Management of cervical cancer during the corona virus disease-19 (COVID-19) era

Abstract

COVID-19 pandemic has had a catastrophic impact on the society, economy and heath-care system all over the globe with virus showing no signs of losing potency. As the situation appears to worsen, extra burden on other specialities like oncology seems to increase. Specific recommendations are necessary for management of cervical cancer in the current context. All concerned specialities must work together in the best interest of the patient. Attempts should be made at managing cervical cancer while limiting the viral spread among the patients and health-care workers without the loss of opportunity. Surgical intervention for early cervical cancer should be postponed or alternative modalities be considered. In a locally advanced disease, concurrent chemoradiation is the treatment of choice. In addition, the following under mentioned suggestions aim to discuss ways of minimizing infection spread, workload rationalization and providing guidance for management of cervical cancer in the presence of COVID-19 infection.

Radiotherapy based management during Covid-19 pandemic – A systematic review of presented consensus and guidelines

“…for node-negative) ( Guidance for radiotherapy for gynaecological cancer and COVID-19 [Online], 2021 ) Pre-invasive, early-stage, locally-advanced disease: Hypo-F RT ( Ramirez, 2020 ) Reduction of chemotherapy dose, plus RT or RT alone. Intact cervix: - Definitive RT (40 - 50 Gy) - IMRT or SBRT boost ( Parashar et al, 2020 ) RT and cCRT (substitute surgery) ( Vordermark, 2020a ) Up to 8–12 weeks: - Inoperable cases or refuse surgery (Stage IA1, IA2) - Postop (Stage IA1-IB2) with indication for adjuvant RT - Postop cases with positive pelvic (or PA nodes), surgical margins, or parametria (CRT) - Metastatic disease with annoyance oral pain or minimum bleeding (palliative RT) Locally advanced Inoperable cases (Stage IB3-IVA or Stage IB1-IIA1) Extreme bleeding secondary to cervical cancer ( Elledge et al, 2020 ) Locally advanced: standard fractionation (46-50 Gy) followed by brachytherapy (HDR) ( Amaoui et al, 2020 ) Not to change or postpone the fractionation ( Starling et al, 1992 ) Adjuvant therapy:12 weeks for adjuvant RT and 8 weeks for adjuvant CRT) Early-stage disease: Radical CRT (prolonged delay of surgery >8 weeks) Local symptomatic central or para-aortic recurrence: Salvage RT Locally advanced disease ((IB3-IVA) - Hypo-F RT (39 Gy/13frs or 39–40 Gy at > 2.5 Gy per fraction in combination with concurrent chemotherapy) -IMRT: 40 Gy/15 frs to the whole with 48 Gy/15frs SIB to enlarged nodes ( Dewan et al, 2021 ) Postop status - the intermediate risk of recurrence: (cC)RT (up to 8 weeks after surgery) Stage IB1, IB2, and IIA1: Neoadjuvant RT Postop status - high risk of recurrence: cCRT Stage IB3 and IIA2: Hypo-F RT Locally advanced (IIB–IVA): Hypo-F cCRT Cervical stump recurrence: RT Local recurrence within pelvis: cCRT Pelvic sidewall recurrence: RT ( Lee et al, 2020b ) Patients with suspected or confirmed COVID-19 (until COVID-19 is cured) Adjuvant RT: postponed within 12 weeks after surgery ...…”

Quality of Life of People with Cancer in the Era of the COVID-19 Pandemic in India: A Systematic Review

“…Included studies were conducted by New Delhi (n=4) [ 12 , 15 - 17 ], followed by other tertiary cancer care institutions (n=2) [ 13 , 14 ] in India. The majority of the studies were review articles [ 13 , 16 ], followed by observational studies [ 14 , 15 ], editorial articles [ 12 ], and guidelines by IAPC [ 17 ]. Most of the included studies were conducted on either cancer patients [ 12 , 13 , 15 , 16 ], advanced cancer patients [ 17 ], or health care workers [ 14 ].…”

“…A study conducted among cervical cancer patients showed that each oncologist followed a “Do No Harm” approach during the treatment of cancer patients. During cancer service delivery, oncologists try to minimize the risk of infection by adopting a holistic approach for the therapy and diagnosis of cancer patients in India [ 16 ].…”

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

“…In very early disease with size less than 2 cm, simple procedures like conization or trachelectomy with or without sentinel lymphadenectomy and neoadjuvant chemotherapy (NACT) can also be considered. 41 In a tertiary care center from New Delhi involving 12 new cases of cervical cancer and 79 follow up cases managed over 4 months during the pandemic, it was seen that there was no morbidity or mortality and the median hospitalization duration was 5 days among the new cases managed by open radical hysterectomy. The COVID infection rate among healthcare personnel during the study duration was only around 3%.…”

“…Considerations for management of preinvasive cervical cancer by Dewan et al suggest that low grade lesions can be followed up after 6 to 12 months, whereas high grade lesions require further evaluation and treatment within 3 months. 41 …”