COVID-19 Global Pandemic: Options for Management of Gynecologic Cancers

In the midst of this devastating pandemic associated with the novel coronavirus 2019 (COVID-19) disease, we must continue to provide high-value care to patients with chronic diseases such as cancer while being mindful of the safety of our patients, their families, and our health care providers. The editorial team of the International Journal of Gynecological Cancer has compiled evidence-based suggestions in this guideline document to both continue high-quality care for our patients and strategically allocate resources to alleviate the burden on our health care system amid the coronavirus pandemic. The management of disease will undoubtedly be affected by this pandemic, including a reduced access to routine visits and elective operations. Options must be explored to modify therapeutic plans to both address disease and limit risk of exposure. Regarding outpatient clinic visits, reduction of personnel and interventions should be considered to those that are absolutely and imminently necessary. This includes possible dismissal of residents, medical students, family members of patients, and nonessential staff. Practices should consider telemedicine be used for follow-up/surveillance visits and consultations. Multidisciplinary practices should be implemented in order to ensure supportive care and hospice care as quickly as possible in order to provide the most comprehensive care and alleviate hospital volume in order to increase capacity for those requiring acute care related to COVID-19. The American Society for Colposcopy and Cervical Pathology has recommended individuals with low-grade cervical cancer screening tests receive further diagnostic testing within 12 months, whereas those with high-grade tests receive testing within 3 months. For early-stage cervical cancer and where access to surgery is limited, consider postponing procedures that may be considered high-risk of prolonged operating time or postoperative complications for 6 to 8 weeks. For locally advanced disease, hypofractionation is recommended, and brachytherapy should not be delayed in patients without COVID-19 symptoms. For patients with grade 1 endometrial cancer, conservative nonsurgical management can be considered. If available, patients with grade 2 or 3 endometrial cancer should be considered for simple hysterectomy and bilateral salpingo-oophorectomy. Advanced endometrial cancer therapy should proceed with systematic therapy. Patients with advanced-stage ovarian cancer should consider proceeding with neoadjuvant chemotherapy until crisis is resolved and consideration of surgery at a later time. In patients who have already begun neoadjuvant therapy, extension of the course from 3 to 6 cycles should be considered. Patients with ovarian cancer who have completed upfront adjuvant platinum-based chemotherapy should consider postponement of further treatment as maintenance therapy would require repeat visits. Patients traveling long distances for treatment should consider arrangements with local oncologists. Regarding clinical trials, limitations should be instated on the number of trials that remain open to new patient accrual based on the necessity for numerous clinic visits. Trials remaining open should preferentially include those with curative intent or those with real lifesaving opportunity over current standard of care. Clinical trial participants should continue involvement, although in the case that a subject tests positive for COVID-19, they should be removed from the trial and treated appropriately.