Review
Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001634 on 23 June 2020. Downloaded from http://ijgc.bmj.com/ on January 28, 2022 at India:BMJ-PG Sponsored. Protected by
1
Academic Department of
Gynaecological Oncology, Royal
Surrey NHS Foundation Trust,
Guildford, United Kingdom
2
Obstetrics & Gynecology
Oncology, Command Hospital,
Pune, Maharashtra, India
3
Department of Gynaecologic
Oncology, Tata Memorial
Hospital, Homi Baba National
Institute, Mumbai, India
4
St Luke’s Cancer Centre,
Department of Oncology, Royal
Surrey NHS Foundation Trust,
Guildford, United Kingdom
5
Department of Oncology,
University of Surrey, Guildford,
United Kingdom
Correspondence to
Dr Geetu Prakash Bhandoria,
Obstetrics & Gynecology,
Command Hospital Pune, Pune
411040, Maharashtra, India; ​
doctor_​071277@​yahoo.​co.​in
Received 18 May 2020
Revised 4 June 2020
Accepted 8 June 2020
© IGCS and ESGO 2020. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
To cite: Uwins C,
Bhandoria GP, Shylasree TS,
et al. Int J Gynecol Cancer
Published Online First: [please
include Day Month Year].
doi:10.1136/ijgc-2020-
001634
COVID-19 and gynecological cancer: a review
of the published guidelines
Christina Uwins,1 Geetu Prakash Bhandoria  ‍ ‍,2 TS Shylasree,3 Simon Butler-­Manuel,1
Patricia Ellis,1 Jayanta Chatterjee,1 Anil Tailor,1 Alexandra Stewart,4 Agnieszka Michael5
Abstract
On March 11, 2020 the COVID-19 outbreak was declared
a ‘pandemic’ by the World Health Organization. COVID-19
is associated with higher surgical morbidity and mortality.
An array of guidelines on the management of cancer
during this pandemic have been published since the first
reports of the outbreak. This narrative review brings all
the relevant information from the guidelines together
into one document, to support patient care. We present
a detailed review of published guidelines, statements,
comments from peer-­reviewed journals, and nationally/
internationally recognized professional bodies and
societies' web pages (in English or with English translation
available) between December 1, 2019 and May 27, 2020.
Search terms included combinations of COVID, SARS-­
COV-2, guideline, gynecology, oncology, gynecological,
cancer. Recommendations for surgical and oncological
prioritization of gynecological cancers are discussed and
summarized. The role of minimally invasive surgery, patient
perspectives, medico-­legal aspects, and clinical trials
during the pandemic are also discussed. The consensus
is that elective benign surgery should cease and cancer
surgery, chemotherapy, and radiotherapy should continue
based on prioritization. Patient and staff face-­to-­face
interactions should be limited, and health resources used
efficiently using prioritization strategies. This review and
the guidelines on which it is based support the difficult
decisions currently facing us in gynecological cancer. It is a
balancing act: limited resources and a hostile environment
pitted against the time-­sensitive nature of cancer
treatment. We can only hope to do our best for our patients
with the resources available to us.
Background
On March 11, 2020 the World Health Organization
Director-­General declared the outbreak of COVID-19
a pandemic on the basis of its spread and severity.1
Early reports in the first nationwide analysis from
China, published in mid-­February 2020, purported to
indicate a 3.5 times higher risk of needing mechan-
ical ventilation, intensive care admission, or dying in
patients with a history of cancer compared with those
without.2 The ongoing CovidSurg project, a new inter-
national multi-­center study, has provided data from
1129 patients with COVID-19 operated on during this
time. Findings showed a high overall mortality rate of
24% and pulmonary complication rate of 51%. Most
deaths followed pulmonary complications (83%), and
elective surgery was associated with a 19% mortality
Uwins C, et al. Int J Gynecol Cancer 2020;0:1–10. doi:10.1136/ijgc-2020-001634
risk. These data support the cancelation or post-
ponement of elective surgeries during the ongoing
pandemic.3 Global predictive modeling estimates
that 28 404 603 operations will have been canceled
or postponed worldwide during the peak 12 weeks
of disruption due to COVID-19.4 It is estimated that,
if countries increase their normal surgical volume by
20% following the resolution of the pandemic, it will
take a median of 45 weeks to clear the backlog of
operations resulting from the COVID-19 disruption.4
There is an emergent need to better understand the
impact of COVID-19 on the care of cancer patients
requiring surgery. CovidSurg-­Cancer and CovidSurg-­
Cancer Gynecological Oncology are international
multi-­center studies launched to understand this
question. Data collection was ongoing for these
studies at the time of submission of this review.5
Since the beginning of March 2020 an array of
copyright.
guidelines, statements, and comments have been
published on the management of gynecological
cancer during the COVID-19 pandemic. We have
reviewed and summarized the surgical and oncolog-
ical prioritization strategies in circumstances where
capacity is limited. Capacity varies between countries
and even within each country.
Many recommendations are pragmatic deviations
from 'standard of care' management, aiming to
balance the risk of treatment and available resources
during this pandemic. It remains to be seen how
short-­term and long-­term oncological outcomes will
be affected. Treatment escalation plans and patients’
wishes regarding resuscitation should therefore be
discussed openly with patients for a range of different
eventualities and documented in the medical notes.
The guidelines reviewed here reflect choices made by
clinicians during the current pandemic and help with
the decision-­making process.
Methods
We performed electronic searches of Embase,
Medline, and Google Scholar for guidelines, state-
ments, or comments (in English or with English
translation available) published between December
1, 2019 and May 27, 2020. Those published in
peer-­reviewed journals or on nationally/internation-
ally recognized professional bodies’/societies’ web
1
Review

pages were included (first guideline published on 14 March, 2020).
Reference lists were hand-­searched to identify any pertinent arti-
cles that had been missed. Search terms included combinations
of: COVID, SARS-­COV-2, guideline, gynecology, oncology, gyneco-
logical, cancer, and variant spellings. Comments, perspectives, and
correspondence published in various journals have not been incor-
porated in this review.
Results
Evolution of the guidelines
The first set of publicly available guidelines appeared in France.
The French High Council for Public Health (Haut Conseil de Santé
Publique) formally released their guidelines on March 14, 2020.
These were followed by a series of guidelines/recommendations
Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001634 on 23 June 2020. Downloaded from http://ijgc.bmj.com/ on January 28, 2022 at India:BMJ-PG Sponsored. Protected by
published by several national/international professional societies/
bodies, as listed in Table 1.6 Due to the rapidly evolving nature of
this pandemic, guidelines are based on expert opinion because of
the lack of available robust scientific evidence.
Recommendations on reduction of infection rate
►► Identification of patients: COVID-19 screening clinics
►► Testing patients admitted for treatment/surgery depending on
available resources or based on symptoms within 14 days
►► Strict tracing of patients' contacts
►► Establishing isolated areas for COVID patients
7
►► 'Clean/COVID-19-­free' hospital sites for cancer surgery
►► Work from home/separated teams to maintain the workforce
►► Travel restrictions

Table 1  Timeline of guidelines

Date of issue/publication
General oncology guidelines (year 2020)
Haut Conseil de Santé Publique6 March 14
National Institute for Health and Care Excellence39 March 20
National Health Service (NHS)12 March 23
60
American College of Surgeons (Statement) March 24
Society of American Gastrointestinal and Endoscopic Surgeons & European Association for March 29
Endoscopic Surgery30
Italian Society of Surgical Oncology, Italian Association of Medical Oncology and Italian March 23

copyright.
Association of Radiation Oncology joint statement9 (Statement)
National Comprehensive Care Network10 April 5 (accepted for
publication March 16)
American Society of Clinical Oncology36 April 28 (accepted for
publication April 8)
Medical Oncology Group of Australia8 April 16 (published May 13)
Gynecological cancer statements/guidelines
British Gynaecological Cancer Society7 March 22 (updated v2.0 April
13, v3.0 May 5)
Society of Gynecologic Oncology49 March 23
45
European Network of Gynaecological Oncological Trial Groups March 23
International Journal of Gynecological Cancer51 March 27 (accepted March
24)
American Association of Gynecologic Laparoscopists (Statement)32 March 27
Australia New Zealand Gynecological Oncology Group47 March 31
61
European Society of Gynecological Oncology (ESGO) Statement March 31
Groupe de Recherche en chirurgie Oncologique et Gynécologique interest group of Collège April 1
National des Gynécologues Obstétriciens Français15
Society of European Robotic Gynecological Surgery31 April 3
Society of Gynecologic Oncology of Canada16 April 7
55
Italian Society for Colposcopy and Cervico-­Vaginal Pathology April 8
54
British Society of Colposcopy and Cervical Pathology April 9
European Society of Medical Oncology56 62 63 April (accessed April 19)
17
Asian Society of Gynecologic Oncology May 8
European Federation for Colposcopy (EFC)-­European Society of Gynecologic Oncology May
(ESGO)59

2 Uwins C, et al. Int J Gynecol Cancer 2020;0:1–10. doi:10.1136/ijgc-2020-001634


►► Fever/severe acute respiratory syndrome coronavirus 2
(SARS-­COV-2) screening for staff and visitors
►► Social distancing
►► Frequent disinfection of areas which are touched frequently
such as door knobs, elevator buttons, or railings8
►► Limitation of family and friends visiting the hospital
Recommendations for outpatient clinics
►► Minimize face-­to-­face appointments9
►► Telephone/video consultations
►► Maintaining ‘social distancing’ in outpatient waiting areas
►► Adequate protection equipment
Recommendations for healthcare personnel safety
►► Personal protection equipment whenever and wherever
applicable
►► Staff training in using personal protection equipment
►► Staff training in the identification of suspected COVID patients
►► Ensuring that staff have access to psychological support
►► Reassignment of clinical duties to administrative roles for immu-
nocompromised staff or those with significant co-­morbidities10
10
►► Strict ‘stay at home when ill’ policy
►► Improving awareness among professionals through regular
webinars with a national and international presence to learn
from others
Recommendations on inpatient management
►► COVID designated wards/intensive care units/operating rooms/
hospitals
►► Blood bank balancing operating room transfusion needs with
shortage of blood products due to a reduction in blood donation
►► Pooling of resources such as shifting patients to COVID-­free
units/hospitals
►► Restricting the number of visitors to ‘none’ or ‘single-­only'
In addition to changes in day-­to-­day practice relating to hospital
visits and minimizing risk of infection, guidelines advise on prioriti-
zation of treatment when faced with low capacity in intensive care
units and staff absence due to COVID-19 infection. As COVID-19 has
had a global effect these guidelines vary, with some countries and
societies defining priorities and others providing various options.11
Surgical prioritization
The general consensus is that elective surgery for benign indica-
tions should cease during this pandemic.12 Recommendations for
the surgical prioritization of gynecological cancer cases may be
broadly divided into four main groups.7 9 12–17
Priority level 1
1a Emergency required within 24 hours to save a life
1b Urgent required <72 hours
Life-­threatening conditions such as obstruction, bleeding, local-
ized infection, spinal cord compression, anastomotic leak, burst
abdomen, torsion, or rupture of suspected malignant pelvic masses,
heavy bleeding from molar pregnancy.13
Priority level 2
Elective surgery required <4 weeks with the expectation of cure
prioritized based on the biology of the disease (expected growth
rate in the case of cancer).
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Review
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Priority level 3
Elective surgery that can be delayed for 10–12 weeks with no
predicted negative outcome.
Oncology patients with highest risk during this pandemic include:
≥65 years old, significant co-­morbidities including cardiovascular
disease, pulmonary disease, and diabetes mellitus, European
Cooperative Oncology Group status ≥2, patients receiving cytotoxic
chemotherapy.14
Enhanced recovery pathways should be used to facilitate early
patient discharge, thus limiting patient exposure to the hospital envi-
ronment and maintaining capacity within the healthcare service.7 18
The primary clinical benefits of implementing these protocols are
shorter hospital length of stay and reduced post-­operative compli-
cations (including respiratory complications) in low, medium,
and highly complex gynecological oncology surgeries. These are
desired outcomes, particularly during the pandemic when inpa-
tient beds and intensive care unit beds are increasingly scarce.18
Surgical management should be delayed for at least 15 days15/end
of symptoms16 in patients with gynecological cancer presenting
with COVID-19.
Patient perspectives
European Society of Gynecological Oncology (ESGO)-­ European
Network of Gynecological Cancer Advocacy Groups (ENGAGe)
conducted a survey in 12 countries with 129 patient responses
obtained. Patients were found to be more fearful of cancer progres-
sion (70.9%) than developing COVID-19.19 Only a minority of
patients (18.3%) were concerned about visiting the oncologist or
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contracting COVID-19 from the hospital (17.5%). Many patients,
however, had high level anxiety that the disruption and uncertainty
resulting from the COVID-19 pandemic would lead to change of
planned cancer treatment. In response to the concerns expressed
by national gynecological cancer charities, the British Gynaecolog-
ical Cancer Society produced a framework of care for women with
gynecological cancer. This document outlines in lay terms recom-
mendations for the treatment of gynecological cancer during the
COVID-19 pandemic.19 20
Minimally invasive surgery
Minimally invasive surgery (either laparoscopic or robotic) is
associated with a reduced inpatient stay, reduced blood loss, and
enhanced recovery, which may be particularly beneficial in patients
with high body mass index.21 During the acquired immuno-­
deficiency syndrome (AIDS) epidemic in the 1990s, laparoscopic
surgery was strongly encouraged over open surgery in patients
infected with human immuno-­ deficiency virus (HIV).22 Despite
this, the theoretical risk exists, with previous studies showing acti-
vated Corynebacterium,23 papillomavirus,24–27 and HIV28 detected
in surgical smoke and four proven cases of occupational expo-
sure and subsequent laryngeal infection by human papillomavirus
(HPV).25–27 Currently, limited data on SARS-­COV-2 suggest that the
risk of transmission from laparoscopic gynecological procedures
not involving the gastrointestinal tract is very low.7 29 Working
with minimal staff and adopting safe distancing recommenda-
tions is feasible with minimally invasive surgery compared with
open surgery. Where it is practicable and within the scope of the
department and individual surgeon’s experience, minimally inva-
sive surgery should be considered due to the benefits of shortened
3
Review

Table 2  Surgery: ovarian cancer
1b7 or High62
Mechanical intestinal obstruction/
impending perforation where lines of life-­
prolonging treatment exist.7
Pelvic mass with torsion or causing
urinary or intestinal obstruction35
27 or Medium62
Malignant germ cell tumors in young patients
should take priority. Complete staging
procedure should be performed with nodal
evaluation.49
Image-­guided/diagnostic laparoscopy for tissue
biopsy/assess operability if high suspicion of
cancer35
Elective surgery with the expectation of cure
to be performed within 4 weeks to save a
life/prevent progression of disease beyond
operability
Priority-­based on:
►► Urgency of symptoms
►► Complications
►► Expected growth rate
Primary debulking surgery for ovarian cancer,
particularly cell types unlikely to respond to
neoadjuvant chemotherapy (low grade serous,
clear cell, or mucinous)16 35
Presumed early-­stage ovarian cancer based on
adnexectomy: completion/staging surgery may
be deferred for 1–2 months15
Ovarian mass with adverse features but
normal tumor markers: ideally operated on
within 4 weeks but could be delayed following
multidisciplinary tumor board discussion16
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3 or Low62
Interval debulking surgery
Secondary surgery in recurrent ovarian cancer:
patients should be managed with chemotherapy
unless surgery would relieve symptoms7
Pelvic masses following multidisciplinary
tumor board discussion, including using MRI/
International Ovarian Tumor Analysis ultrasound/
Risk of Malignancy Index to decide on the
likelihood of malignancy:
►► Thought to be benign: can defer surgery for
3–6 months
►► Risk of Malignancy Index <200: consider
virtual clinic appointments and follow-­up
during the pandemic period7
Risk-­reducing surgery for genetic predisposition35

hospital stay and improved recovery, potentially reducing exposure ►► Surgical patients should be screened pre-­ operatively for
to nosocomial infection with SARS-­COV-2. SARS-­COV-2

There are practical safety considerations that apply to minimally
invasive surgery, but some of the recommendations also apply to
surgery in general. These are listed below:
►► Full personal protection equipment, including Filtering Face
Piece-3/N-95 masks, shoe covers, impermeable gowns,
protective head covering, gloves, and eye protection to be worn
in theater at all times.30–32
►► Aim to reduce smoke/plume production:
–– Low power settings
–– Reduce desiccation time
–– Avoid ultrasonic dissectors and advanced bipolar devices as
these can lead to particle aerosolization30
–– Closed smoke evacuation/filtration system with ultra-­ low
particulate air filtration capability33
–– Various low-­ cost locally available smoke evacuation de-
vices using high efficiency particulate air filters have been
described from developing countries34
–– Reduce venting of the pneumoperitoneum into the room;
laparoscopic suction may be used to remove smoke and
deflate the abdominal cavity prior to removing specimens
through the vagina
►► Use low intra-­abdominal pressure 10–12 mmHg
►► Avoid rapid desufflation, particularly when removing speci-
mens or instruments
►► Aim for tissue extraction with minimal carbon dioxide escape.
Desufflate with closed smoke evacuation filtration system prior
to extraction
►► Minimize blood/fluid droplet spray or spread
►► Minimize leakage of carbon dioxide from trocars. Check seals
in reusable trocars32
copyright.
►► If needed and possible, intubation and extubation should take
place within a negative pressure room30
With departmental support and improved efficiency, a move
towards same-­day discharge can be made for many gynecolog-
ical oncology procedures.35 Minimally invasive surgery is suited
to the surgical management of early-­stage endometrial cancer
and remains the gold standard of care.15 Robotics may be used
for urgent complex procedures that might be less feasible with
conventional laparoscopy.31 36
Oncological treatment guidelines
Many of the recommendations listed above relating to surgical
procedures also apply to oncological treatments. Outpatient
follow-­up has been changed in many hospitals to telephone and
video consultations or patient initiated follow-­up37; non-­essential
follow-­up has been stopped, and other procedures such as blood
tests are done locally or using a drive-­ through service.9 Oral
medication is delivered home and hospital visits are minimized.
Appointments are scheduled so few patients are waiting in the
waiting rooms, and patients who are due to start immunosuppres-
sive chemotherapy and are suspected of having COVID are offered
screening. In hospitals with walk-­in appointments, safe distancing
and preventative COVID-19 etiquette are followed.11 38 Decisions
regarding treatment are usually made by a multidisciplinary team
and steps are taken to modify the chemotherapy regimen by using
growth factors or shortening the length of chemotherapy.7 10 12 39
Chemotherapy
In situations where capacity is severely limited, the following guide-
lines apply12 14:

4 Uwins C, et al. Int J Gynecol Cancer 2020;0:1–10. doi:10.1136/ijgc-2020-001634

 Review

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Table 3  Chemotherapy: ovarian cancer
High62 Medium62 Low62
For advanced ovarian cancer, neoadjuvant chemotherapy may Chemotherapy for Chemotherapy for non-­serous, non-­
be preferred to primary cytoreductive surgery and be effective in platinum-­sensitive relapse endometrioid ovarian cancers and low-­
delaying surgery and inpatient hospitalization7 14–16 Interval surgery should be considered for grade cancers offers limited benefit and
may then follow if local capacity permits, or in some centers clinicians symptomatic patients and adjuvant chemotherapy in these patients
may consider continuing to six cycles to delay surgery7 15 51 delayed where possible for is of lower priority Consider hormonal
Patients should undergo at least two new cycles of chemotherapy asymptomatic patients7 16 therapy (letrozole, anastrozole, tamoxifen)7
after their surgery.15 8

Test for Breast Cancer Antigen (BRCA) mutations, germline and Maintenance bevacizumab used with
somatic so that patients may access poly ADP ribose polymerase caution as it has low survival benefit and
inhibitors may be associated with a higher risk of
Poly ADP ribose polymerase inhibitors should be started at the end bowel perforation7
of chemotherapy, if possible, patients may access Poly ADP ribose Following up-­front adjuvant
polymerase inhibitors before the opportunity for surgery arises7 16 chemotherapy; consideration may be
Consider the routine use of Filgrastim (granulocyte colony stimulating given to oral maintenance therapy, such
factor) to reduce the incidence of neutropenia in patients receiving as PARPi, as maintenance intravenous
combination therapy7 therapy requires repeated visits to the
Malignant germ cell tumors high priority if requiring chemotherapy49 hospital51,16

►► Priority to high-­ grade disease (including ovarian cancer,
sarcomas, gestational trophoblastic neoplasia, and type II
endometrial cancers). Recurrent cancer patients with symp-
toms needing urgent treatment or end of life discussion14
►► Where possible, chemotherapy for platinum-­sensitive relapse
should be considered for symptomatic patients and delayed, if
possible, for patients without symptoms or with small-­volume
disease unlikely to lead to significant pathophysiological
complications in the next 3 months
►► Utilization of chemotherapy regimens that will avoid frequent
a decision should be made together with patients, counseling about
the risks of delaying chemotherapy versus the risks of developing
COVID-19 while on treatment.
Radiotherapy
Prioritization for radiotherapy patients is based on principles similar
to those in chemotherapy patients. Curative radiotherapy should
be prioritized over adjuvant therapy for local disease control.
Where adjuvant radiotherapy is likely to reduce local recurrence
but not prolong survival, radiotherapy may be withheld following

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patient visits careful consideration and counseling.7 17 The recommendations are
►► For patients with metastatic disease, treatment delays may lead summarized below12 40 41:
to worsening performance status; however, chemotherapy for
Priority level 1
a platinum-­resistant disease would be of low priority, particu-
Rapidly growing tumors12 40
larly in the absence of symptoms; consideration should include
►► Curative intent chemoradiotherapy
how such delays may lead to admission for symptom palliation,
►► Treatment already underway—external beam radiotherapy and
which further stresses inpatient resources.10 Alternative strate-
brachytherapy combined treatment plan
gies to manage symptoms should be considered
For patients found to be COVID-19-­positive, do not start chemo- Priority level 2
therapy until their symptoms resolve±they test negative (depending Urgent palliative radiotherapy12 40
on resources).16 Advance care planning discussions should be
documented during discussions with patients. This should include Priority level 3
goals of care and end-­of-­life care.36 When chemotherapy is offered, Less aggressive tumors12 40

Table 4  Surgery, chemotherapy and radiotherapy: endometrial cancer

1b7or High63 263or Medium7 363or Low7
Surgery
7 63 7 7
►► Hemorrhage ►► High-­risk or high-­grade disease ►► Low-­grade, early stage
63 63
►► Peritonitis ►► Uterus confined disease ►► Risk-­reducing surgery in genetically
63
►► Radiotherapy complications ►► Grade 3 endometrioid/grade 2 p53 predisposed63
►► (Fistula/perforation) mutated/serous/carcinosarcoma/ ►► Complex atypical hyperplasia not
►► Post-­operative bleeding/ureteric undifferentiated/clear cell16 controlled with hormonal therapy63
injury63 ►► Known/suspicion of high-­grade uterine ►► Repair of asymptomatic fistula
63

►► Hydatiform mole curettage or sarcoma16 ►► Resection of slow growing central

hysterectomy64 recurrence63
Chemotherapy and radiotherapy
  ►► Adjuvant treatment after curative intent  
surgery

Uwins C, et al. Int J Gynecol Cancer 2020;0:1–10. doi:10.1136/ijgc-2020-001634 5

Review
►► Radiotherapy is the first-­line definitive treatment
►► Post-­operative radiotherapy in known residual disease
following surgery for rapidly growing tumors
Priority level 4
Palliative radiotherapy to reduce the burden on the healthcare
service12 40
Priority level 5
Adjuvant radiotherapy following complete resection of disease
(<20% risk of recurrence at 10 years)12 40 42
Other measures
►► Using biologically equivalent hypofractionated schedule to
reduce hospital visits
43
►► Brachytherapy services to be continued as a priority
►► Personal protection equipment use during administration of
radiotherapy42 43
44
►► 'Clean' radiotherapy teams working on rotation basis
Clinical trials
During the pandemic, recruitment to clinical trials has suffered.
Many countries have put recruitment on hold and have prioritized
COVID-19 research. Overarching principles that apply to all patients
on a clinical trial are listed below:
►► The safety of patients in a clinical trial is of paramount
importance
►► Telephone/video consultation should be utilized to monitor trial
patients
►► Home delivery of medicines should be considered
►► Evaluate enrollment and treatment on clinical trials based on
the availability of clinical and research support. Second opin-
ions may be accomplished with the use of telemedicine as
resources allow45–48
►► Consider the COVID-19 burden and ability to enroll new patients
on trial (safety, staffing resources including clinical trial nurses,
data managers, and regulatory staff)49
Clinical trials have been suspended in some centers while contin-
uing in others, based on the severity of the pandemic and available
resources. This forced variation in trial implementation may create
imbalances in patient cohorts, especially in multi-­center trials,
potentially leading to bias that may affect the outcome of these
trials.50
Ovarian cancer
The diagnostic pathway in advanced ovarian cancer has changed
in some centers as access to radiologically-­guided tissue biopsies
is limited, especially in centers where the numbers of COVID-19-­
positive patients are high. As a consequence, some centers have
had to rely on ‘cytology alone’/cell block of cytology to confirm a
diagnosis of advanced ovarian malignancy prior to commencing
chemotherapy.7 51 Table  2 shows the surgical priorities adopted
by many gynecological cancer surgery groups according to the
urgency of the operation.
Similar priority tables and guiding principles have been set up for
chemotherapy patients. This will vary depending on local capacity.
Table  3 shows recommended prioritization for chemotherapy for
ovarian cancer. Some of the recommendations relate to changing
intravenous maintenance treatment to oral treatments. As an
6 Uwins C, et al. Int J Gynecol Cancer 2020;0:1–10. doi:10.1136/ijgc-2020-001634
Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001634 on 23 June 2020. Downloaded from http://ijgc.bmj.com/ on January 28, 2022 at India:BMJ-PG Sponsored. Protected by
example, some guidelines prioritize Poly ADP ribose polymerase
inhibitors over bevacizumab as these can be given safely once the
correct dose is established. Most patients require monitoring for
the first 2–3 months as bone marrow suppression is commonly
seen; after that period most centers monitor blood tests every 1–2
months and the need for frequent visits can be safely reduced.7 17
Hyperthermic intra-­peritoneal chemotherapy is strongly discour-
aged.15 16
Endometrial cancer
Surgical, chemotherapy, and radiotherapy prioritization is summa-
rized in Table 4.
In cases where capacity does allow, standard management
should continue.
In early-­stage disease, delay methods such as using the
levonorgestrel-­ releasing intra-­
uterine system or oral progester-
ones49 may be used. In advanced stage or recurrent disease, the
following options can be considered:
►► Megestrol/megestrol alternating with tamoxifen (endometroid
histology/estrogen, progesterone receptor positive); oral
everolimus/letrozole49
15 51
►► Neoadjuvant chemotherapy
Similarly, in stage IV disease in asymptomatic patients, treatment
may be delayed.49
Options of treatment need to be carefully discussed with patients
and adjusted to the risk group as outlined below:
Low risk
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Grade 1: Hormonal therapy51 or defer surgery for 1–2 months
(grade 1–2 stage 1A, MRI confirmed)15
High risk
Grade 2/3: hysterectomy and bilateral salpingo-­
oophorectomy±sentinel lymph node assessment if available.
In patients who are high anesthetic risk, consider radiotherapy
instead of surgery.17 52
Gestational trophoblastic neoplasia
Trophoblastic tumors are considered curable but have a high meta-
static potential. These patients should be treated without delay.
Patients with low-­risk trophoblastic tumors can be treated with meth-
otrexate at home.15 Patients with high-­risk tumors should be adminis-
tered multi-­drug regimens without delay15 (chemotherapy with cura-
tive intent).16 Conventional curettage should be offered as it is both
a diagnostic as well as a therapeutic procedure (~40% of patients
subsequently do not require chemotherapy).14 35 Hysterectomy may
be offered, especially if childbearing is not desired.16 35 Patients with
high-­risk disease should be offered inpatient multi-­drug regimens.
Pre-invasive cervical disease
Recommendations from the guidelines on the management of pre-­
invasive cervical lesions are outlined in Figure 1 .7 16 17 51 53–58
Cervical cancer
Despite the unique challenges that this pandemic puts on diag-
nostic and surgical services, it is imperative that centers can
perform surgery with curative intent for early-­stage disease. Table 5
summarizes suggested prioritization for surgery and Table  6 for
chemotherapy and radiotherapy.
 Review

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Figure 1  Pre-­invasive cervical lesions.

Brachytherapy is an essential component of the treatment for
cervical cancer, with poorer outcomes resulting when it is not used.
Brachytherapy should be prioritized whenever possible.17 41
Vaginal cancer
Most patients with vaginal cancer present at an advanced
stage. Treatment is based around radiotherapy/chemotherapy/
brachytherapy treatment. The added benefit of lymph node staging
will be patient-­dependent based on disease stage, location, and
results of imaging investigations.15 For the majority of cases, prior-
itization of treatment of vaginal cancer is as for cervical cancer.
Vulvar cancer
If all surgery, including cancer surgery, is suspended or a patient
is not suitable for surgery, radical radiotherapy with concurrent
chemotherapy is the treatment of choice. Chemotherapy may be
omitted for elderly patients or those with co-­morbidities .41
copyright.
Discussion
Restrictions imposed during lockdown,59 including advice over
social distancing and self-­isolation, have reduced access to health-
care services. Many of the guidelines focus on limiting patient and
staff interactions by limiting the number and length of clinical visits,
and thus limiting exposure. Delays and non-­standard treatment
pathways will undoubtedly be resorted to. Delays could be detri-
mental to patients' health and, in the worst cases, lead to wors-
ening performance and missing the treatment window.10
Multidisciplinary team outcomes should document what the
standard of care is and how it has been modified due to the
COVID-19 pandemic. When surgery is offered, a decision should be
made together with patients, counseling about the risks of delaying
surgery versus the risks of increased mortality and morbidity from
developing COVID-19 peri-­operatively in hospital. A supplementary
consent form describing the increased mortality and morbidity

Table 5  Surgery: cervical cancer

1b7or High56
►► Life-­threatening hemorrhage with ►► Early-­stage (unspecified)7 51
failed conservative measures,
especially surgery likely
curative7 56
►► Peritonitis56
►► Radiotherapy complications56
(fistula/perforation)
►► Post-­operative bleeding/ureteric
injury56
27or Medium56 37or Low56
►► Low volume cervical cancer
►► Stage 1A, 1B1–IIA: radical hysterectomy ± bilateral completely excised at loop
salpingo-­oophorectomy + lymphadenectomy (level excision7
not specified)51 56 ►► Cervical intra-­epithelial neoplasia 3
►► Stage 1A: trachelectomy/hysterectomy ± sentinel conisation56
lymph node sampling (postpone 2 months)51 56 ►► Repair of asymptomatic fistula56
►► Resection of slow growing central
recurrence56
►► Pelvic exenteration (consider
postponing)56

Uwins C, et al. Int J Gynecol Cancer 2020;0:1–10. doi:10.1136/ijgc-2020-001634 7

Review

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Table 6  Chemotherapy and radiotherapy: cervical cancer
High56 Medium56 Low56
Chemotherapy
►► Part of concurrent chemo-­ ►► Continuation of standard chemo-­ ►► First recurrence with good
radiotherapy7 15 49 radiotherapy, with proven benefit56 performance status or advanced
►► Stage IB3, IIB-­IVA: ►► Consider neoadjuvant chemotherapy previous untreated disease (Priority
chemo-­radiotherapy56 for patients with visible tumor49 51 4*)7
7 49
►► Stage IVB: first line, first central ►► Metastatic disease (Priority 6†)
recurrence, >12 months disease-­free56
Radiotherapy: cervical cancer
High15 Medium15 Low15
7 15 49 56 7
►► Part of chemo-­radiotherapy ‡ ►► Haemostatic radiotherapy ►► As adjuvant therapy in positive
►► Salvage radiotherapy for symptomatic surgical margins7
56
local recurrence ►► Palliation for unresectable,
asymptomatic recurrence
*Curative therapy with a low (0%–15%) chance of success or non-­curative therapy with an intermediate (15%–50%) chance of >1 year life
extension.
†Non-­curative therapy with an intermediate (15%–50%) chance of palliation/temporary tumor control and <1 year life extension.
‡Patients with Royal College of Radiologists category 1 tumors currently being treated with chemo-­radiotherapy and brachytherapy for
category 1 tumors on external beam radiotherapy.

associated with COVID-19 disease around the time of cancer treat-
ment, along with the option of deferring surgery or non-­surgical
treatments, can be used in addition to the usual consent form.
The potential of worsening survival if treatment is delayed should
be outlined to patients.7 The options of deferring surgery or non-­
surgical treatments should be included and clearly documented
SARS-­CoV-2 infection: an international cohort study. Lancet 2020.
doi:10.1016/S0140-6736(20)31182-X. [Epub ahead of print: 29 May
2020].
4 CovidSurg Collaborative, Nepogodiev D, Bhangu A. Elective surgery
cancellations due to the COVID-19 pandemic: global predictive
modelling to inform surgical recovery plans. Br J Surg 2020.
doi:10.1002/bjs.11746. [Epub ahead of print: 12 May 2020].
5 COVIDSurg Collaborative. CovidSurg Cancer/CovidSurg-­Cancer

during the informed consent process.7 14
Twitter Geetu Prakash Bhandoria @Bhandoria
Contributors  Study concepts and design: SS, GPB, CU. Data acquisition: CU, GPB.
Manuscript preparation: All authors. Manuscript editing: All authors. All authors read
and approved the final manuscript.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  SB-­M: Proctor for Intuitive Surgical and Plasma Surgical
and Ethicon. JC: Occasionally gives paid lectures on behalf of pharmaceutical
companies. AS: Honorarium from Elekta. AM: Educational grants from Clovis, GSK,
Ipsen, Novartis, Pfizer, and Tesaro.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
This article is made freely available for use in accordance with BMJ’s website
terms and conditions for the duration of the covid-19 pandemic or until otherwise
determined by BMJ. You may use, download and print the article for any lawful,
non-­commercial purpose (including text and data mining) provided that all
copyright notices and trade marks are retained.
ORCID iD
Geetu Prakash Bhandoria http://​orcid.​org/​0000-​0002-​6865-​7856
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