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Sandra Fyfe is a freelance writer for Contemporary OB/GYN.
With coronavirus disease 2019 limiting the availability of health resources, research using a comprehensive review and expert opinion has set pandemic treatment protocols for gynecological cancers.
Effective treatment of gynecological cancers must now occur within the framework of COVID-19. Ibrahim Alkatout, of the Department of Obstetrics and Gynecology at University Hospitals Schleswig-Holstein in the Kiel School of Gynaecological Endoscopy in Kiel, Germany, and colleagues have created guidelines for pandemic treatment of gynecological cancers.
Using the keywords COVID-19, SARS, and MERS, along with gynecological cancer terminology, Alkatout and colleagues comprehensively reviewed international databases. These included Science Direct, PubMed, Cochrane Library, Scopus, and Google Scholar. The authors consulted various countries’ early guidelines and expert opinion for additional data due to the pandemic’s limited time frame.
General treatment guidance during the pandemic
The following protocols are for high-risk cancer patients aged 65 and older; patients with pulmonary disease, heart disease, or diabetes of any age; patients receiving systemic chemotherapy; and patients with an Eastern Cooperative Oncology Group status ≥2.
Surgery should be performed if the patient’s survival is expected to be more than 12 months, according to the authors. Surgery should also be done if the patient does not respond to other treatments, and if the patient may not survive if surgery is delayed.
If non-surgical therapies can be used effectively, the authors recommend delaying surgery if the patient has ready access to ICU and other hospital facilities.
Elective surgeries for benign conditions should be cancelled. Patients should be given alternative treatments to reduce symptoms and be advised to stay home, and healthcare providers should direct their attention to patients severely affected by the coronavirus, the authors noted.
Legally, patients and families must be informed about surgery delays and of non-surgical treatment use. These must be included on an informed consent form, the authors added. They said that a multidisciplinary team should make decisions based on weekly tumor boards, and that COVID-19 is a risk for both patients and staff.
Guidelines for outpatient management and gynecological oncology clinics
The authors recommended telephone screenings prior to appointments and temperature checks for patients upon arrival. In addition, they suggest visits be limited to new patients, patients with acute oncologic issues or who are being treated for serious conditions, such as symptomatic patients with cancer recurrence or molar pregnancies.
Patients who live in towns outside their treatment center should have imaging and labs performed locally and have results electronically transmitted. Only one person should accompany the patient to on-site visits. Their companion should be screened to ensure they are not infected and have not been exposed to COVID-19.
Physical distancing in the waiting room and patient flow should be monitored for safety, the authors noted. They also said surveillance/follow up visits should be postponed or completed through telehealth. The authors recommended screenings such as pap smears and mammography be delayed; if the patient needs follow up, outer time limits of 6 months should be followed. “Any intervention that is not absolutely essential should be postponed,” the authors said.
Specific Condition Guidance
For endometrial cancer in its early stages, the authors reported hormone therapy as the best choice, while recommending radiotherapy for this cancer in its later stages.
The authors said cervical intraepithelial neoplasia 3 and high-grade squamous intraepithelial lesions require immediate treatment after diagnosis. Their guidelines require a minimum of a loop electrosurgical excision procedure and the postponement of major surgery for 10-12 weeks.
Early-stage cervical cancer can start immediate radiotherapy in the interim while surgery can be delayed 2-4 weeks, according to the authors.
Alkatout and colleagues said hormone therapy may be prescribed for 2-3 months for patients with ovarian masses with negative tumor markers if patients have no cancer signs on imaging, a low level of CA-125 in serum, no ascites, and no vegetation or papillary projection in the base of the cyst.
Surgery should be performed quickly, in a maximum of 2-3 weeks, for newly diagnosed ovarian cancer, the authors emphasized.
For vulvar and vaginal cancers, the authors recommend radiotherapy be given preference for treatment within 10-12 weeks.
Suction cutterage is required for molar pregnancy, an oncological emergency. Molar pregnancy patients need to be monitored for metastases, the authors also noted.
Alkatout and colleagues said there is little information to help choose between laparoscopic and open surgery. Any patient may be an asymptomatic carrier, so major surgery “should be preceded by chest computerized tomography, with and without contrast medium, in order to detect lung lesions,” the authors said. They noted that evidence for these recommendations is limited, and added that data on ethical debates over treatment delays and approaches that stray from current guidelines are also limited.
“Any delay in gynecological procedures that could exert a negative effect on the patient’s health and safety should be avoided…practitioners should be aware of the unintentional impact of policies regarding COVID-19, including limited access to time-sensitive obstetric and gynecological procedures,” the authors concluded.