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Table of Contents
MUSINGS
Year : 2020  |  Volume : 3  |  Issue : 5  |  Page : 106-109

Management of cancer during the COVID pandemic: Treatment of gynecological malignancies


Department of Medical Oncology, Homi Bhabha Cancer Hospital, Sangrur, Punjab, India

Date of Submission03-Apr-2020
Date of Acceptance07-Apr-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Alok Goel
Department of Medical Oncology, Homi Bhabha Cancer Hospital, Sangrur, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_108_20

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How to cite this article:
Goel A. Management of cancer during the COVID pandemic: Treatment of gynecological malignancies. Cancer Res Stat Treat 2020;3, Suppl S1:106-9

How to cite this URL:
Goel A. Management of cancer during the COVID pandemic: Treatment of gynecological malignancies. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jun 1];3, Suppl S1:106-9. Available from: http://www.crstonline.com/text.asp?2020/3/5/106/283282




  Introduction Top


Worldwide, as of today (April 2, 2020), around 9 lakh people are affected with COVID-19 and more than 45,000 have died of it.[1] What is more worrisome is that these numbers are increasing at an alarming pace every minute, thus putting the whole world in a state of lockdown and placing an large burden on the prevailing health infrastructure, bringing it to the brim of saturation.

During this extraordinary time of the COVID-19 pandemic, the oncology community faces unique and unprecedented challenges. Data suggest that cancer patients are more susceptible to COVID-19 as compared to the general population (1% vs. 0.29%) and are more predisposed to develop severe acute lung injury (39% vs. 8%). It has also been shown that apart from patients undergoing active treatment, those who have had surgery or chemotherapy within the prior month are also more susceptible to COVID-19 and its complications. In addition, cancer patients show more rapid clinical deterioration.[2],[3] Patients with neutropenia and lymphopenia, both of which commonly occur in cancer patients on therapy, have been shown to have rapid deterioration and a severe clinical course.[4]

Thus, oncologists involved in the diagnosis, treatment, and follow-up of patients with cancer must consider how to (1) balance a delay in the diagnosis of cancer and its treatment against the potential risk of COVID-19 exposure, (2) mitigate the risks for significant care disruptions associated with social-distancing behaviors, and (3) rationally allocate limited health-care resources in this unprecedented time of health-care crisis. We, therefore, need to provide evidence-based strategies and treatment plan to maintain optimal care of patients with cancer, keeping in mind the current health-care crisis as well as patient well-being.

In this article, we have attempted to provide strategies for the management of patients with gynecological cancers, during the current COVID-19 pandemic.

I will start with some of the general principles which should guide our management strategy followed by a discussion on individual gynecological malignancies.


  General Principles Top


  1. Restriction of outpatient department visits to essential visits only and increased use of telemedicine and web-based consultation for follow-ups whenever possible
  2. Limiting prolonged inpatient admissions
  3. Limiting the number of health-care providers actively involved in patient care to minimize exposure
  4. To limit the interventions which may have significant blood product requirement, prolonged and complex surgeries, those which may cause significant neutropenia and immunosuppression, and those which predispose health personnel to the added risk of infection or require intensive care management
  5. To define treatment modalities into a priority level based on the expected efficacy, toxicity, feasibility, and accessibility, and then to judge their usefulness and urgency in each patient based on the patients' characteristics (age, comorbidities, performance status [PS], curative or palliative), and whether alternative therapies/treatment modalities that are less toxic are available.


In a nutshell, management decisions have to be made keeping in mind the global well-being of the patient, the health-care providers, and the society as a whole.


  Specific Malignancies Top


Cervical cancer

Preinvasive disease

Based on recommendations made by the American Society for Colposcopy and Cervical Pathology:[4],[5]

  • In patients with low-grade squamous intraepithelial lesion (SIL), diagnostic evaluations can be postponed up to 6–12 months
  • In patients with high-grade SIL, the diagnostic evaluation can be delayed for up to 3 months.


Early-stage disease

If oncologic surgery is possible without compromising the general principles as described above and there are no resource constraints, proceed with standard-of-care surgery. However, consideration may be given to postponing procedures such as radical hysterectomy and trachelectomy for up to 6–8 weeks or until resolution of the health-care crisis on a case-by-case basis. Procedures such as simple trachelectomy with or without sentinel lymph node dissection or conization may be considered in patients with low risk (low-risk histology, <2 cm) or microscopic disease.

Consider neoadjuvant chemotherapy in patients with gross disease. Definitive concurrent chemoradiation may be used to treat some early-stage cervical cancers that would normally undergo radical hysterectomy, if feasible.

Locally advanced disease

Chemoradiotherapy should be administered whenever feasible. Consider hypofractionation to reduce patient visits.

Efforts should be made to continue brachytherapy without any gaps, whenever feasible.

For patients below 70 years old, with no comorbidities, the following are recommended:

  • Concurrent weekly cisplatin is the treatment of choice as it leads to significant improvement in local control and survival
  • Carboplatin is often associated with higher levels of immunosuppression, so consider avoiding this option
  • However, consider omitting chemotherapy on a case-by-case basis and according to the resources available.


For patients over 70 years old and/or with comorbidity, the following are recommended:

  • Pelvic radiotherapy without concurrent chemotherapy
  • Consider limiting the volume irradiating the “small pelvis” to reduce potential toxicity.


Metastatic disease

In asymptomatic or minimally symptomatic patients, in those with low-burden disease, or older patients with comorbidities and poor PS, Iintravenous chemotherapy can be delayed after discussion with the patient and attendants.

Oral metronomic therapy is an option whenever available and feasible (etoposide alone or in combination with cyclophosphamide and tamoxifen).

  • Symptomatic patients or those with high-burden disease and good PS
  • Palliative radiotherapy can be offered for local symptomatic relief or for symptomatic skeletal metastasis
  • Prefer single-agent carboplatin over combination therapy until the crisis subsides, consider using growth factors, and metronomic chemotherapy may be an option in patients with borderline fitness for intravenous chemotherapy
  • For calculation of the glomerular filtration rate (GFR), consider using the Cockroft–Gault method.[6]


Second line or beyond

There is limited benefit of chemotherapy – delay therapy, oral metronomic therapy is an option whenever available and feasible and if not used before.

Endometrial cancer[4],[5]

Low-risk disease

Consider options such as intrauterine device or systemic hormonal therapy for Grade 1 disease.

High-risk disease

Consider simple hysterectomy with bilateral salpingo-oophorectomy with or without sentinel lymph node dissection, on a case-by-case basis and based on the availability of resources

  • Adjuvant radiotherapy is a low-priority procedure and can be delayed in some cases if feasibility is an issue
  • The decision for administering adjuvant therapy should be individualized based on the disease risk, age, comorbidities, health-care resources, and patient's willingness after explaining the risk–benefit ratio in the prevailing COVID pandemic situation, trying to balance the anticipated efficacy with toxicity. Keeping in mind the current scenario, overzealous use of multiagent chemotherapy when the added benefit is modest at best should be avoided.


Metastatic disease

  • For asymptomatic or minimally symptomatic patients, those with low-burden disease, or older patients with comorbidities and poor PS


    • Intravenous chemotherapy, after discussion with the patient and attendants, can be delayed, and endocrine therapy is a reasonable alternative


    • For symptomatic patients or those with high-burden disease and good PS


    • Prefer single-agent carboplatin over combination therapy until the crisis subsides
    • Consider using growth factors
    • Endocrine therapy is a reasonable alternative
    • For calculation of GFR, consider Cockroft–Gault method[6]


    • Second line or beyond


    • Limited benefit of chemotherapy Delay therapy or use endocrine therapy.


Ovarian cancer[4],[5]

Ovarian cancer poses a unique challenge as many patients even in advanced stages will achieve long and durable remissions, as most of these patients are symptomatic; delaying therapy may adversely affect outcomes as well as the quality of life of these patients.

Early-stage disease

Even in early stages, upfront surgery to achieve optimal cytoreduction often requires prolonged surgery and possible multi-visceral resection, and may lead to prolonged postoperative intensive care unit stay which may pose a challenge in the current scenario, thus making a strong case for the use of neoadjuvant chemotherapy in both early and advanced stage disease.

Neoadjuvant chemotherapy

  • Considerations regarding the risk–benefit ratio of neoadjuvant chemotherapy are similar to those outlined earlier for the use of adjuvant chemotherapy in high-risk patients with endometrial cancer. The decision should be individualized based on the various factors discussed earlier
  • Liberal use of filgrastim should be done to reduce neutropenia
  • For calculation of the GFR, consider Cockroft–Gault method[6]
  • Bevacizumab should be used with caution owing to the lack of survival benefit and possibility of additional toxicity including bowel perforation, which may occur in patients with extensive bowel involvement
  • Neoadjuvant chemotherapy may be extended to six cycles rather than three, before interval debulking surgery if resource constraints are present, but keeping in mind the possible risk of myelosuppression which may lead to higher susceptibility to infections
  • Secondary debulking surgery should be avoided in recurrent ovarian cancer due to the lack of survival advantage.


Adjuvant chemotherapy

  • Intraperitoneal chemotherapy should be avoided in view of significant toxicities
  • Adjuvant chemotherapy should be offered to all eligible patients, as there is a significant survival benefit
  • As delay in the initiation of adjuvant chemotherapy has been shown to have a negative impact on survival, adjuvant therapy should be started preferably within 4–6 weeks of surgery, if feasible, and an individualized decision should be taken after discussing with attendants, if delay is anticipated
  • The combination of paclitaxel and carboplatin is considered the standard of care, and should be the preferred regimen, in view of the lack of data on the efficacy of single-agent platinum[7],[8]
  • Dose-dense weekly paclitaxel and once-every-3-weeks carboplatin should preferably be avoided because of increased hematological toxicities
  • Bevacizumab should be used with caution owing to its survival advantage only in a selected subset of high-risk patients with the risk of additional toxicities
  • Maintenance chemotherapy and bevacizumab should be avoided because of lack of clear benefit and additional toxicities.


Advanced disease

Palliative chemotherapy

  • In view of the significant survival and symptomatic benefit, palliative chemotherapy should be considered in all eligible patients, whenever feasible
  • Use single-agent carboplatin or carboplatin and paclitaxel depending on patients' age, comorbidities, PS, and the feasibility for multiple hospital visits
  • Liberal use of filgrastim should be done.


Platinum-sensitive relapse

For asymptomatic or minimally symptomatic patients with low-burden disease or older patients with comorbidities and poor PS:

  • Intravenous chemotherapy after discussion with the patient and attendants, can be delayed
  • Oral metronomic therapy may offer some benefit.


For symptomatic patients or those with with high-burden disease and good PS:

  • Use single-agent carboplatin or carboplatin and paclitaxel depending on the patient's age, comorbidities, PS, and the feasibility for multiple hospital visits
  • Liberal use of filgrastim should be considered
  • Early starting of poly ADP ribose polymerase inhibitors for eligible patients after cycle 4 may be considered.


Platinum-resistant relapse

  • Avoid chemotherapy in asymptomatic and mildly symptomatic patients
  • Provide symptomatic management
  • Metronomic therapy can offer some benefit with limited toxicities
  • In view of the limited benefit with chemotherapy in patients with low-grade cancers and non-endometrioid and non-serous histologies, chemotherapy can be delayed in asymptomatic and mildly symptomatic patients
  • Consider endocrine therapy in symptomatic patients, patients with bulky disease, or when appropriate in other scenarios, after discussion with the patient.


Germ cell tumors and gestational trophoblastic tumors[5]

  • Chemotherapy should be continued as usual for these patients with active supportive care so as to provide early mitigation of complications and avoid possible delays in treatment.



  Conclusion Top


These are the challenging times for health-care workers. Striking the right balance between optimal patient management and ensuring the physical and mental well-being for themselves is the urgent unmet need at the hour.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncol 2020;21:335-7.  Back to cited text no. 1
    
2.
Bitterman R, Eliakim-Raz N, Vinograd I, Trestioreanu AZ, Leibovici L, Paul M. Influenza vaccines in immunosuppressed adults with cancer. Cochrane Database Syst Rev 2018;2:CD008983.  Back to cited text no. 2
    
3.
Bansal N, Ghafur A. COVID-19 in oncology settings. Cancer Res Stat Treat 2020;3:13-4.  Back to cited text no. 3
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4.
Ramirez PT, Chiva L, Eriksson AG, Frumovitz M, Fagotti A, Martin AG, et al. COVID-19 Global Pandemic: Options for management of gynecologic cancers. Int J Gynecol Cancer Published Online First 2020. doi: 10.1136/ijgc-2020-001419.  Back to cited text no. 4
    
5.
BGCS Framework for Care of Patients with Gynaecological Cancer During the COVID-19 Pandemic; 22 March, 2020. Available from: https://www.bgcs.org.uk/wp-content/uploads/2020/03/BGCS-covid-guidance-v1.-22.03.2020.pdf. [Last accessed on 2020 Apr 02].  Back to cited text no. 5
    
6.
Florkowski CM, Chew-Harris JS. Methods of estimating GFR – Different equations including CKD-EPI. Clin Biochem Rev 2011;32:75-9.  Back to cited text no. 6
    
7.
Sapkota S, Abhyankar A, Dessai S. Ovarian cancer practice survey from the South Asian Association for Regional Cooperation (SAARC) Nations. Cancer Res Stat Treat 2019;2:158-62.  Back to cited text no. 7
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Kaur S, Singh R. Patterns of care for ovarian cancer. Cancer Res Stat Treat 2019;2:217-20.  Back to cited text no. 8
  [Full text]  




 

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