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ESMO management and treatment adapted recommendations in the COVID-19 era: Endometrial 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 endometrial 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 cost/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 pain, complications in the post-surgery recovery, complications during/after pelvic radiotherapy)
  • Systematic persistent severe bleeding from primary/recurrent tumour
  • Anuria, symptoms of DVT/pulmonary embolism in patients with a confirmed diagnosis of endometrial cancer

Medium Priority

  • Investigations for post-menopausal bleeding (US, hysteroscopy)
  • Post-operative patients with no complications requiring adjuvant treatment
  • Established patients with new problems or symptoms from treatment (convert as many visits as possible to telemedicine visits)
  • Follow-up visits in the context of a clinical trial

 Low Priority

  • Fertility-preserving therapy in premalignant disease (AH) or EIN
  • Follow-up in high-risk patients after primary treatment (clinical and pelvic exam) (postpone up to a maximum of 6 months in the absence of symptoms)
  • Follow-up in intermediate-low-risk patients: convert to telemedicine
  • Slowly growing asymptomatic vaginal/central recurrence

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

High Priority

  • Bowel perforation, peritonitis
  • Post-surgery complications (e.g. perforation, anastomotic leak, pulmonary embolism, abscess, haemorrhage)
  • Ureteral compression/dislocation with dilatation/hydronephrosis
  • Completion of staging work-up (i.e. CT scan)

Medium Priority

  • Tumour evaluation if clinical suspicion of tumour recurrence afterradical treatment
  • Follow-up visit (with also clinical and pelvic examination) after palliative treatment for advanced/ recurrent disease (postpone up to 2 months)
  • Follow-up visits in the context of a clinical trial
  • Follow-up visits in the context of fertility-sparing treatment of low-risk endometrial cancer

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 coordinating trials unit for treatment frequency, blood investigations and imaging

 Priorities for endometrial cancer: Surgical oncology

High Priority

  • Uterine/pelvic haemorrhage
  • Radiologically confirmed peritonitis
  • Complication during/after radiotherapy for primary tumour/pelvic recurrence (e.g. fistulisation/bowel perforation)
  • Acute post-surgery complications (e.g. perforation/ureteral dissection, bleeding)

Medium Priority

  • Hysterectomy (+/-BSO) + SLN sampling/lymphadenectomy in newly diagnosed endometrial cancer apparently confined to the uterus

Low Priority

  • Risk-reducing surgery for genetic predisposition to endometrial cancer
  • AH/EIN not controlled with hormonal therapy
  • Reparation of asymptomatic fistula
  • Resection of slowly growing central recurrence

Priorities for endometrial cancer: Medical oncology 

High Priority

  • ChT in previously untreated symptomatic metastatic/recurrent disease not sensitive to HT
  • Continuation of medical treatment in the context of a clinical trial
  • ChT +/- radiotherapy post-surgery in high-risk patients

Medium Priority

  • Metastatic/recurrent disease slowly growing potentially hormone-sensitive (HT) (gr1-2, hormone receptors-positive)

Low Priority

  • Second line ChT in patients not suitable for HT 

 Priorities for endometrial cancer: Radiotherapy 

High Priority

  • EBRT +/- chemotherapy post-surgery in high-risk patients
  • Radiotherapy for symptomatic unresectable primary tumour not suitable for surgery

Medium Priority

  • Brachytherapy in intermediate-high risk
  • Radiotherapy with curative intent for isolated vaginal relapse after surgery

Low Priority

  • Radiotherapy for asymptomatic vaginal/pelvic recurrence

  

List of abbreviations: AH, atypical hyperplasia; BSO, bilateral salpingo-oophorectomy; ChT, chemotherapy; CT, computed tomography; DVT, deep vein thrombosis; EBRT, external beam radiotherapy; EIN, endometrial intraepithelial neoplasia; HT, hormone therapy; SLN, sentinel lymph node; US, ultrasound.

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