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

Radical hysterectomy case volume and cervical cancer treatment in the era of COVID-19: A multi-site analysis of National Cancer Institute-designated Comprehensive Cancer Centers

OBJECTIVE

To compare radical hysterectomy case volume, cancer stage, and biopsy-to-treatment time of invasive cervical cancer diagnosed before and after onset of the COVID-19 pandemic.

METHODS

In a multi-institution retrospective cohort study conducted at 6 large, geographically diverse National Cancer Institute-designated cancer centers, patients treated for newly diagnosed invasive cervical cancer were classified into 2 temporal cohorts based on date of first gynecologic oncology encounter: (1) Pre-Pandemic: 3/1/2018-2/28/2020; (2) Pandemic & Recovery: 4/1/2020-12/31/2021. The primary outcome was total monthly radical hysterectomy case volume. Secondary outcomes were stage at diagnosis and diagnosis-to-treatment time. Statistical analyses used chi-squared and two sample t-tests.

RESULTS

Between 3/1/2018-12/31/2021, 561 patients were diagnosed with cervical cancer. The Pre-Pandemic and Pandemic & Recovery cohorts had similar age, race, ethnicity, smoking status, and Body Mass Index (BMI). During Pandemic & Recovery, the mean monthly radical hysterectomy case volume decreased from 7[SD 2.8] to 5[SD 2.0] (p = 0.001), the proportion of patients diagnosed with Stage I disease dropped from 278/561 (49.5%) to 155/381 (40.7%), and diagnosis of stage II-IV disease increased from 281/561 (50.1%) to 224/381 (58.8%). Primary surgical management was less frequent (38.3% Pandemic & Recovery versus 46.7% Pre-Pandemic, p = 0.013) and fewer surgically-treated patients received surgery within 6 weeks of diagnosis (27.4% versus 38.9%; p = 0.025).

CONCLUSIONS

Lower radical hysterectomy case volume, a shift to higher cervical cancer stage, and delay in surgical therapy were observed across the United States following the COVID-19 outbreak. Decreased surgical volume may result from lower detection of early-stage disease or other factors.

Impact of COVID-19 Pandemic on the Diagnostic and Therapeutic Management of Endometrial Cancer: A Monocentric Retrospective Comparative Study

Endometrial cancer represents an ideal target to evaluate the impact of COVID-19 being the most frequent gynecological malignancy in Italy, generally detected at early stages and correlated with favorable oncological outcomes. The present comparative retrospective study carried out at Campus Bio-medico University Foundation in Rome aims to evaluate the impact of the COVID-19 pandemic on the presentation, diagnosis and treatment of EC. All women with a histological diagnosis of non-endometrioid and endometrioid endometrial cancer between 1 March 2018 and 31 October 2022 were included. The number of cases was higher in period 2 (95 vs. 64 cases). Time to diagnosis did not show statistically significant differences but in period 2, 92.06% of the diagnoses were made following abnormal uterine bleeding, while in period 1, only 67.02% were. The waiting time for the intervention was significantly shorter in period 2. Definitive histology, FIGO staging, surgical technique and adjuvant therapy did not show significant differences between the two periods. The study demonstrates that the impact of the COVID-19 pandemic did not have a direct effect on the diagnostic delay, tumor staging and type of therapy but rather on the presentation pattern of endometrial cancer.

Impact of the Covid-19 pandemic on the management of gynecologic cancer: a Spanish survey. Observational, multicenter study

BACKGROUND

The SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) pandemic changed the distribution of healthcare resources, leading in many cases to the suspension of all non-essential treatments and procedures and representing a challenge for medical professionals. The objective of this study was to evaluate whether clinical protocols in gynecologic oncology care were modified as a result of the pandemic and to assess surgeons' perceptions regarding the management of gynecologic cancers".

METHODS

Data were collected through an anonymous and voluntary survey sent via email to healthcare professionals in the field of gynecologic oncology in Spain.

RESULTS

A total of 75 gynecologic oncologists completed the online survey. Of these, 93.2% (69) reported working in public hospitals and 62.5% (45) in tertiary care hospitals. 97.3% (71) were affiliated with hospitals treating patients infected with SARS-CoV-2. 85.1% (63) of the respondents expressed concern about the SARS-CoV-2 pandemic and 52.1% (38) indicated that the pandemic impacted the diagnostic and therapeutic quality of care for oncology patients. SARS-CoV-2 nasopharyngeal swab PCR (Polymerase Chain Reaction) testing was always performed before surgical interventions by 97.3% (71), being considered a best practice in triage by 94.4% (68). 87.5% (63) reported no change in the type of surgical approach during the pandemic. 62.5% (45) experienced limitations in accessing special personal protective equipment for SARS-CoV-2. An impact on the follow-up of patients with gynecologic cancers due to the pandemic was reported by 70.4% (50).

CONCLUSIONS

Most of the Spanish gynecologic oncologists who responded to our survey reported that the SARS-CoV-2 pandemic had affected their clinical practice. The primary measures implemented were an increase in telemedicine, restricting outpatient visits to high-risk or symptomatic patients and the use of SARS-CoV-2 screening prior to surgery. No major changes in the surgical approach or management of the treatment of ovarian, endometrial or cervical cancer during the pandemic were reported.

Prehabilitation in an ERAS program for endometrial cancer patients: impact on post-operative recovery

OBJECTIVES

Enhanced recovery after surgery (ERAS) and prehabilitation programs are multidisciplinary care pathways that aim to reduce stress response and improve perioperative outcomes. However, literature is limited regarding the impact of ERAS and prehabilitation in gynecologic oncology surgery. The aim of this study was to assess the impact of implementing an ERAS and prehabilitation program on post-operative outcomes of endometrial cancer patients undergoing laparoscopic surgery.

METHODS

We evaluated consecutive patients undergoing laparoscopy for endometrial cancer that followed ERAS and the prehabilitation program at a single center. A pre-intervention cohort that followed the ERAS program alone was identified. The primary outcome was length of stay, and secondary outcomes were normal oral diet restart, post-operative complications and readmissions.

RESULTS

A total of 128 patients were included: 60 patients in the ERAS group and 68 patients in the prehabilitation group. The prehabilitation group had a shorter length of hospital stay of 1 day (p<0.001) and earlier normal oral diet restart of 3.6 hours (p=0.005) in comparison with the ERAS group. The rate of post-operative complications (5% in the ERAS group and 7.4% in the prehabilitation group, p=0.58) and readmissions (1.7% in the ERAS group and 2.9% in the prehabilitation group, p=0.63) were similar between groups.

CONCLUSIONS

The integration of ERAS and a prehabilitation program in endometrial cancer patients undergoing laparoscopy significantly reduced hospital stay and time to first oral diet as compared with ERAS alone, without increasing overall complications or the readmissions rate.

Cervical cancer prevention program in Mexico disrupted due to COVID-19 pandemic: Challenges and opportunities

Introduction

The COVID-19 pandemic disrupted the preventive services for cervical cancer (CC) control programs in Mexico, which will result in increased mortality. This study aims to assess the impact of the pandemic on the interruption of three preventive actions in the CC prevention program in Mexico.

Methods

This study is a retrospective time series analysis based on administrative records for the uninsured population served by the Mexican Ministry of Health. Patient data were retrieved from the outpatient service information system and the hospital discharge database for the period 2017-2021. Data were aggregated by month, distinguishing a pre-pandemic and a pandemic period, considering April 2020 as the start date of the pandemic. A Poisson time series analysis was used to model seasonal and secular trends. Five process indicators were selected to assess the disruption of the CC program, these were analyzed as monthly data (N=39 pre-pandemic, N=21 during the pandemic). HPV vaccination indicators (number of doses and coverage) and diagnostic characteristics of CC cases were analyzed descriptively. The time elapsed between diagnosis and treatment initiation in CC cases was modeled using restricted cubic splines from robust regression.

Results

Annual HPV vaccination coverage declined dramatically after 2019 and was almost null in 2021. The number of positive Papanicolaou smears decreased by 67.8% (90%CI: -72.3, -61.7) in April-December 2020, compared to their expected values without the pandemic. The immediate pandemic shock (April 2020) in the number of first-time and recurrent colposcopies was -80.5% (95%CI:-83.5, -77.0) and -77.9% (95%CI: -81.0, -74.4), respectively. An increasing trend was observed in the proportion of advanced stage and metastatic CC cases. The fraction of CC cases that did not receive medical treatment or surgery increased, as well as CC cases that received late treatment after diagnosis.

Conclusions

Our analyses show significant impact of the COVID-19 pandemic with declines at all levels of CC prevention and increasing inequalities. The restarting of the preventive programs against CC in Mexico offers an opportunity to put in place actions to reduce the disparities in the burden of disease between socioeconomic levels.

How SARS-CoV-2 Infection Impacts the Management of Patients with Vulvar Cancer: Experience in a Third-Level Hospital of Southern Italy

Background: Since February 2020, the spread of Coronavirus Disease 2019 (COVID-19) in Italy has induced the government to call for lockdown of any activity apart from primary needs, and changing the lives of each of us. All that has dramatically impacted the management of patients affected by cancer. Patients with vulvar cancer (VC) represent a particularly frail population because they are elderly and affected by multiple comorbidities. The aim of this study is to evaluate the clinical impact of the SARS-CoV-2 infection on VC patients in terms of delay or impossibility of carrying out the scheduled treatment. Methods: The medical records of patients affected by vulvar tumors, referred to "DAI Materno-Infantile" of AOU Federico II of Naples between February 2020 and January 2022 were retrospectively analyzed. The presence of a positive reverse transcription-polymerase chain reaction (RT-PCR) in nasopharyngeal swab defined the positivity to SARS-CoV-2. Results: Twenty-four patients with VC were analyzed and scheduled for treatment. The median age was 70.7 years (range: 59-80). Seven (29.2%) patients were diagnosed with SARS-CoV-2 infection: In three (42.8%) patients, the treatment was delayed with no apparent consequences, in four (57.2%), the treatment was delayed or changed due to cancer progression and, of these four, one died due to respiratory complications of COVID-19, and one died due to oncologic disease progression. Conclusion: COVID-19 caused, in most cases, significant delays in oncologic treatments and high mortality in our series of patients affected by VC.

Outcomes of gynecologic cancer surgery during the COVID-19 pandemic: an international, multicenter, prospective CovidSurg-Gynecologic Oncology Cancer study

BACKGROUND

The CovidSurg-Cancer Consortium aimed to explore the impact of COVID-19 in surgical patients and services for solid cancers at the start of the pandemic. The CovidSurg-Gynecologic Oncology Cancer subgroup was particularly concerned about the magnitude of adverse outcomes caused by the disrupted surgical gynecologic cancer care during the COVID-19 pandemic, which are currently unclear.

OBJECTIVE

This study aimed to evaluate the changes in care and short-term outcomes of surgical patients with gynecologic cancers during the COVID-19 pandemic. We hypothesized that the COVID-19 pandemic had led to a delay in surgical cancer care, especially in patients who required more extensive surgery, and such delay had an impact on cancer outcomes.

STUDY DESIGN

This was a multicenter, international, prospective cohort study. Consecutive patients with gynecologic cancers who were initially planned for nonpalliative surgery, were recruited from the date of first COVID-19-related admission in each participating center for 3 months. The follow-up period was 3 months from the time of the multidisciplinary tumor board decision to operate. The primary outcome of this analysis is the incidence of pandemic-related changes in care. The secondary outcomes included 30-day perioperative mortality and morbidity and a composite outcome of unresectable disease or disease progression, emergency surgery, and death.

RESULTS

We included 3973 patients (3784 operated and 189 nonoperated) from 227 centers in 52 countries and 7 world regions who were initially planned to have cancer surgery. In 20.7% (823/3973) of the patients, the standard of care was adjusted. A significant delay (>8 weeks) was observed in 11.2% (424/3784) of patients, particularly in those with ovarian cancer (213/1355; 15.7%; P<.0001). This delay was associated with a composite of adverse outcomes, including disease progression and death (95/424; 22.4% vs 601/3360; 17.9%; P=.024) compared with those who had operations within 8 weeks of tumor board decisions. One in 13 (189/2430; 7.9%) did not receive their planned operations, in whom 1 in 20 (5/189; 2.7%) died and 1 in 5 (34/189; 18%) experienced disease progression or death within 3 months of multidisciplinary team board decision for surgery. Only 22 of the 3778 surgical patients (0.6%) acquired perioperative SARS-CoV-2 infections; they had a longer postoperative stay (median 8.5 vs 4 days; P<.0001), higher predefined surgical morbidity (14/22; 63.6% vs 717/3762; 19.1%; P<.0001) and mortality (4/22; 18.2% vs 26/3762; 0.7%; P<.0001) rates than the uninfected cohort.

CONCLUSION

One in 5 surgical patients with gynecologic cancer worldwide experienced management modifications during the COVID-19 pandemic. Significant adverse outcomes were observed in those with delayed or cancelled operations, and coordinated mitigating strategies are urgently needed.

The utility of physical examination in ovarian cancer recurrence detection: a retrospective analysis informing virtual surveillance care

OBJECTIVES

Given the recent rapid increase in telemedicine in the setting of the COVID-19 pandemic, we sought to investigate the utility of symptom review, CA125, and physical examination in the detection of ovarian cancer recurrence to determine the role of virtual surveillance care in the COVID-19 era.

METHODS

This retrospective cohort study included patients diagnosed with ovarian cancer between 2013 and 2020 who achieved remission after primary treatment and then had recurrence while in a routine surveillance program. Modalities that detected recurrence including symptoms, CA125, physical examination, or 'other,' which was denoted if imaging was obtained for reasons other than suspected recurrence and recurrence was incidentally identified, were recorded. Descriptive statistics were performed to summarize the cohort.

RESULTS

One hundred and nine patients met inclusion criteria. At time of recurrence, elevated CA125 was present in 97 (89.0%) patients, symptoms in 41 (37.6%), and abnormal physical exam findings in 27 (24.8%). Recurrence was incidentally found with imaging obtained for reasons other than suspicion of recurrence in six (5.5%) patients. Recurrence was suspected based on multiple modalities in 46 (42.2%) patients. Elevated CA125, symptoms, or both were present in 102 (93.6%) patients. Of patients with abnormal physical exam findings, 26 (96.3%) also had elevated CA125 or symptoms present. Recurrence was suspected based on physical exam findings alone in one (0.9%) patient.

CONCLUSIONS

Over 90% of ovarian cancer recurrences were detected by rising CA125, symptoms, or both. Only one patient had recurrence detected by physical examination alone. Given that review of symptoms and CA125 can be conducted virtually, virtual visits may offer a reasonable alternative to in-person visits for ovarian cancer surveillance for patients who have pre-treatment elevated CA125.

Single centre experience of 800 gynaecologic oncology cases in 2020: influence of pandemy on cancer surgeries

We aimed to evaluate the gynaecological oncology surgeries in the COVID-19 pandemic. A total of 800 operations performed between January and December 2020 were retrieved. Since the COVID-19 pandemic affected operations as of April 1 2020, we compared the cases of the last nine months of the year with the first three months. Of the operations, 265 (33.1%) were performed between January and March and 535 (66.9%) between April and December. Of 168 malignant operations; 78 (46%) were uterine cancer, 58 (35%) ovarian cancer, 28 (17%) cervical cancer and four (2%) vulvar cancer. If we compared the last nine months of the year with the first three months, a significant increase was observed in the rates of malignant and premalignant, while a significant decrease was detected in benign operations (p<.001). Gynaecological oncology surgeries performed with open or laparoscopic approaches during the COVID-19 pandemic should continue by taking preventive measures. Impact StatementWhat is already known on this subject? During the COVID-19 pandemic, many international associations and organisations recommended the suspension of elective surgeries. It is still controversial whether the gynaecologic oncology surgical procedures to be performed in this unprecedented time should be laparoscopic or laparotomic.What do the results of this study add? The malignant and premalignant gynaecological oncology surgeries should be safely performed laparoscopically or by laparotomy in the COVID-19 pandemic.What are the implications of these findings for clinical practice and/or further research? Gynaecologic oncology surgeries can be safely performed by attaching appropriate personal protective equipment procedures with pre-operative COVID-19 PCR testing in the COVID-19 era.

Prognostic impact of waiting time between diagnosis and treatment in patients with cervical cancer: A nationwide population-based study

OBJECTIVE

Prior research underlined the importance of timely oncological care as longer waiting times from diagnosis to treatment may result in poorer survival outcomes. The aim of this study was to determine the impact of waiting time from diagnosis to treatment on overall survival (OS) in patients with cervical cancer treated with curative intent.

METHODS

Patients from a nationwide population-based cohort with newly diagnosed cervical cancer between 2010 and 2019 were studied. Patients who underwent surgery or (chemo)radiotherapy with curative intent were selected. Waiting time (i.e. interval between first pathologic confirmation and treatment) was modelled as continuous (i.e. linear per week), dichotomized (i.e. ≤8 versus >8 weeks), and polynomial (i.e. restricted cubic splines). The association with OS was examined using Cox regression analyses.

RESULTS

Among 6895 patients with cervical cancer, 2755 treated with primary surgery and 1898 who received primary (chemo)radiotherapy were included. Mean waiting time was 8.5 (±4.2) weeks to surgery and 7.7 (±2.9) weeks to (chemo)radiotherapy. Adjusted for confounders, waiting time to surgery was not significantly associated with OS (continuous HR 0.97 [95%CI: 0.93-1.01], dichotomized HR 0.93 [95%CI: 0.68-1.27], polynomial HR not significant). Similarly, a longer waiting time to (chemo)radiotherapy was not significantly associated with poorer OS (continuous HR 0.97 [95%CI: 0.93-1.00], dichotomized HR 0.91 [95%CI: 0.75-1.09], polynomial HR not significant).

CONCLUSIONS

This large population-based study demonstrates that a longer waiting time (of up to 12 weeks) from diagnosis to treatment in patients with cervical cancer treated with curatively intended surgery or (chemo)radiotherapy does not negatively impact survival.

Gynecologic radiation therapy in low and middle income countries during the COVID-19 pandemic

The COVID-19 pandemic has forever affected healthcare and posed an incredible challenge to our society to care for our sick. Patients with cancer were found early on to have higher rates of complications with COVID-19. Radiation therapy is an integral part of treatment for many types of gynecologic cancer and adaptation on its utilization during the pandemic varied across the globe. In this review, we detail certain guidelines for the use of radiation in gynecologic cancers during the pandemic as well as real world accounts of how different countries adapted to these guidelines or created their own based on individualized resources, staffing, government restrictions, and societal norms. Critically, this review demonstrates the breadth of fractionation schemes and technologies used when resources were limited but highlights the importance of long term follow-up for many of our patients during this time.

Two wars on one front: Experiences of gynaecological cancer patients in the COVID-19 pandemic

Objective

The aim of this study is to explore the experiences of gynaecological cancer patients during the COVID‐19 pandemic from their own perspectives.

Methods

The study is a descriptive study with a qualitative design based on thematic analysis. We conducted the study with 17 women with gynaecological cancer and receiving chemotherapy in the Medical Oncology and Chemotherapy Unit of Kütahya Training and Research Hospital. The data were collected between April 2021 and May 2021 via an in‐depth individual interview form. The COREQ checklist was followed in the study.

Results

As a result of the interviews, we identified four main themes: the impacts of COVID‐19 on life, the impact of COVID‐19 on cancer treatment, the biggest fear during the COVID‐19 pandemic and the metaphors of struggling with cancer during the COVID‐19 pandemic.

Conclusion

The disruption of treatment services during the COVID‐19 pandemic and women's fear of infection by the virus led to delays in cancer diagnosis and treatment. This situation caused the women's state of health to deteriorate, and the resultant regret and sadness that they experienced had an adverse effect on their mental health. Furthermore, women's self‐isolation due to the fear of infection by the virus had a negative effect on their psychosocial health. Telehealth services should be provided for cancer patients to obtain accurate information and to easily access information about treatment processes during the pandemic, and telepsychological hotlines and peer support groups should be established to improve the psychosocial health of patients.

Increasing global accessibility to high-level treatments for cervical cancers

Human papillomaviruses (HPV)-related gynecological cancers are a major health care issue, and a leading cause of cancer death in low- and middle-income countries (LMIC). In 2020, the World Health Organization launched a program aimed at cervical cancer elimination, by screening and vaccination strategies. Offering the best possible care to women diagnosed with invasive cancer is a complementary objective. Treatment of cervical cancer as per modern standards is complex and multimodal, mainly relying on surgery, external-beam radiotherapy (+/-chemotherapy) and brachytherapy. In parallel with the pivotal role of multidisciplinary discussion, international societies provide guidance to define the most effective and least toxic anti-cancer strategy, homogenize treatment protocols and provide benchmark quality indicators as a basis for accreditation processes. The challenge is to offer the appropriate diagnostic workup and treatment upfront and to avoid non- evidence-based treatment that consumes resources, impairs quality of life (QoL), and compromises oncological outcome. Various strategies may be applied for improving treatment quality: development of surgical mentorship, companion-training programs and international cooperation. The lack of radiotherapy/brachytherapy facilities is a major concern in LMIC. Reinforcing international support in terms of education, training, research and development and technical cooperation with national projects is required to increase access to minimum requirements but also introduce modern techniques, upgrade radiotherapy/brachytherapy services, and expand access to modern systemic treatments. In countries with robust economies, compliance to standards should also be increased. Integrative cancer care and multidisciplinary approaches are needed to tackle the dual challenge of increasing cure rates while minimizing QoL impairment. Appropriate dimensioning of the resources to avoid harmful treatment delays and access to expert referral centers is also a priority.

Management of Gynecologic Cancer During COVID-19 Pandemic: South Asian Perspective

Management of gynecological cancers has suffered during the pandemic, partly due to lockdown and partly due to directing resources to manage COVID-19 patients. Modification of gynecological cancer management during this pandemic is recommended. Cervical cancer patients who present with stage IA1 disease can have a delay of up to 8 weeks for surgical treatment, considering the slow tumor growth rate. Women with stages IA2, IB1, IB2, IIA1 must undergo radical hysterectomy and lymphadenectomy within 6 to 8 weeks. In areas where surgical treatment is not available, patients should be referred for radiation therapy/areas with adequate surgical expertise. The surgical option is attractive for early cancers during the COVID era, as it involves a single visit compared to the multiple visits required for chemoradiation. The value of lymph node staging needs to be reconsidered. Neoadjuvant chemotherapy should be given preference over primary cytoreductive surgery for advanced ovarian cancers. Surgeries, which demand extended surgical time such as Hyperthermic Intraperitoneal Chemotherapy and pelvic exenterations, should be avoided during this pandemic. For patients scheduled for interval surgery after two or three neoadjuvant cycles, six cycles of chemotherapy should be considered before surgery is performed. For early-stage, low-grade endometrial cancer, consideration should be given to medical management until surgery is possible. The above recommendations have been made keeping in mind the geography, patient load, and availability of resources available to health care providers from southeast Asia. They might not be applicable globally and every practitioner should take call regarding patient's management as per availability of resources and loco-regional circumstances. The implementation of recommended international guidelines for the management of gynecologic cancers should take precedence. Each modification to the standard approach should be approved by a multidisciplinary team depending on the condition of the patients and the locoregional circumstances.

Building a Personalized Medicine Infrastructure for Gynecological Oncology Patients in a High-Volume Hospital

Gynecological cancers require complex intervention since patients have specific needs to be addressed. Centralization to high-volume centers improves the oncological outcomes of patients with gynecological cancers. Research in gynecological oncology is increasing thanks to modern technologies, from the comprehensive molecular characterization of tumors and individual pathophenotypes. Ongoing studies are focusing on personalizing therapies by integrating information across genomics, proteomics, and metabolomics with the genetic makeup and immune system of the patient. Hence, several challenges must be faced to provide holistic benefit to the patient. Personalized approaches should also recognize the unmet needs of each patient to successfully deliver the promise of personalized care, in a multidisciplinary effort. This may provide the greatest opportunity to improve patients' outcomes. Starting from a narrative review on gynecological oncology patients' needs, this article focuses on the experience of building a research and care infrastructure for personalized patient management.

Characteristics and patterns of care of endometrial cancer before and during COVID-19 pandemic

Objective

Coronavirus disease 2019 (COVID-19) outbreak has correlated with the disruption of screening activities and diagnostic assessments. Endometrial cancer (EC) is one of the most common gynecological malignancies and it is often detected at an early stage, because it frequently produces symptoms. Here, we aim to investigate the impact of COVID-19 outbreak on patterns of presentation and treatment of EC patients.

Methods

This is a retrospective study involving 54 centers in Italy. We evaluated patterns of presentation and treatment of EC patients before (period 1: March 1, 2019 to February 29, 2020) and during (period 2: April 1, 2020 to March 31, 2021) the COVID-19 outbreak.

Results

Medical records of 5,164 EC patients have been retrieved: 2,718 and 2,446 women treated in period 1 and period 2, respectively. Surgery was the mainstay of treatment in both periods (p=0.356). Nodal assessment was omitted in 689 (27.3%) and 484 (21.2%) patients treated in period 1 and 2, respectively (p<0.001). While, the prevalence of patients undergoing sentinel node mapping (with or without backup lymphadenectomy) has increased during the COVID-19 pandemic (46.7% in period 1 vs. 52.8% in period 2; p<0.001). Overall, 1,280 (50.4%) and 1,021 (44.7%) patients had no adjuvant therapy in period 1 and 2, respectively (p<0.001). Adjuvant therapy use has increased during COVID-19 pandemic (p<0.001).

Conclusion

Our data suggest that the COVID-19 pandemic had a significant impact on the characteristics and patterns of care of EC patients. These findings highlight the need to implement healthcare services during the pandemic.

The prevalence of patients with early-stage endometrial cancer (EC) has been lower during coronavirus disease 2019 (COVID-19) pandemic than before its onset. Further evidence is needed to assess the impact of COVID-19 pandemic on survival outcomes of EC patients.

Clinical impact of SARS-CoV-2 infection among patients with vulvar cancer: the Gemelli Vul.Can multidisciplinary team

BACKGROUND

'Severe acute respiratory syndrome coronavirus-2' (SARS-CoV-2) infection has dramatically affected the management of patients with cancer, who are most vulnerable to the consequences of the infection. Patients with vulvar cancer are frequently elderly and affected by multiple co-morbidities, thus representing a particularly frail population.

OBJECTIVE

To assess the clinical impact of the SARS-CoV-2 infection among patients scheduled for treatment for active vulvar cancer.

METHODS

Data on patients with vulvar tumors referred to Fondazione Policlinico Universitario Agostino Gemelli IRCCS between February 2020 and July 2021 were retrospectively analyzed. Patients with a positive reverse transcription polymerase chain reaction in nasopharyngeal swab were considered as positive for SARS-Cov-2.

RESULTS

One hundred and ninety-one patients with vulvar cancer were evaluated and scheduled for treatment. The median age was 72 years (range 35-94). Seven (3.7%) patients were diagnosed with SARS-Cov-2 infection: three (42.9%) had their treatment delayed, with no apparent consequences, two (28.6%) had their treatment delayed and later abandoned because of clinical worsening due to oncologic disease progression, and two (28.6%) contracted the infection in the post-operative period and died due to respiratory complications.

CONCLUSIONS

In most cases the infection had major clinical implications, being associated with significant delays in oncologic treatments and extremely high mortality when contracted in the post-operative period.

During the COVID-19 Epidemic: Recommendations for the Admission and Treatment of Patients With Ovarian Cancer

Background: The coronavirus disease 2019 (COVID-19) had become a health care event endangering humans globally. It takes up a large number of healthcare resources. We studied the impact of COVID-19 on patients with ovarian cancer by comprehensively analyzing their admissions before and after the epidemic, and made reasonable suggestions to improve their current situation.

Methods: We randomly divided the enrolled patients into three groups, PreCOVID-19 Group (PCG) (2019.8.20–2020.1.20), COVID-19 Group (CG) (2020.1.21–2020.6.14), and Secondary Outbreak COVID-19 Group (SOCG) (2020.6.15–2020.10.10). One-way ANOVA and chi-square test were used for analysis.

Results: The number of patients from other provinces decreased significantly (p < 0.05). The total hospital stay during the epidemic was substantially more extended (p < 0.05). Before the epidemic, our department performed more open surgery while during the epidemic outbreak, we tended to choose laparoscopy (p < 0.01). We took a longer surgery time (P < 0.05). Patients had significantly less post-operative fever during the epidemic (p < 0.001).

Conclusion: During the COVID-19 epidemic, no patient was infected with COVID-19, and no patient experienced severe post-operative complications. We recommend maintaining the admissions of patients with ovarian cancer during the epidemic following the rules: 1. The outpatients must complete a nucleic acid test and chest CT in the outpatient clinic; 2. Maintain full daily disinfection of the ward and insist that health care workers disinfect their hands after contact with patients; 3. Increase the use of minimally invasive procedures, including laparoscopy and robotics; 4. Disinfect the ward twice a day with UV light and sodium hypochlorite disinfectant; 5. Patients need to undergo at least three nucleic acid tests before entering the operating room.

COVID-19 and Gynecologic Oncology: What Have We Learned?

COVID-19 has transformed the care we provide to gynecologic oncology patients. In addition to directly impacting the diagnosis and treatment of women with gynecologic cancer, it has affected our patient’s ability to undergo recommended surveillance and has made an impact on every caregiver providing care during this time. Herein we review the current literature on the impact of COVID-19 on gynecologic oncology and highlight new approaches and innovations that have resulted in gynecologic cancer care as a result of the pandemic. The impact of COVID-19 on the field of gynecologic oncology has been profound. In addition to directly impacting the diagnosis and treatment of women with cancer, it has also challenged the very ethics with which we practice medicine. The equitable distribution of resources is paramount to upholding the Hippocratic Oath which we all invoke. The COVID-19 pandemic has stripped this oath down to its very core, forcing all medical practitioners to scrutinize who gets what resources and when. As the pandemic continues to unfold, the question remains — in the setting of a strained and overburdened healthcare system, how do we maximize beneficence to one group of patients, while maintaining non-maleficence to others? As gynecologic oncologists, we are responsible for advocating for our patients to ensure that the quality of their cancer care is not compromised, while also not overutilizing resources that are sorely needed for the care of COVID-19 victims, and not making them more likely to succumb to COVID-19 by the very nature of the treatment we provide. The effects of the pandemic are far-reaching and broad, and many of these are yet to be determined. Future studies are needed to analyze how the above-utilized strategies in GYN cancer care during the pandemic will impact the long-term outcomes of our patients.

British Gynaecological Cancer Society recommendations for women with gynecological cancer who received non-standard care during the COVID-19 pandemic

During the COVID-19 pandemic, pressures on clinical services required adaptation to how care was prioritised and delivered for women with gynecological cancer. This document discusses potential 'salvage' measures when treatment has deviated from the usual standard of care. The British Gynaecological Cancer Society convened a multidisciplinary working group to develop recommendations for the onward management and follow-up of women with gynecological cancer who have been impacted by a change in treatment during the pandemic. These recommendations are presented for each tumor type and for healthcare systems, and the impact on gynecological services are discussed. It will be important that patient concerns about the impact of COVID-19 on their cancer pathway are acknowledged and addressed for their ongoing care.

Patient perspectives and experiences of the rapid implementation of digital consultations during COVID-19 - a qualitative study among women with gynecological cancer

Purpose

Due to the first COVID-19 outbreak and subsequent restrictions, standard practice for gynecological cancer quickly evolved to include additional digital consultations. Women with gynecological cancer have a high need for information and experience a high symptom burden. We aimed to explore the experiences and perspectives of the rapid implementation of digital consultations during COVID-19.

Methods

We conducted individual telephone interviews with patients with gynecological cancer 1–4 days after a telephone or video consultation during the COVID-19 outbreak in April and May 2020. We applied Braun and Clarke’s thematic analysis to analyze the qualitative data.

Results

Thirty-two patients with ovarian (50%), cervical (35%), vulvar (12%), and vaginal cancer (3%) participated in the study. The patients experienced that, combined, cancer and COVID-19 restrictions made their situation twice as challenging. In general, the patients valued face-to-face consultations, recommending that they were ideal for the initial appointment to build trust. Overall, there was a willingness to participate in digital consultations because of the restrictions, but the results also showed varying degrees of openness and that individual solutions were favored.

Conclusion

The findings of this study show that digital consultations were an accepted alternative during COVID-19. Even though this temporary solution was deemed to be beneficial for practical reasons, patients also experienced digital consultations to be impersonal. A key message is that face–to–face encounters create the foundation to establish a trusting relationship from where a valuable dialogue arises. Digital consultations should therefore be implemented with caution since no one-size-fits-all model is recommended. Among patients with gynecological cancer, however, digital technologies represent a promising and flexible method depending on the purpose of consultations, patient preferences, and needs.

Neoadjuvant therapy or upfront surgery in advanced endometrial cancer: a systematic review protocol

INTRODUCTION

There is no consensus on the optimal treatment strategy for people with advanced endometrial cancer. Neoadjuvant therapies such as chemotherapy and radiotherapy have been employed to try to reduce the morbidity of surgery, improve its feasibility and/or improve functional performance in people considered unfit for primary surgery. The objective of this review is to assess whether neoadjuvant chemotherapy or radiotherapy improves health outcomes in people with advanced endometrial cancer when compared with upfront surgery.

METHODS AND ANALYSIS

This review will consider both randomised and non-randomised studies that compare health outcomes associated with the neoadjuvant therapy and upfront surgery in advanced endometrial cancer. Potential studies for inclusion will be collated from electronic searches of OVID Medline, Embase, international trial registries and conference abstract lists. Data collection and extraction will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The methodological quality of the studies will be assessed using the Risk of Bias 2 and Risk of Bias in Non-randomised Studies of Interventions tools. If appropriate, we will perform a meta-analysis and provide summary statistics for each outcome.

ETHICS AND DISSEMINATION

Ethics approval was not required for this study. Once complete, we will publish our findings in peer-reviewed publications, via conference presentations and to update relevant practice guidelines.

Impact of COVID-19 in gynaecological oncology care: a systematic rapid review

Purpose

Synthesis of available evidence on clinical practice in gynaecological oncology during the COVID-19 pandemic is highly warranted, as women with cancer are at increased risk due to their systemic immunosuppressed state and changes in their care are inevitable. Rapid review of available data is a quick way of providing useful information and insight into the way medical practice has been affected by the COVID pandemic.

Methods

We conducted a systematic rapid review, based on a literature search of MEDLINE/PubMed, Embase, and Cochrane CENTRAL. We considered all studies on gynaecological oncology care during the COVID-19 pandemic using relevant keywords and MeSH terms. Selection criteria were English language, studies with more than five cases and publication in peer-review journal.

Results

Nine retrospective studies, one systematic review and five questionnaire surveys were included. Quality of the studies has been assessed. Development of higher quality evidence is warranted. Mortality of COVID-19 infection is higher in patients with gynaecological cancer than in non-cancer patients. Reported delays in diagnosis and management of cancer and changes in treatments, may affect the natural history of cancer and increase patients’ anxiety and fear of disease progression while causing concerns to healthcare professionals affecting their clinical practice. The number of new diagnoses has declined. Prioritization is important, face-to-face interactions should be limited, and appropriate protective measures are essential. Cancer surgery, chemotherapy, and radiotherapy should continue as high priority practices.

Conclusion

The COVID-19 pandemic has affected clinical practice significantly. Adaptations in clinical practice may improve mortality and complication rates.

Impact of COVID-19 on gynaecological patient care: results of patient's survey with 327 patients

Purpose

The pandemic SARS-CoV-2 poses new and unprecedented challenges for health care systems on a national and global level. Although the current situation has been going on for more than 1 year, there is limited data on the impact of the pandemic on general hospital and medical practice care. This survey captures the perspective of patients with gynaecological diseases of this impact.

Methods

Using a paper-based questionnaire, 327 patients were asked about medical care and their experiences during the pandemic at the University Hospital Bonn and the University Hospital Charité Berlin. The study was performed from the 1st June to 30th September 2020.

Results

A total of 327 patients participated in the study: 156 stated to have been tested for coronavirus, and 1 patient reported a positive test. 41.3% of the patients felt insecure about the current situation, 30.4% were concerned about the risk of infection during the hospital stay. The pandemic-specific measures in hospitals and medical practices unsettled 6.8% of patients. 18.1% of patients feared that their gynaecological disease would not be treated adequately due to the pandemic. 55.7% of patients reported that their confidence in their physicians has increased during the pandemic.

Conclusion

The results show that patients’ confidence in the healthcare system and the physicians acting significantly increased during the COVID-19 crisis. Transparent and comprehensive information policy regarding actions and restrictions within the COVID-19 crisis eases patients concerns and improves patients’ confidence in their physicians, which is crucial for a successful treatment’s outcome.

The safety of major gynaecologic cancer surgery without routine preoperative COVID-19 testing in the COVID-19 era: a multicentre, retrospective, case-control study

Our goal was to address the safety of major gynaecologic cancer surgery without routine preoperative COVID-19 testing in the COVID-19 era. The databases of seven gynaecologic cancer centres were searched in order to identify all consecutive gynaecologic cancer patients undergoing major surgery between March 11, 2020 and May 15, 2020 for this retrospective, case-control study. The case group consisted of patients with histopathologically confirmed gynaecologic cancers, and each case was matched with two counterparts who had undergone primary surgery before the COVID-19 pandemic. The case and the control groups were compared in terms of length of hospital stay, admission to the intensive care unit (ICU), intraoperative and postoperative complications.During the study period, 154 women with gynaecologic cancer undergoing major surgery were identified. Although the case group had more co-morbidities compared to the control group (103/154 vs. 178/308, respectively; p = .04), the median length of hospital stays, the rate of ICU admission, intraoperative complication rates and postoperative complication rates were similar in the two groups. Gynaecologic cancer surgery may be performed safely in the COVID-19 era with similar rates of ICU admission, intraoperative and postoperative complications compared to the patients operated before the COVID-19 pandemic.IMPACT STATEMENTWhat is already known on this subject? Many societies have announced their guidelines about the surgical management of gynaecologic cancer patients during the COVID-19 pandemic. However, most of them are not evidence-based and mostly on expert opinions.What do the results of this study add? The main findings of this retrospective, case-control study indicate that the short-term (30 day) outcomes of gynaecologic cancer patients undergoing major surgery in the COVID-19 era are similar to those who had been operated before the COVID-19 pandemic. The length of hospital stays, the rates of admission to the ICU, intraoperative and postoperative complications were comparable between women undergoing major gynaecologic cancer surgery in the COVID-19 era and the women who had been operated before the pandemic.What are the implications of these findings for clinical practice and/or further research? We can suggest that definitive surgery may be performed for gynaecologic cancer patients in the COVID-19 era if the resources permit and appropriate precautions such as social distancing, isolation and the use of personal protective equipment are taken.

COVID-19 and the impact on gynecologic cancer care

The COVID‐19 pandemic resulted in significant reconfiguration of gynecologic cancer services and care pathways across the globe, with a transformation of working practices. Services had to adapt to protect their vulnerable patients from infection, whilst providing care despite reduced resources/capacity and staffing. The international gynecologic cancer community introduced modified clinical care guidelines. Remote working, reduced hospital visiting, routine COVID‐testing, and use of COVID‐free surgical areas/hubs enabled the ongoing and safe delivery of complex cancer care, with priority levels for cancer treatments established to guide decision‐making by multidisciplinary tumor boards. Some 2.3 million cancer surgeries were delayed or cancelled during the first peak, with many patients reporting significant anxiety/concern for cancer progression and COVID infection. Although COVID trials were prioritized, recruitment to other cancer trials/research activity was significantly reduced. The impact of resultant protocol deviations on outcomes remains to be established. During the recovery healthcare services must maintain capacity and flexibility to manage future surges of infection, address the large backlog of patients with altered or delayed treatments, along with salvaging screening and prevention services. Training needs/mental well‐being of trainees need addressing and staff burnout prevented. Future research needs to fully evaluate the impact of COVID‐19 on long‐term patient outcomes.

This article reviews the global changes introduced to gynecologic cancer care due to COVID‐19, and their impact on services and patients. Key lessons are considered for the recovery and future.

Impact of COVID-19 on medical treatment patterns in gynecologic oncology: a MITO group survey

OBJECTIVE

COVID-19 is a global public health emergency. The increasing spread of COVID-19 presents challenges for the clinical care of patients with gynecological tumors. The Multicenter Italian Trials in Ovarian cancer and gynecologic malignancies (MITO) performed a survey to evaluate the impact of the COVID-19 pandemic on medical treatment of gynecological cancer, with a focus on chemotherapy and oral treatment with poly(ADP)-ribose polymerase inhibitors (PARP-i).

METHODS

The survey consisted of a self-administered online questionnaire, sent via email between November 2020 and January 2021 to all members of MITO group.

RESULTS

Forty-nine centers completed the questionnaire. The majority of respondents (83%) use screening tests to determine COVID-19 status in patients who were to undergo chemotherapy or oral medications. All respondents to our survey continued cancer therapy in patients who tested negative for COVID-19 during the pandemic. Seventy-three percent of respondents declared they stopped treatment with chemotherapy or PARP-i only after a positive swab and resumed therapy when negative tests were confirmed.

CONCLUSIONS

COVID-19 positivity impacted patterns of treatment in patients diagnosed with ovarian cancer within the MITO group. Further investigations are needed to evaluate whether these modifications influence oncological clinical outcomes.

Practice changes in Italian Gynaecologic Units during the COVID-19 pandemic: a survey study

The impact of Coronavirus disease 2019 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown. Therefore, a survey was conducted among all Italian Gynaecological Units Directors in April 2020. The response rate was 90% (135/150). 77.8% of centres performed surgery only for oncologic or not deferrable pathologies, and 9.6% was closed. 68.7% of directors were at least moderately satisfied by published guidelines/recommendations, but 94.8% of respondents identified limitations, mainly (83%) the absent definition of benign non-deferrable pathology. Responders considered as non-deferrable severe endometriosis (69.6%), endometriosis with organ failure/dysfunction (74.1%), and unresponsive symptomatic fibroids (89.6%). Despite guidelines/recommendations, respondents treated ovarian (77%) and endometrial (71.6%) cancer as usual. Only a minority of respondents reduced the laparoscopic approach (11.2%) and adopted all recommended surgical precautions (9.6%). Compliance with available guidelines/recommendations appears incomplete. Reconsidering guidelines/recommendations regarding oncological cases and specify non-deferrable benign pathologies would improve guidelines/recommendations compliance.Impact statementWhat is already known on this subject? The SARS-CoV-2 pandemic has profoundly influenced medical routine practice worldwide. Surgery units have been forced to reduce or even completely restrict their activity to re-allocate human resources. Many major international gynaecological societies have released statements and guidelines, providing various recommendations to guide practice changes. However, the impact of the SARS-CoV-2 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown.What do the results of this study add? Study results provide evidence showing how the SARS-CoV-2 pandemic has changed surgical activity in the Italian Gynaecological Units. Most centres reduced surgical activity, limiting surgery only for oncologic or not deferrable pathologies. Moreover, our research shows the level of compliance and satisfaction with available guidelines/recommendations and where they need to be improved. Most directors were at least moderately satisfied but identified different limitations. Guidelines/recommendations do not provide enough details, such as the absent definition of benign non-deferrable pathologies.What are the implications of these findings for clinical practice and/or further research? The limited compliance with available guidelines/recommendations and identified limitations suggest reconsidering guidelines/recommendations focussing on identified gaps. Provide more details, such as specifying non-deferrable benign pathologies, would improve guidelines/recommendations compliance.

Nationwide Survey of German Outpatient Gynecologic Oncology Practices during the Coronavirus Disease 2019 Pandemic: Reactions to the First Wave and Future Perspectives

Introduction

In the spring of 2020, coronavirus disease 2019 posed a substantial challenge for countries and their healthcare systems. In Germany, over 70% of all cancer patients are treated in an outpatient setting, so gynecologic oncology practices are the guarantors of optimal patient care. We developed a survey to evaluate the management of gynecologic oncology patients.

Methods

The survey consisted of 38 questions and was sent to the members of the Berufsverband Niedergelassener Gynäkologischer Onkologen in Deutschland e.V. (BNGO), a professional association of gynecologic oncologists in the outpatient sector in Germany.

Results

The survey was completed by 54 out of 133 (41%) gynecologic oncologists from 14 out of 15 (93%) federal states where the BNGO is represented. Facing the pandemic, popular measures were mask requirements (100%), restriction of access to practices (94%), increased number of disinfectant dispensers (85%), installment of panes of acrylic glass (76%), or spatial alterations (67%). For most patients the pandemic had no influence on prioritization of therapies (82%) or prescribed systemic treatments (87%). Despite an increase in perceived psychological burden among the staff (72%), 85% (45/54) of the practices were not offered any additional psychological support.

Discussion and Conclusion

As most cancer patients in Germany are treated in an outpatient setting, a suitable reaction of oncology centers to the new circumstances was crucial to secure optimal treatment and patient care. Nevertheless, the low prioritization of mental health or distress of healthcare workers poses a serious threat to the maintenance of optimal medical care in further waves of the pandemic.

Changes in gynecologic and breast cancer diagnoses during the first wave of the COVID-19 pandemic: analysis from a tertiary academic gyneco-oncological center in Germany

Purpose

With the beginning of 2021, the world has been suffering from the COVID-19 pandemic for more than 1 year. More and more, we are able to evaluate side effects of the pandemic in the healthcare sector. A negative impact on cancer diagnoses is one of them. Careful observation of trends in an academic gyneco-oncological context appears important to identify potential negative developments.

Methods

We analyzed the case number of gynecologic and breast cancer diagnoses in the period from January to June 2020 compared to 2019 and during the period of the first general German lockdown (March 22nd until May 5th 2020). Patients were characterized by age, tumor type, FIGO or TNM stage and presence of symptoms at initial hospital presentation.

Results

The frequency of newly diagnosed gynecologic and breast cancer cases from beginning of January until end of June changed by − 10% and by − 12% during the lockdown in 2020 compared to 2019. In both periods, reduction of breast cancer cases was relatively larger than decrease of gynecologic cancers. Moreover, median patient age decreased. For the first half of 2020, we found a shift towards higher tumor stages (N+/M1 or FIGO III–IV). During the lockdown period, the appearance of tumor-associated symptoms at diagnosis increased by about 12%.

Conclusion

This analysis illustrates the anticipated general decrease in diagnoses of primary cancers during the lockdown periods in 2020 due to COVID-19 pandemic for gynecologic and breast cancer cases.

New developments in rare vulvar and vaginal cancers

PURPOSE OF REVIEW

To provide the latest insight on the rare vulvar and vaginal malignancies, able to impact on clinical practice, and to outline new potential research developments.

RECENT FINDINGS

Many efforts are being made to produce technical and scientific advances in the fields of vulvar and vaginal carcinoma, including imaging work-up, interventional procedures and minimally invasive surgical approach, as well as molecular profiling and identification of new target treatments.

SUMMARY

In the evaluation of lymph node status, ultrasound has demonstrated promising results because of high predictive value, low risk and low cost. Positron Emission Tomography-Computed Tomography is confirmed to be reliable and should be prospectively investigated for its potential applications in radiomics, whilst Fusion-US could allow a precision guidance in diagnostics and interventional procedures. Regarding interventional procedure, surgery is becoming less invasive with the aim to increase quality of life; in carefully selected patients it would be possible to overcome the current strict criteria in the use of sentinel node biopsy. Future research should focus on potential target therapy, on the basis of tumor-specific biological features.Rare cancers should be referred to experienced centers with a high case flow, able to offer a full range of diagnostic and therapeutical options and a multidisciplinary approach. Networking should be encouraged to promote research opportunities and enable data sharing and multicenter trials.

Impact of SARS-CoV-2 on training and mental well-being of surgical gynecological oncology trainees

INTRODUCTION

The SARS-CoV-2 global pandemic has caused a crisis disrupting health systems worldwide. While efforts are being made to determine the extent of the disruption, the impact on gynecological oncology trainees/training has not been explored. We conducted an international survey of the impact of SARS-CoV-2 on clinical practice, medical education, and mental well-being of surgical gynecological oncology trainees.

METHODS

In our cross-sectional study, a customized web-based survey was circulated to surgical gynecological oncology trainees from national/international organizations from May to November 2020. Validated questionnaires assessed mental well-being. The Wilcoxon rank-sum test and Fisher's exact test were used to analyse differences in means and proportions. Multiple linear regression was used to evaluate the effect of variables on psychological/mental well-being outcomes. Outcomes included clinical practice, medical education, anxiety and depression, distress, and mental well-being.

RESULTS

A total of 127 trainees from 34 countries responded. Of these, 52% (66/127) were from countries with national training programs (UK/USA/Netherlands/Canada/Australia) and 48% (61/127) from countries with no national training programs. Altogether, 28% (35/125) had suspected/confirmed COVID-19, 28% (35/125) experienced a fall in household income, 20% (18/90) were self-isolated from households, 45% (57/126) had to re-use personal protective equipment, and 22% (28/126) purchased their own. In total, 32.3% (41/127) of trainees (16.6% (11/66) from countries with a national training program vs 49.1% (30/61) from countries with no national training program, p=0.02) perceived they would require additional time to complete their training fellowship. The additional training time anticipated did not differ between trainees from countries with or without national training programs (p=0.11) or trainees at the beginning or end of their fellowship (p=0.12). Surgical exposure was reduced for 50% of trainees. Departmental teaching continued throughout the pandemic for 69% (87/126) of trainees, although at reduced frequency for 16.1% (14/87), and virtually for 88.5% (77/87). Trainees reporting adequate pastoral support (defined as allocation of a dedicated mentor/access to occupational health support services) had better mental well-being with lower levels of anxiety/depression (p=0.02) and distress (p<0.001). Trainees from countries with a national training program experienced higher levels of distress (p=0.01). Mean (SD) pre-pandemic mental well-being scores were significantly higher than post-pandemic scores (8.3 (1.6) vs 7 (1.8); p<0.01).

CONCLUSION

SARS-CoV-2 has negatively impacted the surgical training, household income, and psychological/mental well-being of surgical gynecological oncology trainees. The overall clinical impact was worse for trainees in countries with no national training program than for those in countries with a national training program, although national training program trainees reported greater distress. COVID-19 sickness increased anxiety/depression. The recovery phase must focus on improving mental well-being and addressing lost training opportunities.

Resumption of the treatment of non-COVID-19 gynecologic patients after lifting lockdown: Triage and infection prevention experiences from Wuhan

Aim

To share our experiences of resuming the treatments for gynecologic patients after lifting the lockdown in a hotspot area for the Coronavirus Disease 2019 (COVID‐19) pandemic.

Methods

The triage process used to resume medical activities for gynecologic patients at the Wuhan Union Hospital after a 76‐day lockdown of the city is described, and its effectiveness in preventing COVID‐19 nosocomial transmission is shown.

Results

Nonemergency patients were pretriaged based on their contact history and body temperature at an outpatient clinic, and negative COVID‐19 screening test results were required for admission to the buffering rooms at the gynecologic department. The buffering lasted at least 3 days for symptom monitoring, and a second round of COVID‐19 testing was required before patients could be transferred to the regular gynecologic wards. For patients who needed emergency surgery, the first screening was completed at the isolation wards after surgery, followed by buffering at the gynecologic department. We received 19 298 outpatient visits, admitted 326 patients, and performed 223 operations in the first 2 months after the lockdown was lifted. No COVID‐19 cases occurred in the hospitalized patients, while the proportion of potentially high‐risk patients with cancer and severe anemia was increased in comparison to that observed during the same period in 2019 and the first 2 months of 2020 before the lockdown.

Conclusions

We provide an effective triage system with buffering at two levels to guarantee safe and timely treatment for non‐COVID‐19 gynecologic patients in the postlockdown phase.

Complex and Challenging Surgery like CRS with HIPEC is Easible Midst the COVID 19 Pandemic: Experience from Tertiary Care Center in India

Background

Amidst the COVID pandemic, most guidelines have recommended delaying surgery and giving chemotherapy for with peritoneal surface malignancies. However, when all options are exhausted, complex surgery like CRS with HIPEC can be performed in select patients.

Method

To facilitate these complex surgeries with maximum safety, RT-PCR test for COVID-19 was performed for each patient. Personal protective equipment including N95 masks and face shields was used. A number of OT personals were limited. Taking these steps minimized the risk of COVID-19 infections among healthcare workers and patients.

Conclusion

After implementing these steps, we were able to perform complex CRS and HIPEC procedure during the pandemic and thus improve oncological outcomes.

COVID-19 pandemic and preparedness of anesthesia team in a stand-alone cancer centre in Eastern India

India came under the grip of the coronavirus disease-2019 (COVID-19) pandemic and is now seeing rising graph. Cancer patients are specially in the high-risk group because of their immunocompromised status on one hand and progressive disease on the other hand. Hence, cancer care facility needs to prepare a clear strategy to manage their space, staff and supplies so that optimum patient care can be continued in the face of COVID-19 pandemic. In addition, infection prevention measures need to be robust to reduce in-hospital transmission. The working area of anesthesia and Critical Care is spread over the whole hospital such as operating room, ICU, isolation area, out-patient dept (OPD) area, various diagnostic areas and in-patient dept (IPD) to attend code blue calls. In this article, we describe the preparedness and initial response measures of the anesthesia and Critical Care department of a stand-alone tertiary level cancer care centre in eastern part of India. These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow, introduction and adequate supply of personal protective equipment for staff and formulation of clinical guidelines for anesthetic management. These containment measures are necessary to continue care of cancer patients, optimize the quality of care provided to COVID-19 positive cancer patients and to reduce the risk of viral transmission to other patients or healthcare providers.

Feasibility of hyperthermic intraperitoneal chemotherapy (HIPEC) in ovarian cancer during COVID-19 pandemic

OBJECTIVE

This study aims to evaluate the effect of the COVID-19 pandemic and related restrictions on patients who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer.

METHODS

We retrospectively evaluated ovarian cancer patients who underwent HIPEC following complete cytoreductive surgery performed during the outbreak of the COVID-19 pandemic in three different centers specializing in gynecological oncology. All patients who underwent cytoreduction plus HIPEC for a primary, interval, and recurrent surgery were evaluated. Primary outcomes was postoperative 30-day morbidity and mortality. The secondary outcome was infection of patient and/or related staff with COVID-19 during the perioperative or early postoperative period.

RESULTS

We performed a total of 35 HIPEC procedures during the pandemic: 15 (42.9%) patients underwent primary/interval surgery, while 20 (57.1%) patients had recurrent disease. Grade 3-4 complications occurred in one patient (2.9%) (chronic renal failure), while mortality did not occur in any patient. Neither the patients nor related staff were infected with the coronavirus during the perioperative or early postoperative period. One patient, who was diagnosed with COVID-19 pneumonia on postoperative day 80 died from the infection. Another patient died on postoperative day 85 due to progressive ovarian cancer, a disorder in vital functions, and organ failure.

CONCLUSION

HIPEC during the COVID-19 pandemic seems a safe and feasible procedure, with acceptable morbidity and mortality rates. Careful selection of patients is important and precautions should be taken before the procedure.

Indirect effects of COVID-19 in referring women to gynecologic oncology, perinatology and gynecology clinics in Iran

Purpose

COVID-19 has captured the world. We hypothesized that this pandemic reduced referral of other non-COVID-19 patients to the hospitals or clinics, including gynecological and perinatological referrals. Women can be at risk in limited use of health services.

Methods

In this retrospective study, referrals from gynecologic oncology, perinatology, and gynecology clinics in a large teaching hospital of Tehran University of Medical Sciences (TUMS) were compared from February 20 to May 20, 2020, with the same period in 2019. Finally, referral trends in 2020 were compared with the COVID-19 admission pattern.

Results

Total admissions to all three clinics declined 63% in 2020 compared to 2019. There was a significant relationship between the number of visits to three clinics during these2  years (p < 0.001). The reduction in referrals to the gynecology clinic was more than gynecologic oncology and perinatology. The COVID-19 referral pattern was conversely linked to gynecology-related admissions.

Conclusion

As the pandemic situation makes patients hesitant to go to the hospitals or not, health policymakers should consider other non-COVID issues, including maternal and fetal concerns. Providing safe places for other patients to visit is a goal that can be achieved through developing guidelines for nosocomial hygiene and training informed healthcare staff. Moreover, non-urgent visits should be avoided or postponed. This issue calls for new strategies, including telemedicine in situations similar to the current pandemic to both identify and manage such conditions.

Non-anesthetist-administered moderate sedation with midazolam and fentanyl for outpatient MRI-aided hybrid intracavitary and interstitial brachytherapy in cervix cancer: a single-institution experience

Purpose

The aim of the study was to determine the feasibility of interstitial brachytherapy under non-anesthetist-administered moderate sedation, to identify factors influencing the insertion, and the total procedural time.

Material and methods

A total of 47 insertions with hybrid intracavitary and interstitial applicators were performed in 23 patients from March 2017 to March 2020. Moderate sedation was achieved with intravenous midazolam and fentanyl administered by non-anesthetist. Insertion time and procedural time was recorded. Univariate and multivariate analysis were performed to evaluate the impact of different factors on insertion and procedural time.

Results

A total of 238 needles (range, 2-8 per insertion) were implanted, with an average insertion depth of 30 mm (range, 20-40 mm). The mean doses for midazolam and fentanyl were 3 mg (standard deviation [SD] = 1) and 53.3 mcg (SD = 23.9) per insertion, respectively. The median insertion time was 30 minutes (interquartile range [IQR] = 22-40), and the median total procedural time was 4.3 hours (IQR = 3.6-5.2). First time insertion, insertions performed before 2019, and higher midazolam dose were associated with significantly longer insertion time, whereas longer insertion time, MRI-based planning, and insertions performed before 2019 were associated with significantly longer total procedural time.

Conclusions

Outpatient interstitial brachytherapy with non-anesthetist-administered sedation is achievable and well-tolerated. This method may significantly lessen the burden on hospital resources and has the potential to be cost-effective.

Report from the European Society of Gynaecological Oncology (ESGO) 2020 State-of-the-Art Virtual Meeting

This is a report from the European Society of Gynaecological Oncology State-of-the-Art Virtual Meeting held December 14-16, 2020. The unique 3-day conference offered comprehensive state-of-the-art summaries on the major advances in the treatment of different types of gynecological cancers. Sessions opened with a case presentation followed by a keynote lecture and interactive debates with opinion leaders in the field. The speakers also presented scientific reviews on the clinical trial landscape in collaboration with the European Network of Gynecological Oncological Trial (ENGOT) groups. In addition, the new ESGO-ESRTO-ESP endometrial cancer guidelines were officially presented in public. This paper describes the key information and latest studies that were presented for the first time at the conference.

Association between definitive chemoradiotherapy wait-time and survival in locally-advanced cervical cancer: Implications during the coronavirus pandemic

OBJECTIVE

The current coronavirus pandemic caused a significant decrease in cancer-related encounters resulting in a delay in treatment of cancer patients. The objective of this study was to examine the survival effect of delay in starting concurrent chemo-radiotherapy (CCRT) in women with locally-advanced cervical cancer.

METHODS

This is a retrospective observational study querying the National Cancer Database from 2004 to 2016. Women with stage IB2-IVA squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix who received definitive CCRT with known wait-time for CCRT initiation after cancer diagnosis were eligible (N=13,617). Cox proportional hazard regression model with restricted cubic spline transformation was fitted to assess the association between CCRT wait-time and all-cause mortality in multivariable analysis.

RESULTS

The median wait-time to start CCRT was 6 (IQR 4-8) weeks. In a multivariable analysis, older age, non-Hispanic black and Hispanic ethnicity, recent year of diagnosis, Medicaid and uninsured status, medical comorbidities, and absence of nodal metastasis were associated with longer CCRT wait-time (P<.05). Women with aggressive tumor factors (poorer differentiation, large tumor size, nodal metastasis, and higher cancer stage) were more likely to have a short CCRT wait-time (P<.05). After controlling for the measured covariates, CCRT wait-time of 6.1-9.8 weeks was not associated with increased risk of all-cause mortality compared to a wait-time of 6 weeks. Similar association was observed when the cohort was stratified by histology, cancer stage, tumor size, or brachytherapy use.

CONCLUSION

An implication of this study for the current coronavirus pandemic is that in the absence of aggressive tumor factors, a short period of wait-time to start definitive CCRT may not be associated with increased risk of mortality in women with locally-advanced cervical cancer.

Care as Usual: An Acceptable Strategy to Apply During the COVID-19 Pandemic in a French Tertiary Gynecologic Oncology Department

We describe and analyze a “care as usual” strategy of a French Comprehensive Cancer Center during the COVID-19 pandemic to manage surgical patients with gynecological cancer. We conducted a retrospective analysis evaluating the surgical activity in our gynecologic oncology department between January 21 and May 12, 2020. We compared the surgical activity and surgical and oncologic outcomes during the pre-lockdown period and the pandemic period. The main objective was to evaluate the impact of the COVID-19 pandemic on surgical activity. The secondary objectives were to analyze the surgical and the oncologic outcomes. We compared the surgical activity during the 8 weeks after the national lockdown (85 procedures) to the surgical activity in the 8 weeks preceding the lockdown (127 procedures). We observed a 33% decrease in activity between the two periods. The clinical and epidemiologic characteristics were similar between the two periods. There were no differences between the surgical approaches (p = 0.592), the surgical complexity (p = 0.323), the length of stay (p = 0.85), and even for the complex procedure (p = 0.96) and the perioperative (p = 0.791) and postoperative complication rates (p = 0.102). We observed a significant decrease in the time of return to intended oncological treatment (RIOT) during the lockdown period with an average of 31.9 days compared to 46.9 days in the pre-lockdown period (p = 0.003). During the COVID-19 pandemic, “care as usual” represents an acceptable strategy without impairing the oncologic outcome in a Comprehensive Cancer Center with a patient-centered clinical pathway for gynecologic oncologic surgical patients.

Medical treatment of patients with gynecologic cancer during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, cancer care had to be reorganized; national and international recommendations were published to manage anticancer treatments safely and to reduce the risk of SARS-CoV-2 infection for patients and health workers.

OBJECTIVE

To evaluate whether the adoption of recommendations for the management of patients with gynaecologic cancer receiving treatment during the pandemic resulted in containment of infections and continuing oncologic care.

METHODS

Based on the published recommendations, and according to the local Health Direction guidelines, we developed and drafted a security protocol to modify access of patients with gynaecologic cancer to the "Fondazione Policlinico Agostino Gemelli-IRCCS, Rome" between February 1 and April 30, 2020 and compared results with the corresponding 3 months of 2019.

RESULTS

Between February and April 2019, we registered 3254 admissions, including 2253 patients receiving intravenous chemotherapies, 298 receiving oral therapies, and 703 having hospital visits. Between February and April 2020, we registered 3213 admissions, including 2221 patients receiving intravenous chemotherapies, 401 receiving oral therapies, and 591 having hospital visits. Oral treatments and general visits were different in the two time periods (p<0.001). Despite the elevated patient flow, only one patient (0.1%) tested positive for COVID-19 and there were no cases among healthcare staff.

CONCLUSIONS

Based on the adopted security protocol we provided continuity of care for all patients and limited the spread of the COVID-19 infection.

COVID-19 free oncologic surgical hub: The experience of reallocation of a gynecologic oncology unit during pandemic outbreak

INTRODUCTION

During the SARS-CoV-2 pandemic, the majority of healthcare resources of the affected Italian regions were allocated to COVID-19 patients. Due to lack of resources and high risk of death, most cancer patients have been shifted to non-surgical treatments. The following reports our experience of a Gynaecologic Oncology Unit's reallocation of resources in a COVID-19 free surgical oncologic hub in order to guarantee standard quality of surgical activities.

MATERIALS AND METHODS

This is a prospective observational study performed in the Gynaecologic Oncology Unit, on the outcomes of the reallocation of surgical activities outside the University Hospital of Bologna, Italy, during the Italian lockdown period. Here, we described our COVID-19 free surgical oncologic pathway, in terms of lifestyle restrictions, COVID-19 screening measures, and patient clinical, surgical and follow up outcomes.

RESULTS

During the lockdown period (March 9th - May 4th, 2020), 83 patients were scheduled for oncological surgery, 51 patients underwent surgery. Compared to pre-COVID period, we performed the same activities: number of cases scheduled for surgery, type of surgery and surgical and oncological results. No cases of COVID-19 infection were recorded in operated patients and in medical staff. Patients were compliant and well accepted the lifestyle restrictions and reorganization of the care.

CONCLUSIONSONCLUSIONS

Our experience showed that the prioritization of oncological surgical care and the allocation of resources during a pandemic in COVID-19 free surgical hubs is an appropriate choice to guarantee oncological protocols.

Impact of COVID-19 on Gynaecological oncology; a global perspective

The coronavirus pandemic caused global devastation with over 2 million deaths and put unprecedented pressure on health care facilities world-wide. The response to the pandemic differed globally as countries faced different challenges. Within Gynaecological oncology, a multitude of guidance was published by various countries and organisations which demonstrated major themes. These consisted of implementations aimed at reducing transmission, managing limited resources, treatment prioritisation whilst continuing urgent oncological surgery where possible and the use of alternative therapies in the management of oncology patients to reduce hospital admission. Due to the novelty of this virus and its global effects, published guidance is currently limited to best practice and small-scale trials. This review aims to summarise the global response to coronavirus with respect to Gynaecological oncology and suggests potential interventions to limit the spread of the virus during resurgence or in the event of a future global pandemic. It also discusses the current trials recruiting relevant to the field of Gynaecological oncology to better inform the specialty on the management of cancer patients during COVID-19.

COVID-19 and gynecological cancers: Asia and Oceania Federation of Obstetrics and Gynecology oncology committee opinion

Since the outbreak of COVID-19, there have already been over 26 million people being infected and it is expected that the pandemic will not end in near future. Not only the daily activities and lifestyles of individuals have been affected, the medical practice has also been modified to cope with this emergency catastrophe. In particular, the cancer services have faced an unprecedented challenge. While the services may have been cut by the national authorities or hospitals due to shortage of manpower and resources, the medical need of cancer patients has increased. Cancer patients who are receiving active treatment may develop various kinds of complications especially immunosuppression from chemotherapy, and they and their carers will need additional protection against COVID-19. Besides, there is also evidence that cancer patients are more prone to deteriorate from COVID-19 if they contract the viral infection. Therefore, it is crucial to establish guidelines so that healthcare providers can triage their resources to take care of the most needed patients, reduce less important hospitalization and visit, and to avoid potential complications from treatment. The Asia and Oceania Federation of Obstetrics and Gynecology (AOFOG) hereby issued this opinion statement on the management of gynecological cancer patients during the COVID-19.

The Impact of COVID-19 on Cancer Care in the Post Pandemic World: Five Major Lessons Learnt from Challenges and Countermeasures of Major Asian Cancer Centres

Objective:

The COVID-19 pandemic has dramatically affected healthcare services around Asia. The Asian National Cancer Centres Alliance and the Asia-Pacific Organisation for Cancer Prevention collaborated to assess the mid- and long- term impact of COVID-19 to cancer care in Asia.

Methods:

The two entities organised a combined symposium and post-meeting interactions among representatives of major cancer centres from seventeen Asian countries to outlining major challenges and countermeasures.

Results:

Participating stakeholders distilled five big questions. 1) “Will there be an explosion of late-stage cancers after the pandemic?” To address and recover from perceived delayed prevention, screening, treatment and care challenges, collaboration of key stakeholders in the region and alignment in cancer care management, policy intervention and cancer registry initiatives would be of essential value. 2) “Operations and Finance” The pandemic has resulted in significant material and financial casualties. Flagged acute challenges (shortages of supplies, imposition of lockdown) as well as longer-standing reduction of financial revenue, manpower, international collaboration, and training should also be addressed. 3) “Will telemedicine and technological innovations revolutionize cancer care?” Deploying and implementing telemedicine such as teleconsultation and virtual tumour boards were considered invaluable. These innovations could become a new regular practice, leading to expansion of tele-collaboration through collaboration of institutions in the region. 4) “Will virtual conferences continue after the pandemic?” Virtual conferences during the pandemic have opened new doors for knowledge sharing, especially for representatives of low- and middle-income countries in the region, while saving time and costs of travel. 5) “How do we prepare for the next pandemic or international emergency?” Roadmaps for action to improve access to appropriate patient care and research were identified and scrutinised.

Conclusion:

Through addressing these five big questions, focused collaboration among members and with international organisations such as City Cancer Challenge will allow enhanced preparedness for future international emergencies.

Challenges and opportunities for ovarian cancer management in the epidemic of Covid-19: lessons learned from Wuhan, China

China and the rest of the world are experiencing an outbreak of the 2019 novel coronavirus disease (COVID-19). Patients with cancer are more susceptible to viral infection and are more likely to develop severe complications, as compared to healthy individuals. The growing spread of COVID-19 presents challenges for the clinical care of patients with gynecological malignancies. Ovarian debulking surgery combined with the frequent need for chemotherapy is most likely why ovarian cancer was rated as the gynecologic cancer most affected by COVID-19. Therefore, ovarian cancer presents a particular challenging task. Concerning the ovarian cancer studies with confirmed COVID-19 reported from large-scale general hospitals in Wuhan, we hold that the treatment plan was adjusted appropriately and an individualized remedy was implemented. The recommendations discussed here were developed mainly based on the experience from Wuhan. We advise that the management strategy for ovarian cancer patients should be adjusted in the light of the local epidemic situation and formulated according to the pathological type, tumor stage and the current treatment phase. Online medical service is an effective and convenient communication platform during the pandemic.