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ESMO management and treatment adapted recommendations in the COVID-19 era: Cervical cancer

The tiered approach of ESMO in delivering a guidance for cancer patients during the COVID-19 pandemic is designed across three levels of priorities, namely: tier 1 (high priority intervention), 2 (medium priority) and 3 (low priority) – defined according to the criteria of the Cancer Care Ontario, Huntsman Cancer Institute and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS), incorporating the information on the value-based prioritisation and clinical cogency of the interventions

  • High priority: Patient's condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g. significant overall survival [OS] gain and/or substantial improvement in quality of life [QoL]);
  • Medium priority: Patient's situation is non-critical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority;
  • Low priority: Patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is non-priority based on the magnitude of benefit (e.g. no survival gain with no change nor reduced QoL).

 

Priorities for cervical cancer

Documented multidisciplinary tumour team (MDT) decision making, taking into account patient condition (vulnerable patients)* and available resources [Intensive Care Unit (ICU) support for surgery]. If not adequate, refer to or discuss with an Oncological Hub for gynaecological cancers.

Patients and family should be adequately informed about the risk/benefit ratio of each intervention with clinicians taking into account of national therapeutic or interventional guidelines or national specialty recommendations in relation to COVID-19.

*vulnerable patients: >65 years, pre-existing cardiovascular disease, pre-existing respiratory disease

Outpatient visit priorities

High Priority

  • Potentially unstable (acute abdominal symptoms, complications in the post-surgery recovery, complications during/after pelvic radiotherapy, renal obstruction)
  • Symptomatic persistent severe bleeding from pelvic/vaginal ulcerated tumour
  • Anuria, symptoms of DVT in patients with confirmed diagnosis of cervical cancer
  • New histologically confirmed patient, no prior surgery, for staging workup (blood tests and imaging close to home if possible)

Medium Priority

  • Post-operative patients with no complications
  • Established patients with new problems or symptoms from treatment – convert as many visits as possible to telemedicine appointments
  • Follow-up visit (clinical and pelvic examination) after palliative treatment for advanced/recurrent disease (postpone up to 2 months)

 Low Priority

  • Follow-up visit (clinical and pelvic examination) after radical treatment for early disease (postpone up to 6 months)
  • Survivorship visits off study

Priorities for cervical cancer: Imaging (CT scan/US)

High Priority

  • Bowel perforation, peritonitis
  • Post-surgery complications (perforation, anastomotic leak)
  • Ureteral compression or hydronephrosis
  • Neurological symptoms suggesting nerve root/spinal involvement
  • Staging workup (if not done)

Medium Priority

  • Tumour evaluation if clinical suspicion of tumour recurrence after radical treatment for early disease
  • Follow-up visit (with also clinical and pelvic examination) after palliative treatment for advanced/recurrent disease (postpone up to 2 months)
  • Follow-up visits within a clinical study

 Low Priority

  • Follow-up visits out of study (blood tests and imaging close to home, convert to telemedicine if possible)

For patients on clinical trials, seek information about changes in management for individual studies from the co-ordinating trials unit – treatment frequency, blood investigations and imaging

Priorities for cervical cancer: Surgical oncology

High Priority

  • Radiologically confirmed bowel perforation, peritonitis
  • Complications during/after radiotherapy for pelvic recurrence (fistulisation/bowel perforation)
  • Acute post-surgery complications (perforation, ureteral dissection)

Medium Priority

  • Radical hysterectomy +/- BSO and lymphadenectomy stage IA2, IB1-IIA
  • Trachelectomy(hysterectomy) +/- SLN sampling stage IA (postpone up to 2 months)

 Low Priority

  • Repair of asymptomatic fistula
  • CIN3 conisation (if appropriate)
  • Resection of slowly growing central recurrence
  • Consider postponing total pelvic exenteration after the COVID-19 pandemic

Priorities for cervical cancer: Medical oncology

High Priority

  • Continuation of medical treatment in the context of a clinical trial
  • Stage IB3*, IIB-IVA chemotherapy in association with radiotherapy (CRT)
  • Stage IVB first line, first local recurrence after >12 months from primary CRT: cisplatin/paclitaxel + bevacizumab (if not contraindicated). When cisplatin is contraindicated, consider carboplatin/paclitaxel or topotecan/paclitaxel with bevacizumab

Medium Priority

  • Continuation of standard chemotherapy in case of confirmed significant benefit

 Low Priority

  • Second-line chemotherapy according to clinical need, patient wishes and resource availability

*2018 FIGO classification.

Immune checkpoint inhibitors only within clinical studies.

Priorities for cervical cancer: Radiation oncology

High Priority

  • Pelvic EBRT in association with chemotherapy (CRT) stage IB3, IIB-IVA
  • Spinal cord compression, brain metastases, other critical metastatic lesions

Medium Priority

  • Salvage radiotherapy for symptomatic localised recurrence (central, retroperitoneal lymph nodes)

 Low Priority

  • Palliative radiotherapy for asymptomatic recurrence not amenable to surgery

Immune checkpoint inhibitors only within clinical studies.

 

List of abbreviations: BSO, bilateral salpingo-oophorectomy; CRT, chemoradiotherapy; CT, computed tomography; DVT, deep vein thrombosis; EBRT, external beam radiotherapy; SLN, sentinel lymph node; US, ultrasound.

 

References

NHS Clinical guide for the management of non-coronavirus patients requiring acute treatment: Cancer 23 March 2020, Version 2. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty-guide-acute-treatment-cancer-23-march-2020.pdf (31 March 2020, date last accessed)

BGCS framework for care of patients with gynaecological cancer during the COVID-19 Pandemic (Final. 22/03/2020). https://www.bgcs.org.uk/wp-content/uploads/2020/03/BGCS-covid-guidance-v1.-22.03.2020.pdf (31 March 2020, date last accessed)

SGO surgical considerations for gynecologic oncologists during the COVID-19 pandemic (March 27, 2020). https://www.sgo.org/clinical-practice/management/covid-19-resources-for-health-care-practitioners/surgical-considerations-for-gynecologic-oncologists-during-the-covid-19-pandemic/ (31 March 2020, date last accessed)

Ramirez et al: COVID-19 Global pandemic: options for managements of gynaecologic cancers. Int J Gynecol Cancer 2020; 1-3.

Marth C., Landoni F., Mahner S., McCormack M., Gonzalez-Martin A. and Colombo N: Cervical Cancer: ESMO clinical practice guidelines. Ann Oncol 2017, 28 (suppl 4): iv72-iv83.

ESGO-ESTRO-ESP Guidelines for the Management of Patients with Cervical Cancer, 2017.  https://guidelines.esgo.org/media/2018/04/Cervical-cancer-Guidelines-Complete-report.pdf (9 April 2020, date last accessed)

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