COVID-19 Impact on Gynaecological Cancer Treatment

Precautions to be taken by gynaecological cancer patients undergoing treatment right now

Patients who are under treatment for gynaecological cancers are at a significant risk of developing coronavirus infection. Patients undergoing chemotherapy, surgery, and radiotherapy usually have low immunity because they have high chances of infections not only coronavirus but other infections too.  Therefore, it is very important to take precautions and be safe in this coronavirus crisis.

Precautions to be taken by cancer patients:

• • Avoid unnecessary visit to hospitals
  • Try to use tele-consultation or video- consultation
  • Avoid any exposure to infected people
  • Use face masks or face covers
  • Take care of your immunity
  • Hydrate yourself regularly
  • Maintain social distancing
  • Try to maintain blood sugar levels and blood pressure within normal  limits

How long can we delay further treatment?

Patients and caregivers should discuss all the possible options of cancer care with their treating oncologists. The patient must be aware of the risks involved with multiple hospital visits and increased complications associated with chemotherapy and surgeries.

The most important issue during the management of cancer is the time period for which cancer therapy has to remain disrupted during this crisis. Certainly, a deviation from standard care for a longer period i.e. beyond 4-6 weeks may cause a significant impact on overall outcomes.

As this is the first of its kind situation, there are no clear-cut evidence-based guidelines. Therefore the role and decisions of the treating oncologists are very important.

Organ-wise management options for common gynaecological cancers

We are advising these treatment options on currently available evidence amidst the coronavirus crisis. These are mostly based on expert recommendations with an aim to bridge this period of around 4-6 weeks. The changes in practices should be directed by the expertise of respective oncology centres, prevalence/incidence of COVID-19 cases in that area, the support system of the hospital, and the patient profile. 

Carcinoma of the cervix

• Pre-invasive disease (CIS)

If there are any precancerous diseases detected on Pap smear, you can delay further assessment for 8-12 weeks.

• Early stage cervical cancer  (disease confined to the cervix)

In the early stages, role of surgery is very important. But due to the COVID-19 lockdown and limited availability of surgical care, you may wait up to 4 weeks. Few studies in the US, show that delaying surgeries for 4 weeks had no poor impact on the overall outcomes.

Few studies have shown the use of chemo-radiation in early cases. The patient may take consult a radiation oncologist for opinion.

• Locally advanced (disease spread beyond cervix)

Chemo-radiotherapy is the ideal treatment for locally advanced carcinoma of the cervix. Chemo-radiation should be used in curative cases with high (> 50%) success rates. Additionally, the patient may also discuss with their radiation oncologist if they can consider giving the same radiation in fewer hospital visits.

• Metastatic disease

Palliative chemotherapy is advisable, but patients should speak to their treating oncologist and discuss on delaying this citing the COVID-19 crisis.

• Recurrent cancer of the cervix

Among patients who had the disease returned after 12 months of treatment, they may take a medical oncologist’s opinion for chemotherapy. For others, symptomatic management and deferring the chemotherapy for 4-6 weeks is advisable.

Ovarian cancer

• Ovarian cancer – early stage

In early or suspicious cases, the patient may initially opt for symptomatic management and continuously observe the condition.

The patient may defer their staging laparotomy for 3-4 weeks, but this decision should be taken after discussing and understanding the pros and cons of delay in surgery with your treating oncologist.

• Advanced ovarian cancer

1. The decision of the treatment should be based on symptomatology, age and associated comorbidities of the patient

2. If the patient appeared to be fit, they may be considered for upfront chemotherapy followed by surgery

3. Patients with poor general condition and low-grade serous ovarian cancers may opt for oral hormonal therapy (adjuvant therapy)

4. If the patient undergoes upfront surgery, an attempt should be made to start adjuvant chemotherapy within 3-4 weeks

• Patients due for surgery after initial chemotherapy

1. Patients who have received three cycles of chemotherapy and waiting for surgery may go for three more cycles of chemotherapy

2. Patients who have completed six cycles of chemotherapy may wait for 4-6 weeks for surgery

3. In this COVID-19 crisis, patients should go for surgery only in hospitals where all facilities are available to combat the coronavirus infection

• Maintenance therapy

Patients who are on maintenance therapy may continue their treatment considering their immunity status.

Carcinoma Endometrium

• Post-menopausal bleeding

Patients who are having normal cervical screening history and an endometrial thickness <4 mm could visit their physician after 6-8 weeks for further evaluation. Till the time, they can consider teleconsultation for interacting with their physicians.

• Early disease (confined to the uterus with low-risk factors)

Patients having disease that is confined to the endometrium (inner layer of uterus) with grade 1 features may opt for conservative management with non-surgical options:

1. 1.  Systemic hormonal therapy 
   2. Intra-uterine devices, Mirena 

• Disease confined to the uterus with high-risk factors

Patients with grade 2 to grade 3 histology without any co-morbidity may opt for surgery.

Patients with high-risk disease and co-morbidities should avoid surgery for a short while as they may need ICU care during the post-operative period. Hence, the decision for surgery should be taken very cautiously.

In this COVID-19 crisis, patients should go for surgery in those hospitals only where all facilities are available to combat coronavirus infection.

• Advanced endometrial cancer

Patients with advanced, hormone receptor positive endometrial cancer with endometroid histology may choose hormonal therapy till the time of lockdown.

The patient may choose chemotherapy if surgery is not feasible upfront. If the patient has already been operated, then she should go for further chemotherapy ± radiotherapy within 3-4 weeks

 

Precautions for patients undergoing chemotherapy or radiotherapy

When patients have to go to the hospital for chemotherapy and radiotherapy, the following precautions should be ensured –

General precautions

• • Reach hospital on your scheduled time to minimise the waiting time and avoid waiting areas
  • Follow social distancing
  • Request your physician for early and prompt care
  • Minimise visitors while you are on active treatment
  • Wear face masks or face covers all the time
  • Take plenty of water and maintain a good hydration
  • Consume a healthy and nutritious diet
  • Ensure adequate sleep
  • Take immune-boosters as prescribed by treating physician
  • Practice yoga and breathing exercises

Treatment-related precautions 

• Discuss with your oncologist for at least 3 weekly chemotherapy regimens if can’t be delayed
• Avoid those chemotherapy regimens which causes extensive myelosuppression and decreases immunity
• Immunity boosters 
• Chest physiotherapy
• Maintain adequate hydration to avoid any unwanted renal problems
• Discuss with your oncologist for tailored radiotherapy protocols that can reduce hospital visits

 

Can radiotherapy be delayed in gynaecological cancers?

Usually, it is difficult to delay radiotherapy because it extends the total treatment time of radiotherapy, which could have a bad impact on tumour control. If the patient has undergone surgery, there usually is a time limit within which they have to undergo radiotherapy to take the best possible advantage of this additional treatment. Another important point is that there are some advanced stages and tumour types where radiotherapy is the only helping modality of treatment, and therefore any delay in radiotherapy is not advisable. In most cases after initial surgery, radiotherapy should be started in 4-6 weeks’ time.

Situations where patient should not delay radiotherapy

• • Radical radiotherapy for cervical, vaginal and vulvar cancers
  • Intrauterine brachytherapy for cervical cancer
  • Urgent palliative radiotherapy in patients with malignant spinal cord compression 
  • Adjuvant radiotherapy for residual disease
  • Positive resection margins or lymph nodal involvement in cervical, vaginal, vulval and endometrial cancers

Situations where the patient may delay radiotherapy for a short time period

• Palliative radiotherapy for metastatic disease and pelvic masses
• Post-operative radiotherapy for fully resected high-risk endometrial cancer

Radiotherapy during COVID-19 pandemic

Patient may request their treating radiation oncologist for 

• • Hypo-fractionated schedule (fewer hospital visits)
  • Simplified techniques for planning and treatment
  • Consider omission of adjuvant radiotherapy when there is no or limited survival advantage

 

What are the risks of continuing treatment and risks of withholding treatment of breast cancer in the present situation?

Risks of continuing treatment

• Chemotherapy and other anti-cancer treatments may result in significant decrease in the patient’s immunity
• Increased infection rates (for all bacterial and viral disease including corona)
• Increased mortality due to the risk of coronavirus infection
• Decreased treating manpower that may result in poor care in hospitals
• May face compromised cancer care and treatment plans

Risks Of withholding treatment

• Disease progression
• Borderline operable tumours may get converted into Inoperable tumours
• Poor over all treatment outcomes