Impact of COVID-19 on gynaecological cancer treatment
On the 25 March 2020, all non-urgent elective surgery was temporarily suspended in Australia. Only Category 1 (cancer) and some urgent Category 2 surgery will continue until further notice.
The definitions for elective surgery are assessed as:
- Category 1 – Needing treatment within 30 days. Has the potential to deteriorate quickly to the point where the patient’s situation may become an emergency
- Category 2 – Needing treatment within 90 days. Their condition causes pain, dysfunction or disability. Unlikely to deteriorate quickly and unlikely to become an emergency
- Category 3 – Needing treatment at some point in the next year. Their condition causes pain, dysfunction or disability. Unlikely to deteriorate quickly.
Decisions on the category of patients are at the discretion of their treating doctor.
Why the suspension? The suspension is to preserve resources including protective equipment for doctors, nurses and other staff to help prepare hospitals for the extra services required in the COVID-19 outbreak. We can expect that healthcare resources may be limited. This applies to both public and private hospitals.
We know that leaving cancer untreated is life threatening. Diagnosing cancer and treating cancer will not be affected in this suspension as cancer surgery falls within Category 1. Diagnostic tests will continue which include investigations for vaginal bleeding, surgery for pelvic masses, and medical imaging. Treating cancer includes surgery, chemotherapy and radiation treatment. Follow-up appointments will continue using telehealth methods (video or phone consultations) where possible.
If you have both COVID-19 or pneumonia, and gynaecological cancer it is important to prioritise COVID treatment first.
Research data suggests that should the COVID-19 situation worsen in Australia, it is reasonable and safe to delay surgery for patients with gynaecologic cancers for 4-6 weeks and potentially longer. For example, a study observed no difference in survival when 28 women with early-stage cervical cancer who were diagnosed in pregnancy (average wait time 20 weeks from diagnosis to treatment) were compared with the outcomes of 52 patients who were not pregnant at cancer diagnosis (average wait time 8 weeks). Their survival was 89% versus 94% respectively (P = .08).
Below are my recommendations:
- Alternative option #1: Medically compromised patients can have intrauterine Progestins. Up to a 6 month delay is okay.
- Alternative option #2: Delay less than 6-8 weeks for intermediate and high-risk uterine cancers.
- Follow up: Travel may be difficult. Involve Telehealth. Symptoms (bleeding, pain) need to be investigated using medical imaging and blood tests. A local GP can arrange these investigations.
- Symptoms should be evaluated (such as bloating, fullness, bowel symptoms). These are investigated using tumour markers and medical imaging (such as ultrasound, CT, PET/CT) and can be arranged by your GP.
- Patients need to be seen and examined by gynaecological oncologist (ideally within 1 week).
- Some patients require surgery (laparoscopic or open) – avoid surgery that requires ICU admission (chemotherapy instead). If surgery: within 4 weeks.
- Some patients need upfront chemotherapy with investigations after 3 cycles. Start within 4 weeks.
- Follow up: Ovarian cancer is ideal for online follow-up due to limited physical exams. needed. Any symptoms need to be investigated; such as medical imaging and CA 125 monitoring.
- Treatment of recurrence: Needs to be determined individually.
- Very early cervical cancer (stage 1a). Cone biopsy or simple hysterectomy; Can be delayed for 8 weeks.
- Localized cervical cancer (stage 1b). Radical hysterectomy + pelvic lymph nodes. To be treated in less than 4 weeks.
- Locally advanced or advanced cervical cancer (stage 2+). Chemo-Radiation treatment. This does not take up resources that are needed otherwise. To be treated in less than 4 weeks.
- Follow up: Travel may be difficult. Involve Telehealth, medical imaging and local GP for investigations (PAP smear).
- Vulval tumour (proximity of tumour to urethra, clitoris or anus)
- Groin nodes
- Surgery within 4 weeks (advanced cancers for chemoradiation treatment)
- Delay of longer may result in disease progression (cancer may become much more difficult to treat).
- Follow up: Self-examination. Physical examination infeasible through telehealth. See GP. Ultrasound of groins is possible remotely.
Your gynaecological oncologist will be available throughout the crisis. However, some aspects of treatment and communication will need to adjust.