General considerations :
- A balance between adequate individualized treatment and limited risk of exposure needs to be established.
- Where possible, telecommunication should be prioritised for appointments. If an in-hospital visit is necessary, the patient should preferably come alone.
- Interventions such as labs and imaging studies could be postponed if the risk for recurrent/still present disease is low according to the last clinical evaluation.
- The only trials that should remain open to new patients are the ones with a curative intent or a life-prolonging/saving purpose. If COVID-19 positive patients are part of an ongoing trial, they should be removed from it.
- Clinician should discuss the expected benefits and the risks (including infections) before debuting chemotherapy.
- Chemotherapy with curative intent is considered urgent and should therefore be offered without delay.
- Hyperthermic intraperitoneal chemotherapy and procedures requiring a lot of resources should be avoided if possible.
- Surgical interventions should be reduced to the minimum. Most gynecologic cancers surgery indications are classified as semi-urgent and could be delayed up to 3-8 weeks.
Ovarian cancer :
- Chemotherapy should be considered for advanced disease cases in which it has been decided to delay the surgery.
- When possible, patients already treated with neoadjuvant chemotherapy could receive six cycles instead of three to delay the cytoreductive surgery.
- High-risk mass with elevated markers or ascites should go under surgery by 1-4 weeks.
Cervical cancer :
- The decision to practice surgery in early-stage disease needs to be based on the tumor imaging studies.
- Early-staged disease could benefit from LEEP under local anesthesia. An imaging of lymph nodes is recommended.
- Hypofractionation could be considered for locally-advanced disease and brachytherapy procedures should not be delayed in patients asymptomatic for COVID-19.
Endometrial cancer :
- In symptomatic patients with low-suspicion for cancer, the biopsy and hysteroscopy under anesthesia could be delayed due to OR access restrictions.
- Conservative management with non-surgical options should be prioritised for low-risk patients.
- Hysterectomy and bilateral salpingo-oophorectomy (± sentinel lymph nodes removal) should be considered for high-risk patients.
- Patients with advanced disease could gain benefits from tissue biopsy and systemic therapy.
Vulvar cancer :
- Surgery is often the only treatment option for large tumors and should therefore be offered. In older patients with early-stage disease, it could be delayed by a few weeks.
- Chemoradiotherapy could be considered if the sphincters are involved.
Trophoblastic tumors :
- Methotrexate for low-risk tumors should be managed at home by the patient if possible.
- High-risk cases should be treated quickly considering the probability for metastasis.
- Hydatidiform moles should be managed as usual with in-hospital curettage under echographic guidance or hysterectomy.
This data comes from multiple records. Akladios and al. produced guidelines for the management of surgery for cervical, ovarian, endometrial, vulvar, vaginal and trophoblastic tumors. Dowdy and Fader produced clinical guidelines about surgery considerations for gynecologic cancers in this time of limited resources. Pothuri and al. produced guidelines about what should be considered in anti-cancer therapy during the COVID-19 pandemic. Ramirez and al. produced strategy guidelines based on evidence-based articles about general considerations for oncologic patients and about the management of cervical, endometrial and ovarian cancers. Sebastianelli and al. produced guidelines for the Society of Gynecologic Oncology of Canada. The British Gynaecological Cancer Society produced guidelines about the management of ovarian cancer during the pandemic.
- Akladios C., Azais H. and al. (March 25 2020) Recommandations pour la prise en charge chirurgicale des cancers gynécologiques en période de pandémie COVID-19.Groupe français de recherche en chirurgie oncologique et gynécologique (FRANCOGYN). https://doi.org/10.1016/j.gofs.2020.03.017
- Dowdy S. and Fader AN. (March 27 2020) Surgical Considerations for Gynecologic Oncologists During the COVID-19 Pandemic. Society of Gynecologic Oncology. Retrieved from : https://www.sgo.org/wp-content/uploads/2020/03/Surgical_Considerations_Communique.v14.pdf
- Pothuri B. , Secord AA. and al. (April 3 2020) Anti-cancer Therapy and Clinical Trial Considerations for Gynecologic Oncology Patients During the COVID-19 Pandemic Crisis. Society of Gynecologic Oncology. Retrieved from : https://www.sgo.org/wp-content/uploads/2020/04/chemotherapy_communique_v6.pdf
- Ramirez PT., Chiva L. and al. (March 27 2020) COVID-19 Global Pandemic: Options for Management of Gynecologic Cancers. International Journal of Gynecological Cancer.http://dx.doi.org/10.1136/ijgc-2020-001419
- Sebastianelli A., Plante M., and al. (April 7 2020) Position Statement: Treatment and Management of Women with Gynecologic Cancer during the COVID-19 Pandemic Situation. The Society of Gynecologic Oncology of Canada. Retrieved from : http://g-o-c.org/wp-content/uploads/2020/04/20GOC_COVID-19_PositionStatement_FINAL_Apr7.pdf
- The British Gynaecological Cancer Society (2020) BGCS framework for care of patients with gynaecological cancer during the COVID-19 pandemic. Ovacome website. Retrieved from : https://www.ovacome.org.uk/bgcs-framework-for-care-of-patients-with-gynaecological-cancer-during-the-covid-19-pandemic