UK Head and neck cancer surgical capacity during the second wave of the COVID—19 pandemic: Have we learned the lessons? COVIDSurg collaborative

Abstract Objectives The aim of this study was to evaluate the differences in surgical capacity for head and neck cancer in the UK between the first wave (March‐June 2020) and the current wave (Jan‐Feb 2021) of the COVID‐19 pandemic. Design REDcap online‐based survey of hospital capacity. Setting UK secondary and tertiary hospitals providing head and neck cancer surgery. Participants One representative per hospital was asked to report the capacity for head and neck cancer surgery in that institution. Main outcome measures The principal measures of interests were new patient referrals, capacity in outpatients, theatres and critical care; therapeutic compromises constituting delay to surgery, de‐escalated surgery and therapeutic migration to non‐surgical primary modality. Results Data were returned from approximately 95% of UK hospitals with a head and neck cancer surgery specialist service. 50% of UK head and neck cancer patients requiring surgery have significantly compromised treatments during the second wave: 28% delayed, 10% have received radiotherapy‐based treatment instead of surgery, and 12% have received de‐escalated surgery. Surgical capacity has been more severely constrained in the second wave (58% of pre‐pandemic level) compared with the first wave (62%) despite the time to prepare. Conclusions Some hospitals are overwhelmed by COVID‐19 and unable to offer essential cancer surgery, but all have neighbouring hospitals in their region retaining good (or even normal) capacity. It is noteworthy that very few patients have been appropriately redirected away from the hospitals most constrained by their burden of COVID‐19. The paucity of an effective central or regional strategic response to this evident mismatch between demand and surgical capacity is to the detriment of our head and neck cancer patients.


| OBJEC TIVE S
For head and neck (HN) cancers treated by surgery in the first wave of the COVID-19 pandemic between March and June 2020, it was evident that surgical and critical care capacity was greatly reduced. As a consequence of these constraints, as well as concerns over cross-infection with SARS-CoV-2, HN surgery was minimised, de-escalated or avoided in many centres. 1 Additionally, many patients underwent therapeutic migration away from primary surgery. 2 The consequences for oncology and functional outcomes are unknown but form the focus for an international follow-up to A severe second wave of COVID-19 during winter 2020/21 was indeed widely predicted, even during the first wave. 6 A plea was made for governments to act through preparation of labour, resources and facilities to reduce the burden, not only on COVID-19 mortality, but also for other life-limiting conditions including cancer. 6 Understanding that the backlog in HN cancer is incompletely resolved, second-wave surgical capacity appears particularly critical.
The reassuring data on safety in the first wave reinforce that with appropriate testing, PPE and cross-infection measures, HN cancer surgery should continue without fear of excess risk, even through a period of very high community COVID-19 incidence.
The aim of this study was to evaluate the differences in surgical capacity for head and neck cancer in the UK between the first (March-June 2020) and the current (Jan-Feb 2021) COVID-19 pandemic waves. Further, we report on efforts in strategic planning and mutual aid between hospitals.

| DE S I G N
REDCap (Research Electronic Data Capture) was employed to record all data through its web application. A 13-item survey questionnaire (Appendix S2) was constructed according to established survey design and conduct guidance. 7,8 Both pre-testing and pilot testing evaluation of the questionnaire was undertaken by members of the COVIDSurg-HN writing group prior to survey distribution.

| S E T TING AND PARTI CIPANTS
A confidential survey was distributed electronically to existing COVIDSurg-HN collaborative members, a wide group which had collected in excess of 5000 head and neck cancer treatments carried out during March-June 2020. 2 All UK HN specialty associations were contacted as well as using direct social media. Respondents were requested to provide a single response on behalf of their hospital. Duplicates were reviewed and averaged for subsequent analysis.
The UK responses were compared with a list of all units providing HN cancer surgery (DAHNO). 9 Each participating hospital's data referred to the management of adult patients undergoing HN cancer surgery with curative intent. -This restriction in capacity is no better than the first wave response, despite advanced warnings for winter 2020/21, and 6 months lead time to prepare the NHS strategic response.

Keypoints
-Hospitals with HN surgical capacity particularly badly affected by COVID-19 all have neighbouring units with very good capacity-but patients have not generally been redirected -New HN cancer referrals have picked up from 65% to 80% of pre-COVID level, with some units reporting >100% -Urgent action is needed at central strategic level to manage the "bow wave" of cancers still awaited 4 | MAIN OUTCOME ME A SURE S The survey period was from 1 to 7 February 2021. Respondents were requested to complete the survey with estimates of HN cancer service capacity at three distinct timepoints: • prior to the COVID-19 pandemic.
The entry fields represented either percentage estimates, defined response criteria or direct yes/no responses. In all instances, these responses were classified as required fields to complete the survey. Data collected included the geographical location of the hospital, access to operating lists, face-to-face versus virtual outpatient clinic attendance and degree of access to critical care beds following HN cancer surgery. Data were collected regarding operating capacity at alternative hospital sites, and if so whether surgery performed by a differing surgical team. We ascertained the extent of delay to HN cancer surgery beyond 62-day rule, surgical de-escalation and therapeutic migration away from primary surgery. No specific reporting guideline was followed.

| RE SULTS
Data were obtained from 73 individual returns but were incomplete for one hospital. Ten hospitals had (understandably) entered duplicate data given the multiple channels of communication employed. In most cases, the duplicate data returned were very closely matched and for others represented a difference in caseload between the ENT and OMFS surgeons entering their own data, so a crude mean of the two data entries was employed in these cases.
By comparison with the DAHNO list 9 of HN surgery units, a further three UK centres did not provide data, providing a best estimate for survey response rate of 95.5%. Following data cleaning, complete data on surgical capacity for head and neck cancer for the 62 hospitals are presented.

| Data summary
Estimates of HN cancer referrals are currently (Jan-Feb 2021) on average, at 85% of pre-pandemic levels (range 35%-120%) compared with mean 61% (range 20%-100%) during the first wave in March-June 2020. Notably, 5 of the 62 (12%) units report an even higher current caseload than prior to the COVID-19 pandemic, a feature not apparent in the first wave in any centre. Theatre capacity was slightly lower in the second wave, estimated as a mean 58% (Jan-Feb 2021) versus 62% (March-June 2020) of pre-pandemic levels. Pre-pandemic delay was only 6% on average. A switch in therapeutic modality away from primary surgery is reported in 10% of secondwave cases, and surgical de-escalation in 12% second wave, compared with 20% and 17%, respectively, during the first wave.

| Categorisation by geographical region
UK hospitals were categorised geographically into 10 regions, and their data comparing the impact of surgical capacity on therapeutic compromise are presented in Table 2. The regions reported broadly similar surgical capacity, ranging between 40% and 75% of prepandemic levels. However, the impact on therapeutic compromise differed greatly by region: delay to surgery between 2% and 62% of patients; surgical de-escalation between 0% and 23%; and therapeutic migration between 0% and 40% of patients. Regions hosting hospitals with surgical capacity that were particularly affected by COVID-19 had neighbouring units with very good capacity maintained ( Figure 1). This did not appear to result in movement of cases between sites nor minimise therapeutic compromises. The distribution of surgical capacity therefore did not align well with demand.
The 6 units with less than 5% of their pre-pandemic levels of access to operating theatres were spread amongst 5 geographic regions.
None of these had any current access to CCU, half did not have access to operate on alternative sites and two-thirds had not referred patients elsewhere. This study has been conceived, data have been collected, cleaned and analysed, written, peer-reviewed and pre-published within a 2-

| D ISCUSS I ON
week window. The penetration to UK HN surgery centres has been greater than 95%, and colleagues have returned data irrespective of regional or specialty allegiances. Once again, the medical profession has stepped up to the challenges of COVID-19 and rapidly established new ways to work and collaborate, as amply demonstrated by the COVIDSurg 2,4,5 collaborative effort. Admittedly, all data collected reflect the respondents' best estimates and some of the analyses would be best regarded semi-quantitatively, or as qualitative impressions. There has been no attempt to weigh the data by size of unit or HN cancer caseload. There is a risk of false precision in "over-analysis" of the reported numerical data, and consequently, detailed statistical analyses were unwarranted.
It appears that the UK second COVID-19 wave is somewhat more severe than the first, as evidenced by daily announced death rates reaching 1820 early in 2021, 10  These issues reveal considerable fragility within the NHS, where life-critical but elective services can apparently be so vulnerable to acute emergency pressures. This lack of resilience in elective care is often seen to a lesser extent as "winter pressures," but not nearly as severely as in the current second COVID-19 wave. The lack of national strategic response is of great concern, but it is perhaps not yet too late to act. The "bow wave" of delayed HN cancer cases remains ahead of us and many more months of COVID-19 restrictions remain.

ACK N OWLED G EM ENTS
COVIDSurg collaborative*, Birmingham Centre for Observational and Prospective Studies (BiCOPS).

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to declare.

E TH I C A L A PPROVA L
No ethical approval was obtained as confidentiality of responders / hospitals, and anonymity of data presentation was maintained. Other than encouragement to contribute to better understanding of the impact of COVID-19 on Head & Neck services, there were no incentives to respond. The authors have no conflicts of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
Anonymised source data are available by contacting BiCOPS through the corresponding author.