N1604




COVID-19


Impact of COVID-19 restrictions on hospitalisation
and post-operative rehabilitation of head and neck
cancer patients
L’impatto delle restrizioni da COVID-19 sulla degenza e la riabilitazione post-operatoria
dei pazienti con carcinoma cervico-cefalico
Erika Crosetti1, Martina Tascone1, Giulia Arrigoni1, Marco Fantini1, Giovanni Succo1,2
1
 Head and Neck Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy; 2 Department of Oncology, University
of Turin, Orbassano (TO), Italy


SUMMARY
Objective. The COVID-19 pandemic emergency forced the health system in Italy to imple-
ment an immediate reorganisation to support the care of tens of thousands of patients and to
maintain the quality of care for patients with other pathologies, such as oncologic diseases.
The main goal of this study was to evaluate the impact of COVID-19 restrictions on the
hospitalisation and post-operative rehabilitation of head and neck oncologic patients and to
determine whether the introduction of new technologies such as video-communication may                  Received: April 7, 2021
be useful to mitigate social distancing by close family members.                                        Accepted: September 13, 2021
Methods. Fifty-one consecutive patients underwent surgery for head and neck cancer dur-
ing the period of lockdown caused by the COVID-19 pandemic. The data collected (post-                   Correspondence
operative pain, post-operative complications, duration of hospitalisation) were compared                Erika Crosetti
with those of 51 consecutive patients treated for head and neck cancer in the period im-                Head and Neck Oncology Unit, FPO-IRCCS, Candio-
mediately preceding lockdown.                                                                           lo Cancer Institute, 10060 Candiolo, Turin, Italy
Results. The average duration of hospitalisation was longer in patients operated on in the              Tel. + 39 011 9933663
COVID-19 period, and, in particular, among patients who underwent a more demanding                      E-mail: erika.crosetti@ircc.it
rehabilitation protocol. Despite this, our study did not show a significant difference in psy-
chological aspects during hospitalisation.                                                              Funding
Conclusions. The greatest difficulties that occurred in the COVID-19 period were met by a               This research was funded by: Regione Piemonte,
                                                                                                        Progetto A Funzione (years 2019-2021); FPRC
greater commitment from medical staff, allowing the quality of life of head and neck cancer
                                                                                                        5x1000 2016 Ministero della Salute Progetto
patients during post-operative rehabilitation to be maintained at a similar level to that before        ARDITE – BioHeNeC; Fondi Ricerca Corrente
the pandemic. In the future, there will be a need for technological solutions to bring the              2021, Ministero della Salute.
patient closer to family members.
KEY WORDS: COVID-19, head neck cancer, rehabilitation                                                   Conflict of interest
                                                                                                        The Authors declare no conflict of interest.

RIASSUNTO
                                                                                                          How to cite this article: Crosetti E, Tascone M,
Obiettivo. L’emergenza causata dalla pandemia da COVID-19 ha costretto il sistema sanitario
                                                                                                          Arrigoni G, et al. Impact of COVID-19 restric-
italiano ad attuare un’immediata riorganizzazione per supportare la cura di decine di migliaia            tions on hospitalisation and post-operative reha-
di pazienti e mantenere la qualità delle cure di pazienti con altre patologie, quali le malattie on-      bilitation of head and neck cancer patients. Acta
cologiche. L’obiettivo principale di questo studio è stato quello di valutare l’impatto delle restri-     Otorhinolaryngol Ital 2021;41:489-495. https://
zioni da COVID-19 sulla degenza e sulla riabilitazione post-operatoria di pazienti oncologici             doi.org/10.14639/0392-100X-N1604
testa-collo e determinare se l’introduzione di nuove tecnologie, come la videocomunicazione,
possa essere utile per mitigare il distanziamento sociale dai familiari stretti.                        © Società Italiana di Otorinolaringoiatria
Metodi. Durante il periodo di lockdown causato dalla pandemia da COVID-19, 51 pazienti                  e Chirurgia Cervico-Facciale
consecutivi sono stati sottoposti a intervento chirurgico per tumori maligni testa-collo. I
dati raccolti (dolore post-operatorio, complicanze post-operatorie, durata della degenza)                              OPEN ACCESS
sono stati confrontati con quelli di 51 pazienti consecutivi trattati per tumori maligni testa-         This is an open access article distributed in accordance with
collo nel periodo immediatamente precedente il lockdown.                                                the CC-BY-NC-ND (Creative Commons Attribution-Non-
Risultati. La durata media della degenza è stata più lunga nei pazienti operati nel periodo             Commercial-NoDerivatives 4.0 International) license. The
                                                                                                        article can be used by giving appropriate credit and mentio-
del COVID-19, in particolare nei pazienti sottoposti a un protocollo riabilitativo più im-              ning the license, but only for non-commercial purposes and
pegnativo. Nonostante ciò, il nostro studio non ha dimostrato una differenza significativa              only in the original version. For further information: https://
negli aspetti psicologici durante il ricovero.                                                          creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                                489
E. Crosetti et al.




Conclusioni. Le maggiori difficoltà che si sono incontrate nel periodo del COVID-19 sono state superate da un maggiore impegno da parte
di tutto il personale sanitario, consentendo di mantenere la qualità di vita dei pazienti a un livello simile a quello precedente la pandemia. In
futuro, saranno necessarie soluzioni tecnologiche per avvicinare il paziente ai familiari.
PAROLE CHIAVE: COVID-19, carcinoma testa-collo, riabilitazione



Introduction                                                              underwent surgery for head and neck cancers. All patients
                                                                          were treated at the Head and Neck Oncological Unit of the
The emergency caused by the Severe Acute Respiratory
                                                                          FPO IRCCS, Candiolo Cancer Institute, Turin, Italy in the
Syndrome Coronavirus 2 (SARS-CoV-2) pandemic forced
                                                                          period of lockdown caused by the COVID-19 pandemic
the health system in Italy to implement an immediate reor-
                                                                          (March-June 2020). During this period, only non-deferra-
ganisation to support the care of tens of thousands of Coro-
                                                                          ble surgical procedures were carried out.
navirus Disease 2019 (COVID-19) patients and at the same
                                                                          The study received approval from the Committee of Ethics
time to maintain the quality of care for patients with other
                                                                          in Research in our hospital. All of the procedures were con-
pathologies 1-3. Diverting the attention of the healthcare
                                                                          sidered to be conventional in terms of technique and indica-
system to focus on overcoming the pandemic has increased
                                                                          tions, in accordance with current guidelines and therefore
the risk of overlooking other important and urgent patholo-
                                                                          also in accordance with the ethical standards of the Insti-
gies, such as oncologic ones 4. Indeed, oncologic patients
                                                                          tutional and/or National Research Committee and with the
have a more severe treatment to face and overcome, from
                                                                          1964 Helsinki Declaration and its later amendments.
both physical and psychological points of view 5, and es-
                                                                          During the health emergency caused by the COVID-19 pan-
pecially those affected by head and neck cancer. Head
                                                                          demic, entry into our hospital by any person was regulated
and neck oncologic surgical procedures are considered to
                                                                          by triage: measurement of external body temperature, hand
be onerous treatments with a severe impact on physical,
                                                                          sanitisation and wearing a surgical mask. Access was only
functional and psychological domains; post-operative re-
                                                                          allowed to patients and in the case of non-self-sufficient
covery involves rehabilitation of important functions from
                                                                          patients access was also restricted to a single caregiver.
both physical and social perspectives (swallowing, verbal
                                                                          All oncologic patients were hospitalised the day before
communication, breathing) 6,7. In the rehabilitation period,
                                                                          surgery to collect a nasopharyngeal swab for SARS-CoV-2
a fundamental role is played not only by healthcare staff,
but also by caregivers. Relatives and close family members                RNA and a chest X-ray. Patients remained hospitalised in a
offer the patient important psychological and motivational                dedicated isolation ward awaiting their results. If both tests
support when it is often difficult to face the disease in a               (nasopharyngeal swab and chest X-ray) were negative, pa-
positive and rational way. For this reason, in the normal                 tients were transferred to the ward in the afternoon.
pre-pandemic situation, the caregiver can be present during               During the patients’ period of hospitalisation, no relative
the hospitalisation period and this is highly recommended                 was admitted to the ward, except for non-self-sufficient pa-
for motivational reinforcement of the patient. This support               tients (11 patients in the pre-COVID-19 period and 5 pa-
was lost during the COVID-19 pandemic, which forced the                   tients in the COVID-19 period), for whom the presence of
adoption of strict rules to counter the spread of viral infec-            a caregiver was mandatory. For the same reason, patients
tion, including banning caregivers from entering hospitals.               were not allowed to leave the ward.
This situation meant that the oncologic patient had to en-                The following data were collected: post-operative pain
dure the treatment process without the important psycho-                  (Visual Analog Scale (VAS) scores), post-operative com-
logical support of a family member.                                       plications and duration of hospitalisation. Furthermore, at
The main goal of this study was to evaluate the impact of                 the end of the hospitalisation period, patients completed
COVID-19 restrictions on hospitalisation and post-opera-                  the Hospital Anxiety and Depression Scale (HADS) ques-
tive rehabilitation of head and neck oncologic patients and               tionnaire 8,9. The Hospital Anxiety and Depression Scale
to determine whether the introduction of new technologies                 (HADS) is a self-report questionnaire designed to assess
such as video-communication may be useful to mitigate so-                 anxiety and depressive states in hospitalised patients. The
cial distancing by close family members.                                  HADS uses two scales of 7 questions each. One scale as-
                                                                          sesses the anxiety component and the other the depression
                                                                          component. The HADS Scale is useful to identify patients
Materials and methods                                                     with mood disorders. A maximum score of 21 can be ob-
This study evaluated 51 consecutive patients (35 males                    tained for each scale of the questionnaire. Patients scoring
and 16 females, age (mean ± SD) 65.4 ± 14.1 years) who                    between 0 and 7 are indicated as normal, those scoring be-



490
                                                                                                                 Head neck cancer, COVID-19




tween 8 and 10 are indicated as at-risk of developing mood                     tients (40 males and 11 females, mean age 66.0 years,
disorders (borderlines), while patients scoring above 10 are                   SD 14.6) treated for head neck cancers in the period im-
indicated as full cases.                                                       mediately preceding lockdown (September 2019 - January
This data were compared with that of 51 consecutive pa-                        2020) (Tabs. I-III).


Table I. Demographic characteristics of patients treated in the pre-COVID-19 and COVID-19 periods.
 Characteristics                                         Pre-COVID-19 period               COVID-19 period            p-value
                                                          No. of patients (%)            No. of patients (%)
 Age, years                                                                                                            0.695
    Mean                                                              66                        65
    Range                                                            16-87                     20-89
 Sex                                                                                                                   0.370
    Male                                                             40 (78)                   35 (69)
    Female                                                           11 (22)                   16 (31)
 Pre-treated patient                                                                                                   0.091
    No                                                               44 (86)                   36 (71)
    Yes                                                              7 (14)                    15 (29)
 Non-self-sufficient patients                                                                                          0.172
    No                                                               40 (78)                   46 (90)
    Yes                                                              11 (22)                   5 (10)
 Tumour site                                                                                                           0.806
    Neck (CUP, skin cancers)                                         13 (25)                  14 (27)
    Oral cavity and oropharynx                                       16 (31)                  16 (31)
    Larynx and hypopharynx                                           15 (29)                  17 (33)
    Salivary glands                                                  7 (14)                    4 (8)
 Type of surgery                                                                                                       0.468
    Without reconstruction                                           40 (78)                  35 (69)
    With reconstruction                                              11 (22)                  16 (31)
    Pedicled flap                                                    6 (12)                   11 (22)
    Free flap                                                        5 (10)                   5 (10)
 Tracheostomy                                                                                                         > 0.999
    No                                                               25 (49)                  25 (49)
    Yes                                                              26 (51)                  26 (51)
 NGT                                                                                                                   0.216
    No                                                               36 (71)                  29 (57)
    Yes                                                              15 (29)                  22 (43)
 Dindo classification of surgical complications
    I                                                                 1 (2)                     1 (2)
    II                                                                0 (0)                     2 (4)
    IIIa                                                              0 (0)                     1 (2)
    IIIb                                                              2 (4)                    6 (12)
    IVa                                                               0 (0)                    0 (0)
    IVb                                                               0 (0)                    0 (0)
    V                                                                 0 (0)                    0 (0)                   0.072
 Duration of hospitalisation
    ≤ 7 days                                                         27 (53)                  28 (55)                  0.281
    > 7 days                                                         24 (47)                  23 (45)
CUP: carcinoma of unknown primary (origin); NGT: nasogastric tube.




                                                                                                                                      491
E. Crosetti et al.




Table II. Tumour staging of patients treated in the pre-COVID-19 and COVID-19 periods.
 Tumour site                           Pre-COVID-19 period                        COVID-19 period                               p-value
                                        No. of patients (%)                     No. of patients (%)
 Neck (CUP, skin cancers)                                                                                                        0.759
   Stage I                                           4 (8)                              2 (4)
   Stage III                                         4 (8)                             6 (12)
   Stage IVA                                         2 (4)                              2 (4)
   Stage IVB                                         3 (6)                              4 (8)
 Oral cavity, oropharynx                                                                                                         0.981
   Stage I                                          6 (12)                             8 (16)
   Stage II                                          4 (8)                              4 (8)
   Stage III                                         1 (2)                              1 (2)
   Stage IVA                                         3 (6)                              2 (4)
   Stage IVB                                         2 (4)                              1 (2)
 Larynx, hypopharynx                                                                                                             0.802
   Stage I                                          6 (12)                             5 (10)
   Stage II                                          0 (0)                             1 (2)
   Stage III                                         4 (8)                             4 (8)
   Stage IVA                                         2 (4)                             4 (8)
   Stage IVB                                         3 (6)                             3 (6)
 Salivary glands                                                                                                                 0.284
   Stage I                                           1 (2)                              2 (4)
   Stage II                                          2 (4)                              2 (4)
   Stage III                                         1 (2)                              0 (0)
   Stage IVA                                         3 (6)                              0 (0)
CUP: carcinoma of unknown primary (origin).




Table III. Hospital Anxiety and Depression Scale and Visual Analogue Scale scores of patients treated in the pre-COVID-19 and COVID-19 periods.
 Characteristics                                             Pre-COVID-19 period                       COVID-19 period                  p-value
                                                              No. of patients (%)                     No. of patients (%)
 HADS score (anxiety scale)                                                                                                              0.975
   ≤7                                                                      38 (75)                      43 (84)
   8-10                                                                     7 (14)                        3 (6)
   > 10                                                                     6 (12)                       5 (10)
 HADS score (depression scale)                                                                                                           0.652
   ≤7                                                                      41 (80)                      40 (78)
    8-10                                                                    8 (16)                       7 (14)
   > 10                                                                     2 (4)                        4 (8)
 VAS score                                                                                                                               0.739
   0                                                                       21 (41)                      20 (39)
    1                                                                      13 (25)                      17 (33)
    2                                                                      12 (24)                      12 (24)
    3                                                                       1 (2)                        1 (2)
    4                                                                       3 (6)                        1 (2)
    >4                                                                      1 (2)                        0 (0)
HADS: Hospital Anxiety and Depression Scale; VAS: Visual Analogue Scale.




492
                                                                                                                  Head neck cancer, COVID-19




Statistical analysis was carried out with GraphPad Prism                     The mean value for post-operative pain verified with the
software (Version 7.0, GraphPad Software, Inc, San Die-                      Visual Analog Scale (VAS) score did not show a significant
go, CA). The D’Agostino-Pearson normality test was used                      difference between the COVID-19 period and pre-COV-
to verify Gaussian distributions of continuous variables.                    ID-19 period (Tab. III).
Means, ranges and standard deviations were calculated for                    Complications were classified according to the Dindo clas-
continuous variables. Fisher exact tests and Chi-square tests                sification of surgical complications 10. Post-operative com-
were used to compare categorical variables, while Mann                       plications were higher in patients operated on during the
Whitney tests were used to compare continuous variables,                     COVID-19 period: 10 vs 3. Nonetheless, no significant dif-
since none of the tested variables passed the normality test.                ference was found between groups.
An alpha of 0.05 was considered for statistical procedures.                  The HADS questionnaire did not report a significant differ-
                                                                             ence before and during the COVID-19 period (mean score
Results                                                                      on depression scale of 5.0 ± 3.1 and 5.2 ± 4.1, respectively;
                                                                             mean score on anxiety scale of 5.3 ± 3.8 and 5.3 ± 3.5,
No significant differences were found concerning age,                        respectively) (Tab. III). For the 11 non-sufficient patients
gender distribution, tumour site and stage, type of surgery,                 admitted with a caregiver in the pre-COVID-19 period and
number of positioned NGTs and tracheostomies between the                     the 5 patients in the COVID-19 period, the mean scores on
groups of before and after the COVID-19 period (Tabs. I-II).                 the depression scale were 6.9 ± 2.4 and 7.2 ± 8.1, respec-
The duration of hospitalisation for patients who underwent                   tively; the mean scores on the anxiety scale were 6.2 ± 2.0
head and neck surgery during the lockdown ranged from                        and 6.8 ± 5.9, respectively.
3-91 days with a mean of 12.9 ± 14.4 days, whereas for pa-
tients operated in the pre-COVID-19 period, the range was
2-23 days with a mean of 9.0 ± 5.7 days. The average dura-                   Discussion
tion of hospitalisation was longer in patients operated on in                In Italy, restrictions on access to hospitals imposed by the
the COVID-19 period, considering both the tumour loca-                       COVID-19 pandemic have undoubtedly made head and
tion and type of surgery, even if no significant difference                  neck post-operative rehabilitation more difficult 11. Patients
was found between groups. Additionally, considering pa-                      were not allowed to leave the ward, they were alone, and
tients who required a more demanding rehabilitation pro-                     lacked the possibility of distraction from a psychologically
tocol, duration of hospitalisation was found significantly                   stressful situation caused by the illness and the physical
longer for the group during the COVID-19 period, with a                      difficulties they faced. Generally, in the post-operative pe-
mean hospital stay of 25.1 ± 19.3 days (95% confidence in-                   riod, head and neck patients can walk, but unfortunately,
terval: 14.5-35.8 days) compared to a mean hospital stay of                  this activity was drastically limited during the pandemic.
15.3 ± 3.9 days (95% confidence interval: 13.1-17.4 days)                    It is well known that, in normal times, the role of caregiv-
for the pre-COVID-19 period (Fig. 1).                                        ers is fundamental not only in assisting patients, but also in
                                                                             supporting and encouraging them during rehabilitation. A
                                                                             delicate phase during the post-operative period in head and
                                                                             neck oncology is rehabilitation of swallowing and resump-
                                                                             tion of oral intake 12-14. The speech therapist instructs the
                                                                             patient for several hours every day, but rehabilitation exer-
                                                                             cises must also be carried out during the rest of the day. In
                                                                             normal times, the caregiver is instructed in the appropriate
                                                                             exercises required and this makes a significant difference
                                                                             in helping the patient to carry out these exercises correctly
                                                                             during meals.
                                                                             Assistance from the caregiver also stimulates rehabilitation
                                                                             of verbal and non-verbal communication, a function that
                                                                             is difficult to practice alone. Furthermore, post-operatively,
                                                                             most head and neck patients can only communicate non-
                                                                             verbally; this makes it very difficult to stay in touch with
                                                                             family members who cannot be physically present close to
Figure 1. Mean duration of post-operative hospitalisation for patients who   the patient. Hospitalisation is also more psychologically
required swallowing rehabilitation or less demanding rehabilitation.         stressful if the patient can no longer communicate verbally



                                                                                                                                       493
E. Crosetti et al.




and when there is no support from a family member who             Conclusions
can reassure him/her.
                                                                  The COVID-19 pandemic has forced cancer patients to
This particular situation prompted the medical staff to try
                                                                  endure the treatment process without the important psy-
to fill these care gaps during the COVID-9 period, paying
                                                                  chological support of a caregiver, especially during post-
more attention to oncologic patients than they normally
                                                                  operative recovery. This particular situation has resulted in
would in the non-COVID period, and to aspects that are
                                                                  an increase in duration of hospitalisation, particularly for
normally entrusted to caregivers.
                                                                  patients who require more demanding post-operative reha-
In our study, the results show that the percentage of post-
                                                                  bilitation. Nevertheless, the HADS score did not report a
operative complications was higher in the group of pa-
                                                                  worse psychological situation from hospitalisation during
tients operated in the COVID-19 period compared with
                                                                  COVID-19 restrictions.
the pre-COVID19 period (10 vs 3 patients, respectively).
                                                                  The greatest difficulties that occurred in the COVID-19 pe-
A selection bias could be attributed to the greater number
                                                                  riod were met by a greater commitment from all medical
of critically-ill patients who underwent surgery during the
                                                                  staff. Thanks to this, during the pandemic, it was possible
period of reorganisation of health activities caused by the
                                                                  to maintain the quality of life of head and neck cancer pa-
pandemic. In fact, hospitals were only allowed to operate
                                                                  tients during post-operative rehabilitation at a similar level
on non-deferrable cases.                                          to that before the pandemic.
Patients are generally discharged when they are self-suffi-       This study highlights the fact that, in future, there is a need
cient from a swallowing and respiratory perspective. The in-      for technological solutions to bring the patient closer to
crease in average duration of hospitalisation (13 vs 9 days)      family members, particularly when those members cannot
is a consequence of the rehabilitation difficulties caused by     be physically present.
COVID-19 restrictions and patient isolation encountered in
the post-operative period. The difference in length of hospi-
talisation was more evident for patients who had to undergo       References
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