Total Laryngectomy Volume During the COVID-19 Pandemic: Looking for Evidence of Stage Migration

Responding to the coronavirus disease 2019 (COVID-19) pandemic necessitated resource redistribution and disrupted health care access. Several groups offered recommendations to safeguard head and neck oncologic care in this setting.^1-3 Patients with advanced head and neck cancers were prioritized. In cases of clinical equipoise, nonsurgical treatment modalities were preferred.^4,5

It will take years to fully appreciate the downstream consequences of COVID-19 and the effects of these recommendations on head and neck cancer care. Most cancer registries with accurate staging information experience a significant time lag. Nonetheless, larynx cancer treatment may serve as an important litmus test. Larynx-preservation protocols are favored in localized disease (T1b, T2, T3), with total laryngectomy reserved for advanced cases (T4a). Increased total laryngectomy volume during the COVID-19 pandemic would provide early evidence of diagnostic delay and stage migration. Therefore, we sought to determine whether there were any differences in the total laryngectomy volumes between the pre- and peri-COVID periods.

This was a population-based retrospective cohort study in Ontario, Canada. The province of Ontario offers universal health care to its 14.6 million residents. All head and neck cancer care is provided at 7 high-volume designated cancer centers.⁶ A robust system is in place to support complete case capture. This provides a unique ability to study pandemic-related effects. These data sets were linked using unique encoded identifiers and analyzed at ICES, a nonprofit organization that has held patient-level health records for Ontario’s residents since 1986.

We defined a cohort of patients undergoing total laryngectomy using Canadian Institute for Health Information procedure codes (1GE89-total, 1GE91-radical). The 6-week volume of laryngectomy procedures between January 24, 2016, and February 13, 2021, were defined. The 6-week window was selected to minimize reidentification risk (ie, <6 observations at a given time point as per ICES policy). Segmented regression models were constructed to quantify (1) the surgical volume trend pre–COVID-19 (January 24, 2016-March 14, 2020), (2) the immediate decrease in surgical volume at the start of the pandemic (March 15, 2020; change in intercept), and (3) the surgical volume trend during the COVID-19 period (periperiod slope). This allowed for nearly 10 full months of data in the COVID-19 period. Distributions of patient characteristics in the pre–COVID-19 and COVID-19 period were compared. A standardized difference of 0.1 or greater indicates a meaningful difference between groups. All analyses were 2-sided, with P < .05 defined as significant.

The study was approved by the research ethics board at Sunnybrook Health Sciences Centre. The use of the data in this project is authorized under section 45 of Ontario’s Personal Health Information Protection Act (PHIPA) and does not require review by a research ethics board. Reporting was in line with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Statistical analysis was performed using SAS statistical software (Enterprise Guide 7.15; SAS Institute, Inc).

There were 576 eligible patients. A 21% drop in mean laryngectomy volume was observed at the start of the pandemic, though this quickly recovered by the next 6-week interval. The change in mean laryngectomy volume in the COVID-19 period was stable compared with the pre–COVID-19 period (relative rate, 1.00; 95% CI, 0.99-1.01; P = .86) (Figure). There was no clinically meaningful difference in patient characteristics between the pre–COVID-19 and COVID-19 groups (Table). The proportion of salvage laryngectomy cases in the pre–COVID-19 and peri–COVID-19 groups was similar (127 [27.3%] vs 28 [25.2%]), implying that borderline advanced cases were not more likely to be offered primary chemoradiation during the pandemic.

The current study did not show an increase in laryngectomy surgical volume during the COVID-19 pandemic. This study provides early, real-world evidence suggesting that Ontario’s head and neck oncology response may have mitigated adverse health outcomes stemming from broader diagnostic and treatment delays. Care has been equitable during the pandemic compared with the prepandemic period, with no group disproportionately affected. This work should be followed with more granular staging data and repeated in other jurisdictions because the present study results are limited in that they may not be directly transferrable.

Accepted for Publication: July 4, 2021.

Published Online: August 19, 2021. doi:10.1001/jamaoto.2021.2019

Corresponding Author: Antoine Eskander, MD, ScM, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, room T2 047, Toronto, ON M4N 3M5, Canada (antoine.eskander@mail.utoronto.ca).

Author Contributions: Dr Eskander had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Sutradhar and Eskander were co–senior authors.

Concept and design: Noel, Sutradhar, Eskander.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Noel, Sutradhar.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Sutradhar, Eskander.

Administrative, technical, or material support: Eskander.

Supervision: Sutradhar, Eskander.

Conflict of Interest Disclosures: Dr Noel receives salary support through a Canadian Institutes of Health Research doctoral award, an Ontario Ministry of Health Clinician Investigator Award, an Ontario Graduate Scholarship, a Raymond Ng Doctoral Award, the Chapnik, Freeman Friedberg Clinician Scientist Award, and the Levinsky Waratah Hold’EM for Life Oncology Fellowship.

Funding/Support: This work was supported by a Sunnybrook Research Institute and Sunnybrook Foundation COVID-19 Response Grant. This study was supported by the ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Role of the Funder/Sponsor: The ICES had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. The analyses, conclusions, opinions, and statements reported in this article are those of the authors and do not necessarily reflect those of Cancer Care Ontario (CCO) or Canadian Institute for Health Information (CIHI). No endorsement by the ICES or the MOHLTC or CCO or CIHI is intended or should be inferred.

Additional Contributions: We thank Immigration, Refugees and Citizenship Canada (IRCC) for providing access to the database used in this study.

Additional Information: Parts of this material are based on data and information provided by CCO and the CIHI.