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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 335-337

Gynecological cancer care in the COVID-19 era: Shifting focus from short term to the long term


1 Department of Surgical and Gynecologic Oncology, Manipal Comprehensive Cancer Center, Bengaluru, Karnataka, India
2 Department of Gynecological Oncology, Manipal Comprehensive Cancer Center, Manipal Hospital, Bengaluru, Karnataka, India
3 Department of Minimal Access Gynaecologic Oncology, University of Pittsburgh School of Medicine, Magee-Women's Hospital of UPMC, Pittsburgh, USA

Date of Submission07-May-2020
Date of Decision08-May-2020
Date of Acceptance11-May-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
S P Somashekhar
Department of Surgical and Gynecologic Oncology, Manipal Comprehensive Cancer Center, Manipal Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_177_20

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How to cite this article:
Somashekhar S P, Ahuja V, Olawaiye AB. Gynecological cancer care in the COVID-19 era: Shifting focus from short term to the long term. Cancer Res Stat Treat 2020;3:335-7

How to cite this URL:
Somashekhar S P, Ahuja V, Olawaiye AB. Gynecological cancer care in the COVID-19 era: Shifting focus from short term to the long term. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 7];3:335-7. Available from: http://www.crstonline.com/text.asp?2020/3/2/335/287286



This is pertaining to two of the articles [1],[2] published in the recent issue of your esteemed journal, regarding the management of gynecologic cancers during the coronavirus disease 2019 (COVID-19) pandemic. We have made the following interpretations from these two articles: at the outset, both the articles have a considerable overlap and present similar information.

[TAG:2]Management of Patients With Gynecological Cancers during the Covid-19 Pandemic [1][/TAG:2]

Positive aspects of this article are:

  1. The viral agent responsible for the current pandemic, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is novel, highly contagious, and associated with a high case fatality rate. As a result, there has not been enough time for cancer care providers to adopt an evidence-based approach for the treatment of cancer during the pandemic. Therefore, this review represents an excellent guide for cancer care providers
  2. In the introduction, the authors have provided a concise summary of the pandemic and the differential implications for the patients with cancer
  3. The authors have also outlined measures to be taken by hospitals and other acute care settings that are focused on safe cancer care provision amidst the pandemic
  4. Using the available evidence from the literature, the authors then delved into the management of various gynecological cancers, with comprehensive details of measures that can be taken to keep the patients safe, from both cancer progression and the impact of COVID-19
  5. Finally, the key aspects of the suggested management approach by the authors are well represented, which addresses the three most common gynecological cancers.


Limitations of this article are:

  1. In discussing the management of ovarian cancer, the authors advised to avoid para-aortic lymph node dissection. Pelvic lymph node dissection appears to be endorsed, but the pelvic lymph nodes are involved much less frequently in ovarian cancer. Therefore, low utility exists in dissecting them given the rarity of this scenario. Better advice would have been to clinically palpate both the pelvic and the para-aortic lymph nodes and to resect the clinically enlarged ones where possible
  2. For adjuvant therapy in early ovarian cancer, the authors quoted the International Collaborative Ovarian Neoplasm trial-1 (ICON-1) and the European Organisation for Research and Treatment-Adjuvant Chemotherapy in Ovarian Neoplasm (EORTC-ACTION) studies, both of which did not specifically address the question of the number of cycles, and they recommended four cycles. A study that addresses this better is the Gynecologic Oncology Group (GOG) 157 trial, which showed the noninferiority of three versus six cycles of adjuvant chemotherapy for early ovarian cancer
  3. For the treatment of gestational trophoblastic neoplasia (GTN), the authors recommend “no delay,” which I agree with; however, their explanation for this recommendation is the occurrence of tumor chemoresistance, which is not supported by the literature. The authors could have cited the following reasons instead to expedite the treatment: (a) GTN is highly curable and (b) the common types grow and spread fast.


[TAG:2]Management of Cancer during the Covid Pandemic: Treatment of Gynecological Malignancies [2][/TAG:2]

Positive aspects are:

  1. The author recognized the acute need for guidance in treating gynecologic cancers in the face of COVID-19 and decided to rise to the occasion; this is commendable
  2. In the introduction, the author has reported the overall rate of SARS-CoV-2 infection along with the rate of severe illness in patients with cancer compared to the general population. This is a small piece of information that is critically important in helping the readers understand the magnitude of the problem
  3. The author has advocated evidence-based strategies and treatment plans to provide optimal care for patients with cancer amidst the COVID-19-induced health-care crisis
  4. The author has also outlined a set of general principles to guide cancer care.


Limitations of this article are:

  1. Although most of the advice given under specific gynecologic cancer subsites is reasonable, the author used very little literature support; thus, it mostly represents personal opinion
  2. In treating locally advanced cervical cancer with chemoradiation, the author advocated to avoid carboplatin because it is highly immunosuppressive. I do not understand the rationale for this recommendation. However, he appropriately advocated the use of cisplatin, which is significantly more toxic than carboplatin, as demonstrated by large Phase III trials like GOG 158. The reason to use cisplatin is that it is the preferred agent which has been tested in many large randomized trials
  3. The author advocated the use of metronomic dosing in treating metastatic cervical cancer and also specified etoposide and cyclophosphamide; however, this is not supported by the available literature
  4. Regarding the management of metastatic endometrial cancer, the author mentioned that there is limited benefit from second-line (and beyond) chemotherapy, and therefore, one could consider a delay in therapy or endocrine treatment. Although the advice regarding consideration of endocrine treatment is reasonable, especially for the typical, low-grade, estrogen receptor/progesterone receptor positive endometrioid histotype, to say there is limited benefit from the second-line chemotherapy is not accurate. The three most active chemotherapeutic agents for endometrial cancer are carboplatin, paclitaxel, and doxorubicin.[3] Usually, the carboplatin plus paclitaxel combination is utilized first, depending on when the patient's disease progresses; this same combination can be given again (second line), and when the combination is no longer an option, doxorubicin can be utilized, either as second-line or even as third-line treatment. Finally, other systemic agents, e.g., checkpoint inhibitors and vascular endothelial growth factor-receptor antagonists, have become important in treating metastatic/recurrent endometrial cancer, typically after chemotherapy agents have failed. For instance, pembrolizumab is active in programmed cell death protein/programmed death-ligand 1 or microsatellite instability high positive endometrial cancers. Recently, the combination of pembrolizumab and lenvatinib was shown to be effective in treating microsatellite-stable endometrial cancers.[4] However, we understand that these agents are expensive and may not be readily available to the treating physician.



  Our Opinion Top


The COVID-19 pandemic has not yet reached its peak in our country. The care of patients with cancer has been sidelined because of the curtailment of non-COVID-19-related activities in various hospitals. This is coupled with the perception of risk of infection and detrimental outcome, both in caregivers and patients.[5] The recommendations put forward by various societies and working groups are based on the premise that the pandemic could last a few months. Therefore, most of the guidelines advocate delaying standard treatment options, especially surgery,[6] for a couple of months and avoiding intensive therapy. There are two problems with this approach:

  1. The pandemic will not get over unless an effective vaccine is developed and is made universally available or a herd immunity develops in the population. Both of these are unlikely to happen in a time frame of 1 year in our country because of the size of the population
  2. Cancer outcomes are better in the early stages than late stages, and in the later stages of the disease, adherence to standard established protocols provides the best chance for survival. Hence, in an effort to reduce the anticipated COVID-19-associated mortality, there should not be an increased cancer-related mortality in the coming years.


Both the articles give good alternatives for cancer treatment for the various gynecologic tumor sites and stages. However, the stress is on tiding over the next few months. Therefore, if the COVID-19 situation remains the same or becomes worse, there is no clarity of care. Even in areas that are relatively less affected by COVID-19, optimal cancer treatment would be deferred to a time when it becomes less effective or not feasible, either because of the disease itself or the pandemic.

An alternative approach would be to segregate cancer care facilities and as far as possible provide treatment categorized as standard of care for a particular malignancy. To accomplish this, it is important to create appropriate patient care pathways for initial evaluation; treatment, including surgery, radiation, and chemotherapy; and follow-up. These pathways could be specific to the treating center, based on the pandemic severity. It is important to explain to the patients the risks associated with immediate treatment and COVID-19 infection as well as the likelihood of adverse outcomes if standard care is delayed inordinately. The following recommendations are made for cancer care during this COVID-19 era:[7],[8]

  1. Initial evaluation


    • Teleconsultation, followed by hospital visit. Strict appointment timings and limiting the numbers to enforce social distancing
    • COVID-19 triage and testing: complete as many investigations as possible (biopsy or other suitable diagnostic procedures) in a single visit.


  2. Follow-up of report by teleconsultation and advice regarding COVID-19 testing before definitive treatment. The algorithms for treatment based on COVID-19 testing (which have already been established by the authors) and decisions for surgery could be taken
  3. Standard protocols for chemotherapy and radiotherapy should be employed, and investigational or experimental therapies or protocols should be avoided, especially if there is a higher likelihood of complications
  4. Follow-up visits should be minimized; however, tumor markers/imaging for certain tumors such as GTN and germ cell tumors should be done as per protocol
  5. COVID-19 testing, personal protective equipment in the outpatient department/ward/operation theater, and segregation of patients should be standardized as per local hospital policy.[9]


Both articles have laid down short-term measures, while this pandemic is going to stay with us for years. Therefore, we need to acknowledge the prolonged nature of this crisis and shift focus from short-term to long-term plans and protocols for the management of gynecological oncology patients and the protection of health-care professionals. Now is the time for a change in the mindset and a paradigm shift from short-term policies to long-term solutions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dessai S, Nachankar A, Kataria P, Abyankar A. Management of patients with gynecological cancers during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:40-8.  Back to cited text no. 1
    
2.
Goel A. Management of cancer during the COVID pandemic: Treatment of gynecological malignancies. Cancer Res Stat Treat 2020;3 Suppl S1:106-8.  Back to cited text no. 2
    
3.
Charo LM, Plaxe SC. Recent advances in endometrial cancer: A review of key clinical trials from 2015 to 2019. F1000Res 2019;8. pii: F1000 Faculty Rev-849.  Back to cited text no. 3
    
4.
Makker V, Taylor MH, Aghajanian C, Oaknin A, Mier J, Cohn AL, et al. Lenvatinib plus pembrolizumab in patients with advanced endometrial cancer. J Clin Oncol 2020. pii: JCO1902627.  Back to cited text no. 4
    
5.
Noronha V, Behel V. Catch-22: COVID versus Cancer. Cancer Res Stat Treat 2020;3 Suppl S1:1-2.  Back to cited text no. 5
    
6.
Prem A, Patel S, Pai E, Pandey D. Surgical management of cancer during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:119-22.  Back to cited text no. 6
    
7.
Bhatla N, Singhal S. The COVID-19 pandemic and implications for gynaecologic cancer care. Indian J Gynecol Oncolog 2020;18:48.  Back to cited text no. 7
    
8.
International Gynecologic Cancer Society Recommendations. COVID-19 Resource Center. International Gynecologic Cancer Society Recommendations; 2020. Available from: https://igcs.org/covid-19/. [Last accessed on 2020 May 06].  Back to cited text no. 8
    
9.
Srivastava P, Tilak TV, Patel A, Das CK, Biswas B, Mahindru S, et al. Advisory for cancer patients during the COVID pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:145-8.  Back to cited text no. 9
    




 

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