COVID-19 pandemic impact on gynaecological cancers: a perspective.

Editor

On 11 March 2020, the Director-General of the WHO declared that COVID-19 had reached pandemic proportions. COVID-19 has spread to much of the world, with over three million cases and more than 200 000 deaths now recorded globally[1,2]. Many countries have locked down, advising social distancing and self-isolation, resulting in reduced access to healthcare, either perceived or real. Benign elective surgery has ceased entirely in many areas, to release theatre and anaesthetic staff and resources for the care of patients with COVID-19. The recent global collaborative initiative ‘COVIDSurg-Cancer’ aims to review the care of patients planned for curative cancer surgery during the COVID-19 pandemic and the impact of the pandemic on delaying or changing their treatment plans.

Lockdown restrictions have reduced access to healthcare services, with increasing difficulty accessing general practitioners and diagnostics services, and delays in patients receiving timely care. Women with early-stage gynaecological malignancies are potentially cured by their surgery; in contrast, advanced stage disease can be resistant to systemic therapy with poor outcomes. Delays can have considerable detrimental physical and mental as well as social repercussions. Cancer surgery is urgent and needs to be considered as such or we will see further needless deaths due to cancer added to the COVID-19 death toll.

A recent report from Norway has found ‘abdominal pain’ as a possible feature of COVID-19 infection. Abdominal pain is also part of the symptom complex of most gynecological cancers, especially uterus and ovary. Concerns have been raised regarding minimally invasive surgery during the COVID-19 pandemic due to the potential for transmission via surgical smoke. The evidence supporting this is weak. Minimally invasive surgery (either laparoscopic or robotic) is associated with reduced length of stay, reduced need for intensive care support, reduced blood loss and enhanced recovery. This is key at a time when we are trying to reduce hospital exposure for our patients, both to protect them and to maintain capacity for the care of COVID-19 patients. Patients with raised BMI (a known risk factor for endometrial cancer) and the elderly often have most to gain from a minimally invasive surgical approach and are some of those identified as being most at risk from COVID-19. Switching these patients to open surgery will likely worsen surgical outcomes and increase potential exposure to COVID-19 in the postoperative period. Cancer guidelines are being modified and prioritized due to the restrictions imposed on us. If this ultimately results in a large-scale delay in treating low-risk/low-stage malignancies or increased use of chemoradiotherapy (cervical cancer)/prolonging neoadjuvant chemotherapy (ovarian cancer), we may soon be facing a second mortality and morbidity peak.

We are currently in the midst of a delicate balancing act of protecting our patients from COVID-19 and providing timely treatment of their cancer. We can only hope to do the best for our patients with the resources available to us.