The stage of head and neck diagnosed malignancies in COVID‐19 outbreak versus before outbreak: A retrospective study

Abstract Background Global COVID‐19 pandemic has affected cancer care systems. Recent studies show that the number of cases diagnosed with cancer has drastically decreased compared to the same period before the pandemic. Therefore, we are confronted with delayed diagnosis of critical cancers. Aim The aim of this study is to investigate whether the stage of known cancers has been affected by delayed diagnosis and to compare the stages of head and neck cancers diagnosed during and before the pandemic. Methods The present study was conducted on 132 patients with malignant head and neck tumors referred to the otolaryngology, head and neck cancer department of Taleghani Hospital from 2019 to 2021. The stage of cancers was compared between two groups of patients with head and neck malignancy referred to the Otolaryngology, Head and Neck Department of the Taleghani Hospital before and during the COVID‐19 outbreak. Results The results from tumor (T), nodes (N), and metastases (M) (TNM) staging (p‐value = .015) and T score (value = 0.045) showed that the stage of tumor diagnosed in patients during the COVID‐19 pandemic significantly increased compared to patients diagnosed with a tumor before pandemic. Conclusion In the present study, it was observed that the early symptoms of malignant head and neck tumors have been neglected by patients during COVID‐19 pandemic and resulted in delayed diagnosis. This result may be explained by the fear of COVID‐19 infection in patients, which discouraged them from visiting a doctor at healthcare centers.


| INTRODUCTION
In December 2019, after the first reported cases of the new and unknown severe acute respiratory syndrome Coronavirus2 (SARS-CoV-2) in Wuhan, China, this virus spread worldwide and turned into Level of evidence: retrospective study, level II. a global outbreak. The effects of this global epidemic on healthcare systems, specifically cancer care systems, have been significant. 1 Since patients diagnosed with cancer are more prone to be infected with this virus, with higher morbidity and mortality, it was hypothesized that the fear of getting infected discouraged cancer patients from follow-up visits and continuing their treatments. Moreover, the involvement of most systems in the diagnosis and treatment of a large number of patients with COVID-19 resulted in less attention to patients with cancer. Therefore, being exposed to the COVID-19 virus during the use of diagnosis modalities, limited capacities for elective surgeries, and patients' reluctance to follow up on their treatment after a definite diagnosis might lead to a delay in either diagnosis or treatment of important cancers. [2][3][4][5] Different countries implemented various approaches to resolve this issue. One of these approaches is telemedical services to recognize probable cancer red flags rather than postponing the investigation of unlikely symptoms. However, the diagnosis and treatment of cancers are not back to the norm before the pandemic. 6,7 In 2020, De Vincentiis et al. 8 have shown that the rate of cancer diagnosis has decreased by 39% compared to 2018 and 2019. In these years, the COVID-19 pandemic has been a significant factor and has adversely affected the diagnosis and screening of cancers.
However, the role of both patients and healthcare systems in creating this problem needs further investigation.
In this work, the potential effects of COVID-19 outbreak on the stage of cancers diagnosed during the pandemic were studied.

| Study design and sampling
The present study was a retrospective study conducted on 132 patients with malignant head and neck tumors referred to the otolaryngology, head and neck department of Taleghani Hospital from 2019 to 2021. Information of the patient has not been revealed in the study findings. The stage of cancer was compared between two groups of patients from before and during the COVID-19 outbreak.
All enrolled patients were diagnosed with malignant head and neck tumors-confirmed by postoperative or biopsy pathology reports. In this study, in addition to reviewing the clinico-pathological TNM staging by a specialist for enrolling the patients, gender and age of the two groups were considered. The known cancer cases with recurrence malignancy were excluded from the study. At the end, the patients were asked two questions: (1) Is there any delay between the onset of the symptoms and visiting a doctor? (2) What is the reason for this delay? Finally, the information was then recorded.

| Statistical analysis
After collecting the data, the Kolmogorov-Smirnov test showed normal distribution of the data. Therefore, parametric statistical tests were used. The quantitative variables were compared using descriptive statistics (average). The qualitative variables were assessed using the chi-square test. Statistical analysis was performed using SPSS software Version 22. The statistical significance was considered to be less than .05. This study investigated the impact of COVID-19 pandemic on diagnosis and treatment of cancers by considering other causes both before and during the corona were sustained. [16][17][18] In this study, the data was obtained only from patients in Iran, however, since there is a uniform cancer stage system across most coun-

CONFLICT OF INTEREST STATEMENT
The authors have stated explicitly that there are no conflicts of interest in connection with this article.

DATA AVAILABILITY STATEMENT
Data in the current study are available from the corresponding author on reasonable request.

ETHICS STATEMENT
The present study is in compliance with ethical standards and standards of research involving humans. This article does not contain any studies involving animals performed by any of the authors. In our institute at the time of the study, retrospective studies that were just medical field reading and without medical intervention were not presented to the ethics committee and therefore were not assigned an ethical code to them, but there was a rule to which information of the patient should not be revealed in the study findings.

CONSENT TO PARTICIPANTS
Written informed consent was obtained from the patients for participating in the study and publication of the results retrieved form their information before enrolling stage. Information of the patient have not been revealed in the study findings.