Primary Diagnoses of Squamous Cell Carcinoma of the Head and Neck During the COVID-19 Pandemic

Results of a Registry Study From Eastern Bavaria

Apart from the direct consequences of COVID-19 itself, the pandemic also had enormous secondary effects on a variety of different medical fields. For example, a decrease in the diagnosis of myocardial infarction (1) and various malignant tumors (2) has been observed. This has been attributed to a delay in initial presentation to a medical doctor as well as reduced capacity for early detection and screening examinations. Smaller, predominantly monocentric studies have also shown a decline in new diagnoses (3) and the presentation of more advanced tumor sizes in comparison with pre-pandemic levels (4) for squamous cell carcinoma of the head and neck (head and neck squamous cell carcinomas [HNSCCs]). Yet available data has so far been conflicting, and some authors have even identified an unchanged incidence of HNSCCs (5).

Materials and methods

The present retrospective, register-based, multicenter cohort study was conducted in cooperation with the Regensburg regional center of the Bavarian Cancer Registry. The Regensburg Ethics Committee has given its positive approval (Reference no.: 23–3308–104). Patients with permanent residence in Lower Bavaria or the Upper Palatinate and diagnosed between March 1, 2017, and February 28, 2022, for the first time with the histopathological diagnosis of an HNSCC were included in the study. Distant metastatic spread was defined as exclusion criterion. The cohort was divided into a pre-COVID-19 subcohort (03/2017–02/2020) and two COVID-19 subcohorts (03/2020–02/2021 and 03/2021–02/2022), based on the date of diagnosis. These subcohorts were compared with respect to their number of new cases, tumor stage, primary treatment modality, and time between diagnosis and start of primary treatment. The anonymized data were evaluated using SPSS (Version 26, IBM, USA) and presented using Prism software (Version 9, GraphPad Software, USA). All results are stated as mean values ± standard deviation. Testing for significance was performed using ANOVA and the chi-squared test. A significance level of p < 0.05 was considered statistically significant or adjusted using the Boniferroni correction for multiple tests.

Results

A total of 1672 patients were included in the study. The subcohorts did not differ significantly with respect to sex distribution or age (Table).

Table

Incidence, demographics, tumor stages, primary treatment modality, and time from diagnosis to start of treatment for the subcohorts

Three hundred and nine cases with an initial diagnosis of HNSCC were registered during the first year of the COVID-19 pandemic (March 2020 through February 2021). This was a decline of 9.2% in comparison with the mean value of the pre-pandemic period (March 2017 thru February 2020; mean value 340). This effect was particularly pronounced during the first two waves of the pandemic: In March and April 2020, a decrease of 13.2% in initial diagnoses was observed, and between November 2020 and February 2021, there was a reduction of 14.9% (Figure).

Figure

Relative incidence of newly diagnosed HNSCC during the first 24 months of the COVID-19 pandemic relative to the mean of the previous three years, incidence of COVID-19

The cancers of the subcohorts of the first year of the pandemic were on average more advanced than in the previous years (UICC stages III/IV: 65.7% versus 59.6%). This was primarily due to a significantly smaller proportion of cancers with an early UICC stage (UICC I: −27.7 percent; UICC II: −27.3 percent), while the incidence of more advanced cancers hardly changed (UICC III: −12.1 percent; UICC IV: −3.3 percent).

Interestingly, the primary treatment modality changed significantly during the first twelve months of the pandemic: The proportion of primarily operated cancers fell from 60.9 percent to 50.0 percent (p = 0.018). This may, on the one hand, have been due to the more advanced tumor stage, which is generally associated with a higher probability for deciding in favor of non-surgical treatment (radiation therapy and/or chemotherapy/immunotherapy). On the other hand, a significant shift towards a non-surgical form of primary treatment was observed for advanced cancers and not, however, for cancers of an earlier stage (UICC I/II: 14.3% versus 19.4%; p = 0.945; UICC III/IV: 53.9% versus 66.9%; p = 0.033). Fortunately, a delay in treatment was ascertained neither for the primarily surgical approach nor for primary radiotherapy (Table).

With a total of 342 cases, a renewed increase of new diagnoses was registered in the second year of the pandemic. However, there was once again a drop in the numbers of new diagnoses by 15.9 percent during the fourth wave of the pandemic from October 2021.

Discussion

In Eastern Bavaria, significantly fewer, yet more advanced, cancers were newly diagnosed during the first pandemic year compared with previous years, mainly due to a lower number of UICC stage I and II tumors.

Furthermore, a shift in the primary treatment modality for more advanced cancers in favor of non-surgical therapeutic procedures was also noticed. This was possibly due to the, at times, severely restricted theater capacities during the peak phase of the pandemic. In order to avoid a delay in treatment, an increasing number of cancers—especially those that were borderline resectable—received radiochemotherapy as recommend by the guidelines. The data suggest that this prevented delay in commencing treatment.

There was a significant rise in new diagnoses evident at the start of the second year of the pandemic. This may well be regarded as a catch-up effect. A renewed decline in new diagnoses was registered during the fourth wave of the pandemic, although it should be noted that possibly not all cancer cases have yet been reported.

The results of the present study show that statistically verifiable changes with respect to new diagnoses of HNSCCs were found to have occurred during the pandemic. Thus, even in times of a pandemic, prompt specialist assessment and further diagnostics are obligatory for any persistent symptoms in the upper aerodigestive tract. Further investigations should be carried out to determine whether the lower incidence of early tumor stages results in a rise of more advanced cancers during the post-pandemic phase, with a subsequent negative effect on long-term survival.

Constantin A. Hintschich, Michael Gerken, Steffen Spoerl, Christopher Bohr, Julian Künzel

Department of Otorhinolaryngology, University Hospital Regensburg (Hintschich, Bohr, Künzel), [e-mail]

University Cancer Center Regensburg, Center for Quality Management and Health Services Research of the University of Regensburg (Gerken)

Department of Cranio-Maxillofacial Surgery, Regensburg University Medical Center (Spoerl)

Conflict of interest statement

The authors declare that they have no conflict of interest.

Manuscript received on 22 May 2023, revised version accepted on 13 July 2023.

Translated from the original German by Dr. Grahame Larkin MD

Cite this as:
Hintschich CA, Gerken M, Spoerl S, Bohr C, Künzel J: Primary diagnoses of squamous cell carcinoma in the head and neck region during the COVID-19 pandemic—results of a registry study from Eastern Bavaria. Dtsch Arztebl Int 2023; 120: 719–20. DOI: 10.3238/arztebl.m2023.0177

References

1. Baumhardt M, Dreyhaupt J, Winsauer C, et al.: The effect of the lockdown on patients with myocardial infarction during the COVID-19 pandemic—a systematic review and meta-analysis. Dtsch Arztebl Int 2021; 118: 447–53

2. Voigtlander S, Hakimhashemi A, Inwald EC, et al.: The impact of the COVID-19 pandemic on cancer incidence and treatment by cancer stage in Bavaria, Germany. Dtsch Arztebl Int 2021; 118: 660–1

3. Schoonbeek RC, de Jel DVC, van Dijk BAC, et al.: Fewer head and neck cancer diagnoses and faster treatment initiation during COVID-19 in 2020: a nationwide population-based analysis. Radiother Oncol 2021; 167: 42–8

4. Metzger K, Mrosek J, Zittel S, et al.: Treatment delay and tumor size in patients with oral cancer during the first year of the COVID-19 pandemic. Head Neck 2021; 43: 3493–7

5. Balk M, Rupp R, Craveiro AV, et al.: The COVID-19 pandemic and its consequences for the diagnosis and therapy of head and neck malignancies. Eur Rev Med Pharmacol Sci 2022; 26: 284–90