COVID-19 & Management of Gynecological Cancers

The scale of the COVID-19 pandemic and the impact on health care services will inevitably necessitate modifications on how we would usually care for women with gynaecological cancers. The diversity and varied infra-structures of health care services around the globe means that there is no ‘one fits all’ protocol that can be devised. Instead here are some general comments and also links to resources you may find useful during this difficult time.

As many women with gynaecological cancer are of the ‘high risk’ group for severe effects of COVID-19, a frank discussion needs to take place regarding the benefits of delaying or modifying therapies against the risk of proceeding with treatment. For example – modelling has suggested that there is a doubling of death from chemotherapy with associated COVID-19 - see BGCS guidelines. Hence this increased risk may well render the benefits of such therapy questionable- for example, adjuvant therapies in early-stage ovarian cancer.

Some other examples of alternative strategies:

Uterine Malignancies

The majority of women with endometrial cancer will have disease localised to the uterine cavity. Primary surgery, of course, is the ideal management. Oral progesterone and use of the levonorgestrol- secreting intrauterine system (e.g. Mirena) are options where surgery is not possible, and deferment is necessary. Equally, primary radiotherapy is an effective therapy where available.

Ovarian Malignancies

In early-stage disease, surgery is normally undertaken. However, there are many women with a moderate or lower risk, particularly if pre-menopausal, where it may be preferential to delay surgery. For example, with a risk of malignancy score of less than 200 in some countries, it may be a score of 250, combined with the clinical scenario, surgery may be safer if deferred.

In advanced widespread disease high-grade serous carcinoma, primary surgery is a common primary intervention, though about 25-30% of patients will be given neoadjuvant chemotherapy, with surgery after 3 cycles of treatment followed by another 3 cycles. It may be necessary to consider neoadjuvant chemotherapy in all women with extra-pelvic disease. In some situations, extending neoadjuvant chemotherapy cycles to 4 or even a full 6 cycles before surgery may be required. Equally, where an excellent response to neoadjuvant therapy is achieved, i.e. no detectable disease, further deferral of surgery may be considered appropriate.

Cervical Cancers

In early-stage cervical cancer, surgery remains, for most, the primary intervention. Where surgery is delayed, and it is difficult to determine when surgery is possible, then radiotherapy with or without concomitant chemotherapy could be the best therapeutic option for such women.

Vulvar Cancers

In these cancers, the main symptoms often relate to pain caused by the primary vulval tumour. Resection of these tumours is successful in alleviating such pain, which can be difficult to control by other means. Sometimes it may be possible to undertake surgery under local anaesthetic. Removal of the sentinel nodes should be undertaken where at all possible. However, there may be a need to defer groin lymphadenectomy until a time that is safer for the patient.

Though not a comprehensive list, the following links give some national guidelines and Q&A’s, together with some advice for patients:

         https://www.asco.org/asco-coronavirus-information

         https://www.bgcs.org.uk/professionals/guidelines-for-recent-publications/

         https://www.esgo.org/useful-link-covid-19/

         https://igcs.org/covid-19/

         https://www.nice.org.uk/guidance/cg122/chapter/Appendix-Risk-of-malignancy-index-RMI-I

         https://www.nccn.org/covid-19/

         https://www.sgo.org/

Contact

Dr Sean Kehoe
Chair FIGO Committee for Gynecologic Oncology