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      COVID-19 and gynecological cancer: a review of the published guidelines

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          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.

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          Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China

          China and the rest of the world are experiencing an outbreak of a novel betacoronavirus known as severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). 1 By Feb 12, 2020, the rapid spread of the virus had caused 42 747 cases and 1017 deaths in China and cases have been reported in 25 countries, including the USA, Japan, and Spain. WHO has declared 2019 novel coronavirus disease (COVID-19), caused by SARS-CoV-2, a public health emergency of international concern. In contrast to severe acute respiratory system coronavirus and Middle East respiratory syndrome coronavirus, more deaths from COVID-19 have been caused by multiple organ dysfunction syndrome rather than respiratory failure, 2 which might be attributable to the widespread distribution of angiotensin converting enzyme 2—the functional receptor for SARS-CoV-2—in multiple organs.3, 4 Patients with cancer are more susceptible to infection than individuals without cancer because of their systemic immunosuppressive state caused by the malignancy and anticancer treatments, such as chemotherapy or surgery.5, 6, 7, 8 Therefore, these patients might be at increased risk of COVID-19 and have a poorer prognosis. On behalf of the National Clinical Research Center for Respiratory Disease, we worked together with the National Health Commission of the People's Republic of China to establish a prospective cohort to monitor COVID-19 cases throughout China. As of the data cutoff on Jan 31, 2020, we have collected and analysed 2007 cases from 575 hospitals (appendix pp 4–9 for a full list) in 31 provincial administrative regions. All cases were diagnosed with laboratory-confirmed COVID-19 acute respiratory disease and were admitted to hospital. We excluded 417 cases because of insufficient records of previous disease history. 18 (1%; 95% CI 0·61–1·65) of 1590 COVID-19 cases had a history of cancer, which seems to be higher than the incidence of cancer in the overall Chinese population (285·83 [0·29%] per 100 000 people, according to 2015 cancer epidemiology statistics 9 ). Detailed information about the 18 patients with cancer with COVID-19 is summarised in the appendix (p 1). Lung cancer was the most frequent type (five [28%] of 18 patients). Four (25%) of 16 patients (two of the 18 patients had unknown treatment status) with cancer with COVID-19 had received chemotherapy or surgery within the past month, and the other 12 (25%) patients were cancer survivors in routine follow-up after primary resection. Compared with patients without cancer, patients with cancer were older (mean age 63·1 years [SD 12·1] vs 48·7 years [16·2]), more likely to have a history of smoking (four [22%] of 18 patients vs 107 [7%] of 1572 patients), had more polypnea (eight [47%] of 17 patients vs 323 [23%] of 1377 patients; some data were missing on polypnea), and more severe baseline CT manifestation (17 [94%] of 18 patients vs 1113 [71%] of 1572 patients), but had no significant differences in sex, other baseline symptoms, other comorbidities, or baseline severity of x-ray (appendix p 2). Most importantly, patients with cancer were observed to have a higher risk of severe events (a composite endpoint defined as the percentage of patients being admitted to the intensive care unit requiring invasive ventilation, or death) compared with patients without cancer (seven [39%] of 18 patients vs 124 [8%] of 1572 patients; Fisher's exact p=0·0003). We observed similar results when the severe events were defined both by the above objective events and physician evaluation (nine [50%] of 18 patients vs 245 [16%] of 1572 patients; Fisher's exact p=0·0008). Moreover, patients who underwent chemotherapy or surgery in the past month had a numerically higher risk (three [75%] of four patients) of clinically severe events than did those not receiving chemotherapy or surgery (six [43%] of 14 patients; figure ). These odds were further confirmed by logistic regression (odds ratio [OR] 5·34, 95% CI 1·80–16·18; p=0·0026) after adjusting for other risk factors, including age, smoking history, and other comorbidities. Cancer history represented the highest risk for severe events (appendix p 3). Among patients with cancer, older age was the only risk factor for severe events (OR 1·43, 95% CI 0·97–2·12; p=0·072). Patients with lung cancer did not have a higher probability of severe events compared with patients with other cancer types (one [20%] of five patients with lung cancer vs eight [62%] of 13 patients with other types of cancer; p=0·294). Additionally, we used a Cox regression model to evaluate the time-dependent hazards of developing severe events, and found that patients with cancer deteriorated more rapidly than those without cancer (median time to severe events 13 days [IQR 6–15] vs 43 days [20–not reached]; p<0·0001; hazard ratio 3·56, 95% CI 1·65–7·69, after adjusting for age; figure). Figure Severe events in patients without cancer, cancer survivors, and patients with cancer (A) and risks of developing severe events for patients with cancer and patients without cancer (B) ICU=intensive care unit. In this study, we analysed the risk for severe COVID-19 in patients with cancer for the first time, to our knowledge; only by nationwide analysis can we follow up patients with rare but important comorbidities, such as cancer. We found that patients with cancer might have a higher risk of COVID-19 than individuals without cancer. Additionally, we showed that patients with cancer had poorer outcomes from COVID-19, providing a timely reminder to physicians that more intensive attention should be paid to patients with cancer, in case of rapid deterioration. Therefore, we propose three major strategies for patients with cancer in this COVID-19 crisis, and in future attacks of severe infectious diseases. First, an intentional postponing of adjuvant chemotherapy or elective surgery for stable cancer should be considered in endemic areas. Second, stronger personal protection provisions should be made for patients with cancer or cancer survivors. Third, more intensive surveillance or treatment should be considered when patients with cancer are infected with SARS-CoV-2, especially in older patients or those with other comorbidities.
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            Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal

            The first confirmed case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 20, 2020, in Snohomish County, Washington. At the epicenter of COVID-19 in the United States, the Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, and University of Washington are at the forefront of delivering care to patients with cancer during this public health crisis. This Special Feature highlights the unique circumstances and challenges of cancer treatment amidst this global pandemic, and the importance of organizational structure, preparation, agility, and a shared vision for continuing to provide cancer treatment to patients in the face of uncertainty and rapid change.
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              COVID-19: global consequences for oncology

              As the coronavirus disease 2019 (COVID-19) pandemic escalates and countries struggle to contain the virus, health-care systems are under increasing pressure. Emergency departments and intensive care units are nearing breaking point, and medical resources are being diverted to tackle the crisis. Moreover, conferences are being cancelled, and research trials are grinding to a halt. So what does COVID-19 mean for patients with cancer, their physicians, and the wider oncology discipline? Patients with cancer are a high-risk group in the COVID-19 pandemic. They are already vulnerable to infection because of their underlying illness and often immunosuppressed status, and are at increased risk of developing severe complications from the virus, including intensive care unit admission or even death. Moreover, for those who develop COVID-19, treatment of the disease will be prioritised, and further cancer therapy could be delayed, although such decisions must be made on a patient-by-patient basis and not based only on the early small reports published in the first few weeks of the pandemic. Media reports have described patients with cancer in quarantined cities being unable to travel to appointments or struggling to obtain essential medicines; the risk of interruptions in drug supply chains and consequent shortages will exacerbate this issue. Scheduled operations, some types of cancer treatment, and appointments are being cancelled or postponed to prioritise hospital beds and care for those who are seriously ill with COVID-19. In England, UK, despite the 2020 budget promising several billion pounds of extra NHS funding to help tackle the outbreak, when cases of COVID-19 peak in the coming weeks the NHS will undoubtedly be forced to delay non-urgent treatments and surgeries as resources and personnel are repurposed. Unfortunately, the effects of COVID-19 are not solely limited to the treatment of patients with cancer, but will also hit the wider oncology community, with inevitable consequences for research, education, and collaboration. University campuses in the worst hit countries have shut down, with many others expected to follow. Some of those affected, including the University of Bologna, Italy, have responded by digitising their teaching programmes, moving classes and exams online to alleviate the educational impact. However, such solutions cannot be used for practical laboratory work or field studies, and ongoing research projects are being jeopardised. Limited resources and capacity will force institutions to decide which clinical trials to prioritise and which to suspend. Many institutions, including the Dana Farber Cancer Institute (Boston, MA, USA) are restricting employees’ work-related travel, and others such as the Fred Hutchinson Cancer Research Center (Seattle, WA, USA—one of the worst-affected US cities) are implementing mandatory work from home policies. However, not all centres in affected regions have similar policies, and such heterogeneity might create imbalances in patient cohorts in multicentre trials, potentially biasing eventual results. With some governments advising against or banning non-essential travel and large-scale events, at least eight major cancer meetings and conferences have been cancelled or postponed, with many more expected to follow. As a result, innumerable opportunities for discussion and collaboration will be lost, the latest research will not be presented, and patients will subsequently be affected by the delay in dissemination of information on the latest treatment to their doctors. Although some congresses are being reorganised to take place online, face-to-face meetings are a crucial aspect of team science and cannot be eliminated completely. Furthermore, societies and organisations postponing or cancelling meetings will probably face financial consequences that could have long-term effects on their ability to fund key activities in the future. The American Society of Clinical Oncology—which at the time of writing had not yet decided about their 2020 annual meeting—relied on a huge US$43 million in revenue from education and meeting registration fees in 2018. For smaller societies that rely on their annual meetings financially, cancellations could threaten their existence. With the situation constantly changing, all we can do for now is watch, wait, and adapt as best we can until the immediate and long-term effects of this pandemic fully materialise. Ultimately, the situation might lead to substantial changes in how research and medicine are practiced in the future, such as reduced international travel and increased remote networking and telemedicine. Until the COVID-19 pandemic is over, we can only hope that the consequences are not too devastating for patients and that the oncology community and beyond are able to weather this unprecedented storm. © 2020 CDC/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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                Author and article information

                Journal
                International Journal of Gynecologic Cancer
                Int J Gynecol Cancer
                BMJ
                1048-891X
                1525-1438
                June 23 2020
                : ijgc-2020-001634
                Article
                10.1136/ijgc-2020-001634
                32576608
                2c296b6c-300c-4d17-a814-201711c94553
                © 2020

                Free to read

                https://bmj.com/coronavirus/usage

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