Journal of Oncology Research and Treatment
Open Access

Corona virus disease: COVID-19 caused by novel corona virus SARS-CoV-2 is impacting the countries across the globe as the worst public health crisis in recent history [1]. Availability of and accessibility to routine health care services become pivotal to cancer survivors in this difficult time [2]. Oral cancer denotes a multi-faceted public health challenge across the globe and especially in developing countries of the Asia-Pacific region which carry the highest burden of the disease [3]. Despite, occurring at a most accessible site of the body and often preceded by Oral Potentially Malignant Disorders, oral cancers are being diagnosed at late stages having less than 50% of 5-year-survival rate due to recurrences [4].

Furthermore, not only the disease but its main treatment modalities such as surgery, radiotherapy and chemotherapy may show devastating impact on oral cancer survivors [5,6] thus making them susceptible to face difficulties in performing their vital daily functions of eating, speaking, swallowing and socially interacting demonstrating a profound negative impact at early stages of treatment as well across cancer trajectory [5-9]. This in turn combined with delays in surgical wound healing could give rise to restricted food intake and nutritional deficiencies [5]. Explorations into supportive care needs of oral cancer survivors therefore, revealed an array of unmet needs across wider domains while top most being emotional compounded by poorer physical and mental health influenced by selected demographic and clinical variables [6].

Furthermore, there is research evidence on increased susceptibility of cancer patients for COVID-19 infection and its severity especially pertaining to oral cancer patients [10,11]. It is well-known that head and neck, oro-pharyngeal and oral cancer survivors have an array of supportive care needs pertaining to multiple domains across cancer survivorship trajectory [9,12-23] but little is known on those needs that could get exaggerated by COVID-19 lock down scenarios. Therefore, COVID-19 induced health service modifications that restricted availability of and accessibility to routine health care services for oral cancer survivors [24-28] has created an urgent need for supportive care targeted to them. Against this backdrop, a rapid mini-review was conducted to synthesis evidence on supportive care needs of oral cancer survivors amidst COVID-19 global pandemic.

Two rapid searches were conducted on PubMed and Google scholar data bases on publications available in English language using the key words “supportive care”, “oral cancer”, “COVID-19” for the first review and “supportive care” and “oral cancer” for the second review. Moreover, supplementary search was conducted on impact of COVID-19 on oral cancer care. Two authors (GS and IP) conducted the search of literature independently based on the pre-determined search strategy. Eligible studies were selected in the first screening that was relevant to the scope of the present mini-review. All authors engaged in the subsequent stage of meticulous appraisal of the full texts of given publications and extracting data for the evidence synthesis within the scope of this rapid mini-review. The data were extracted from selected publications on supportive care needs of oral and pharyngeal cancers, head and neck cancers and oral cancer survivors and supportive care needs of oral cancer survivors in COVID-19 lock-down scenario. A narrative synthesis of the evidence is presented.

The results are presented in (Table 1) pertaining to salient evidence synthesis highlighting supportive care and supportive care needs of head and neck, oro-pharyngeal and oral cancer survivors whilst highlighting the translational value of main findings of selected studies into COVID-19 global pandemic context. As emerged from the findings, there is a high burden of multi-dimensional supportive care needs of those cancer survivors along cancer trajectory, from diagnosis to completion of treatment and long term survival. Furthermore, coping with short term, medium term and long term ramifications of the disease and its treatment becomes challenging influenced by sociodemographic and clinical attributes. Accordingly, management of pain, addressing difficulties in chewing, swallowing, information needs on disease and its treatment, nutritional advice, managing psychological distress and financial support are among the well-known supportive care needs of head and neck, oro-pharyngeal and oral cancer survivors.

Table 1: Selected studies on supportive care needs of oro-pharyngeal, head and neck and oral cancer survivors with translational value in COVID-19 global pandemic.

Knowledge and know-how transfer in the ‘lessons learned’ perspective has become fundamental to navigating and optimizing the health system response to cancer survivors and cancer care providers grappling with uncertainties of cancer trajectory and persisting COVID-19 pandemic. Therefore, evidence synthesis of published literature offers a promising approach in this regard. Nevertheless, the collective response to COVID-19 pandemic was challenged by an array of factors such as population and geographical heterogeneity of virulence and resilience to the disease [29], heterogeneous health care delivery models compounded by scientific uncertainties, scarcity of relevant research, proliferation of misinformation and fake news, poor access to actionable evidence, time constraints, and weak collaborations among relevant stakeholders [1].

As the COVID-19 global pandemic demonstrates waves of escalation, resurgence and higher virulence, countries are dragged on to lock down scenarios ranging from state-wise stringent imposition to localized flexible models with varying degrees of travel restrictions. Therefore, global dynamic intervention strategies for COVID-19 are in place demonstrating varying degrees of success [30]. In strictly imposed lock-down scenarios underpinned by social and physical distancing, availability of and accessibility to routine treatment care services and medication becomes a serious cause for concern among cancer survivors [2]. Therefore, the impact o f C OVID-19 on oral cancer survivors deemed multifaceted. Accordingly, a recent rapid living systematic review of the impact of COVID-19 on cancer survivors, updated to 27^th August, 2020, critically reviewed 19 selected publications [31]. Authors concluded that, currently available literature provided preliminary insights into a wide-range of supportive care needs of cancer survivors across the globe impacted by new norms of COVID-19 induced practice modifications of oncological services [31]. Social isolation, financial hardships and uncertainties ingrained into accessing on going cancer care had given rise to many issues in the physical, psychological, social and spiritual well-being of contemporary cancer survivors [31].

Oral cancer care is predominantly being provided by oral and maxillofacial practices. However, COVID-19 heavily impacted on oral and maxillofacial practices across the globe particularly during its first wave that resulted in postponement of elective surgeries and early discharge of cancer patients who underwent surgeries [32]. Therefore, as discussed in the clinical correspondence on supportive care for oral cancer survivors in stringently imposed COVID-19 lock down, many oral cancer patients who underwent recent surgeries were grappling with pain and difficulties in swallowing not knowing how to access to routine health care services [2]. Thus, the simple pilot intervention that was offered over-the-phone by a health professional demonstrated promising outcomes [2]. Facilitating patients and their care givers to navigate the health care system to ensure that they can continue in receiving timely treatment deemed the most crucial component of the pilot intervention [2]. The complimentary advice on practicing “mindfulness therapy” to maintain psychological well-being during difficult times added further value to the simple intervention [2]. This pilot intervention was an extension of a major research project to introduce a novel model of psycho-oncological supportive care for oral cancer survivors for the first time in Sri Lanka.

Many countries across the globe are strained in ensuring access to cancer care services in the era of COVID-19 induced uncertainties and challenges [33-37]. Furthermore, the relative prominence of supportive care needs varies across the cancer survivorship trajectory from immediate post-treatment to long term survival [12-23]. Information needs on the disease, treatment modalities, managing complications, oral care, nutritional advice, financial issues, addressing fears and concerns of recurrence, addressing psychological distress emerged as priority needs in an array of studies that explored unmet supportive care needs of head and neck, oro-pharyngeal and oral cancer survivors [12-23]. Surprisingly, there is a notable deficiency of research in this regard from developing countries in the Asia-Pacific region which carry the highest burden of oral cancer.

It is reasonable to argue that those largely unmet supportive care needs of oral cancer patients could get worsened in difficult times of COVID-19. Therefore, the clinical correspondence [2] makes a valuable contribution to development of an intervention to improve life situation of oral cancer survivors specifically applied to low-middle-income country context. Development of the intervention package by comprehensive triangulation method of an extensive critical literature search followed by gaining inputs from oral cancer survivors, caregivers and experts through a qualitative exploration has enhanced its validity and the translational value for similar settings [2]. Core components of the intervention package comprised of: Addressing information needs of the current condition, details about surgery and life after surgery including care and oral care and information on empowering the oral cancer survivor to become an ambassador of goodwill/role model, practice of mindfulness therapy to ensure psychological well-being and navigating the existing administrative social support system of financial assistance. Therefore, the indicated intervention package seemed aimed at addressing the well-known burden of unmet multi-dimensional supportive care needs of oral cancer survivors [12-23] applied to the Sri Lankan context as oral cancer being the leading cancer category among males. Nevertheless, present promising findings needs validation by further findings on efficiency and effectiveness of the given intervention package. Furthermore, a recent commentary from the USA reported an intervention of remotely delivered mind-body services to cancer survivors aged ≥ 18-years during COVID-19, that included mind-body group therapy sessions in fitness, meditation, yoga, dance, tai chi, and music delivered using Zoom video conferencing [38]. Session duration was 30 – 45 minutes and led by an integrative medicine clinician. Among 5498 unique visits, the majority (42.2%) attended fitness sessions with highest endorsement [38]. Authors recommended virtual mind-body services as a promising service mode of remote delivery thereby increasing the accessibility to such services by cancer survivors [38]. Further, research on therapists assisted internet delivered mindfulness-based cognitive therapy indicated success among cancer survivors suffering from anxiety [39]. However, lack of formal psychooncological supportive care services with access to on-line web-portals of supportive care for cancer survivors in many developing countries compared to developed countries necessitates use of appropriate technology in resource constrained settings.

The lessons learned on innovative models on providing supportive care for cancer survivors could be integrated into strengthening the role, structures and mandates of knowledge and know-how transfer platforms. COVID-19 global pandemic has overwhelmed the health systems of developed countries as well as developing countries by exhausting scarce health resources. Therefore, evidence on costeffective delivery of supportive care for cancer survivors could inform policies and practices during public health crises such as COVID-19. In light of evidence of unique supportive care needs of oral cancer survivors dearth of research on offering supportive care targeted to them had created many information gaps. Therefore, further research warranted in this regard that provides platforms of knowledge and experience translation.

There are notable lacunae in research exploring supportive care needs and innovative models offering supportive care for oral cancer survivors in difficult times of COVID-19. Nevertheless, several researchers had expressed their opinion on impact of COVID-19 global pandemic on oral cancer patients and oral oncological serves. The burden of oral cancer is more on low socio-economic groups in developing countries that are grappling with the double burden of resource constraints and rising burden of COVID-19. Compared to their developed counterparts, developing countries are seriously constrained in accessing successful vaccines to combat the pandemic. Moreover, formal psycho-oncological care services are not available in many developing countries. Therefore, it is well argued that oral cancer survivors could be disproportionately affected by limitations in availability of and accessibility to routine health care services whilst, grappling with many unmet supportive care needs. In this context, further rigorous research is warranted on multi-dimensional impact of COVID-19 on unmet supportive care needs of oral cancer survivors especially in resource constrained setting.

GS and IP conceptualized the research and conducted the search of literature independently based on the pre-determined search strategy. All authors GS, IP, NR, MP and CH equally contributed in all other steps of the mini-review, writing the manuscript and making the final version.

Authors wish to acknowledge oral cancer survivors and their care givers who participated in research included in this mini-review.

No funding in this manuscript.

The authors have no conflicts of interest to declare.