SHORT COMMUNICATION

Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 121-126

Management options for gynecological cancers in low- to middle-income countries amidst COVID-19 pandemic

Ashutosh Mishra¹, MD Ray¹, Sandeep Bhoriwal¹, Jyoti Sharma², Chitresh Kumar², Kunal Dhall¹, Manoj S Gowda¹, Akash Kumar^3
1 Department of Surgical Oncology, IRCH, AIIMS, New Delhi, India
² Department of Surgical Oncology, National Cancer Institute, AIIMS, New Delhi, India
³ Departments of Medical Oncology, National Cancer Institute, AIIMS, New Delhi, India

Correspondence Address:
Dr. Ashutosh Mishra
Department of Surgical Oncology, IRCH, AIIMS, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCRP.JCRP_14_20

Objective: Due to Covid-19 pandemic, the oncologists and cancer patients are in a dilemma, whether they should continue with the planned treatment or wait till the pandemic is over. This review is intended to explore the management options for gynaecological cancers during the pandemic. Data sources: We searched for literature from Pubmed database and oncological socities pertaining to the management of gynaecological cancers and Covid-19 pandemic. Study Selection: For such once in a century pandemic, there is a paucity of evidence based literature. Therefore, to address this issue all the available relevant studies were reviewed. Results: Definitely, a deviation from a standard care for a longer period i.e. beyond 4-6 weeks may lead to a significant impact on over all outcomes. As this current scenario is one of the first after the advent of modern medicine, there are no clear-cut evidence based suggestions to adopt for clinicians. Various organizations like NCCN, ACS, SGO, ESMO have suggested few recommendations for present situation. Here again, a role of multidisciplinary team is of pivotal importance and every case merits discussion by multi-disciplinary team (MDT) before finalizing a strategy. We share our perspective on the issue, which is based on currently available evidences as well as the practices we intend to follow at our centre. We agree that the quality of evidence remains of low grade and are mostly based on expert recommendations with an aim to tide over this period of around 4-12 weeks. Conclusion: Precise triage of patients will play a pivotal role in preserving resources and protecting health care workers and patients. The expertise at the respective oncology centres, prevalence/incidence of COVID-19 cases in that area, the support system of the hospital and the patient profile should direct the changes in practices. We also recommend that the standard therapy should be resumed as soon as the situation improves.

Keywords: COVID-19, gynecological cancers, pandemic

Introduction

Need for the Revised Management Options during the Covid-19 Pandemic

1. Ovarian cancer – early stage:



1. Symptomatic management
2. Wait and watch strategy.



2. Advanced ovarian cancer



1. Choice of neoadjuvant regimen (NACT) 3–4 weekly paclitaxel and carboplatin (TP) may be appropriate. Addition of growth factors during the course may be preferable^[6],[7]
2. Intraperitoneal chemotherapy and other invasive procedures should be avoided
3. Patients should be started on poly ADP ribose polymerase inhibitors (PARPi), if eligible and affordable, after a good response to initial few cycles of chemotherapy
4. Oral hormonal monotherapy can be considered in patients with low-grade serous ovarian cancers^{[6],[7],[8],[9]}
5. Post upfront cytoreduction, attempt should be made to start adjuvant chemotherapy (TP, 3–4 weekly) as early as possible.



3. Patients due for interval cytoreduction



1. Patients waiting for interval cytoreduction may go for few more cycles of chemotherapy with growth factor support
2. Patients with post 6 cycles of NACT may wait for 4–6 weeks for surgery
3. Emergency surgery indications – Obstruction, bowel perforation, peritonitis, torsion, and rupture of suspected malignant pelvic masses.



4. Maintenance therapy



1. Oral PARPi can be considered in a patient with high benefit-to-risk ratio (i.e., BRCA mutation) and tumors with homologous recombination deficiency. Although PARPi is an expensive treatment, it should be offered to patients if they can afford it with the help of civil societies, nongovernmental organizations, or government aid
2. Olaparib demonstrated high efficacy as a maintenance treatment in first and subsequent lines of therapies for platinum-sensitive BRCA1/2-mutated ovarian cancer patients^[10],[11]
3. BRCA testing should be done before starting first-line PARPi. Whereas patients with a positive family history who had already been tested for BRCA can be shifted on olaparib easily
4. Niraparib and rucaparib proved to be effective in maintenance setting for platinum-sensitive recurrent ovarian cancer regardless of BRCA status^[12],[13]
5. For patients already on bevacizumab maintenance, therapy may be continued provided that drug-related complications such as hypertension are controlled.



5. Recurrent disease



1. In platinum-sensitive recurrent disease, platinum-based chemotherapy should be offered
2. In patients with complete response or partial response to platinum-based chemotherapy, maintenance therapy with PARPi is recommended. Similarly, in those patients who cannot tolerate further platinum-based chemotherapy, PARPi may be offered as monotherapy in select cases^[14]
3. Platinum refractory cases should be managed symptomatically or with single-agent paclitaxel.

1. Carcinoma in situ/preinvasive disease: The American Society for Colposcopy and Cervical Pathology recommends that women presenting with low-grade cervical cancer screening test should postpone their further diagnostic assessment for 6–12 months. For women who are presenting with high-grade cervical cancer screening test, further diagnostic assessment could be delayed up to 12 weeks^[15]



2. Early-stage cervical cancer: Although in early-stage carcinoma cervix radical trachelectomy or radical hysterectomy is recommended, in this scenario, it may be managed accordingly:



1. Patients with low-risk or microscopic disease (<2 cm, low-risk histology) could be considered for conization or simple trachelectomy ± Sentinel Lymph Node Biopsy (SLNB)
2. High-risk patients should postpone their surgeries for a period of 4–6 weeks or till the crises is over^[2]
3. Chemoradiation may be started wherever appropriate.^[16],[17]



3. Locally advanced/metastatic carcinoma cervix



1. Chemoradiation should be used in curative setting (Stage 1B3-IVA stages) with an expected high success rate (>50%).^{[18],[19],[20]}
2. Hypofractionation may be offered to reduce hospital visits
3. As per the American Brachytherapy Society, brachytherapy procedures should not be delayed in non-COVID patients
4. Stage IVB – Chemotherapy regimens such as paclitaxel + cisplatin + bevacizumab, 3–4 weekly, may be started. Cisplatin may be replaced with Paclitaxel and Carboplatin.



4. Recurrent carcinoma cervix

1. Postmenopausal bleeding:



1. Many patients are unlikely to have access to an examination by their physician, so those with a low-risk profile, normal cervical screening history, and an endometrial thickness <4 mm could be managed by patient-initiated follow-up over a 3–6-month period.^[22]



2. Low-risk and low-burden disease: Disease confined to endometrium with Grade 1 features can be managed by conservative managements:



1. Systemic hormonal therapy (endometrioid type, low grade)
2. Levonorgestrel intrauterine devices (Mirena^®).^[23],[24]



3. High-risk and low-burden disease: Patients with Grade 2–Grade 3 histology



1. Patients may be considered for total abdominal hysterectomy with bilateral salpingo-oophorectomy ± SLN biopsy
2. Laparoscopic hysterectomy could be considered with a safe, reproducible, and reliable filtering and evacuation system for pneumoperitoneum gases.^[25] As per the European Society of Gynaecological Endoscopy, laparoscopic surgery for gynecological emergencies and cancer is beneficial for the health system and the society by reducing hospital stay and enabling quicker recovery, compared to open surgery. Laparoscopy might have some advantage over open surgery by confining the surgical smoke to a closed space, which gives the opportunity to control the release of smoke to the operating room more effectively and reduce the exposure of the operating team.^[26] Therefore, laparoscopic gynecological surgeries could be performed with all personal protective equipment (PPE) and reliable smoke evacuation measures.



4. Advanced endometrial cancer



1. For advanced endometrial cancer, especially low grade, consider megesterol acetate,^[27] or megesterol acetate alternating with tamoxifen^[28] for endometroid histology, and if hormone receptor is positive
2. Neoadjuvant chemotherapy can be attempted if surgery is not feasible upfront
3. If operated and surgically staged upfront, adjuvant chemotherapy ± radiotherapy should be initiated. The regimen may include standard regimen (TP, 3–4 weekly) with growth factors for prophylaxis.



5. Recurrent



1. Symptomatic management.

1. Early disease:


Radiotherapy may be considered as a nonsurgical option in selected cases.


2. Locally advanced/metastatic disease



1. Locally advanced disease: Neoadjuvant chemoradiation should be considered in this scenario^[29]
2. Metastatic disease:First-line chemotherapy may be considered based on the symptoms. Symptomatic support should be the mainstay in relapsed cases.

• Decision for all the modalities of treatment, specially chemotherapy doses and schedules, must take into account high-risk vulnerable population, i.e., patients with age >65 years, those with associated cardiovascular comorbidities, and those with preexisting respiratory conditions.

Principle for Managing Surgery of Cancer Patients during the Covid Crisis

1. Availability of workforce, resources, PPE, and preparedness of hospital
2. Alternative treatment options such as chemotherapy and radiotherapy
3. Biology of the disease and impact of surgery on survival (risk–benefit ratio)
4. Type of surgery (major/minor), expected complications, and postoperative stay.

Society of Gynaecologic Oncology Guidelines for emergent, semi-urgent, and nonurgent gynecologic oncology surgeries Click here to view

Outpatient Department Triage

Conclusion

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