Evaluation of the medically necessary, time sensitive triage score during and beyond the local COVID-19 pandemic in the Gynaecologic Oncology Unit of a tertiary hospital in South Africa.

OBJECTIVE: The main objective of this study was to evaluate the Medically Necessary Time Sensitive (MeNTS) scoring system in triaging gynaecologic oncologic surgery during and beyond the COVID-19 pandemic. MATERIAL AND METHODS: This was a retrospective cross-sectional study including 209 patients who either had surgery (151) or surgery postponed (58) between the 26th March and 30th September 2020 in an academic hospital in South Africa. The MeNTS score was used to independently score each patient three times by two observers. RESULTS: The mean age of the participants was 46.6 ± 15 years and the cumulative mean MeNTS score was 51.0 ± 5.1. Over two-thirds of the cases had surgery. There was no significant difference between the first and second observers' cumulative scores, 51.0 vs 51.1 (p 0.77). The cumulative score among those who had surgery was significantly lower than that for those whose surgeries were postponed, 49.8 vs 54.1 (p <0.0001). The intra-observer and inter-observer reliability were 0.78 and 0.74 respectively. After adjusting for confounding variables, those with low cumulative MeNTS scores were about 5 times more likely to have surgery than those with high scores (Adj. OR = 4.67, 95% CI: 1.92-11.4, p <0.001. Patients with malignant diagnosis were also 5 times more likely to be operated than those with benign diagnosis (Adj. OR = 5.03, 95% CI: 1.73-14.6, p <0.001. The area under the curve (AUC) was 0.85 suggesting an excellent discriminatory power between those who were operated and those who were postponed. CONCLUSION: The study provided some insight into the potential usefulness of MeNTS score in prioritizing patients for surgery in gynaecologic oncologic sub-specialty. The score performed well across a range of gynaecologic conditions and procedures with good intra-observer and inter-observer consistency and reliability. This is a prioritization tool that is dynamically adaptable to accommodate changes in resources availability and operating theatre capacity.

Single centre experience of 800 gynaecologic oncology cases in 2020: influence of pandemy on cancer surgeries.

We aimed to evaluate the gynaecological oncology surgeries in the COVID-19 pandemic. A total of 800 operations performed between January and December 2020 were retrieved. Since the COVID-19 pandemic affected operations as of April 1 2020, we compared the cases of the last nine months of the year with the first three months. Of the operations, 265 (33.1%) were performed between January and March and 535 (66.9%) between April and December. Of 168 malignant operations; 78 (46%) were uterine cancer, 58 (35%) ovarian cancer, 28 (17%) cervical cancer and four (2%) vulvar cancer. If we compared the last nine months of the year with the first three months, a significant increase was observed in the rates of malignant and premalignant, while a significant decrease was detected in benign operations (p<.001). Gynaecological oncology surgeries performed with open or laparoscopic approaches during the COVID-19 pandemic should continue by taking preventive measures. Impact StatementWhat is already known on this subject? During the COVID-19 pandemic, many international associations and organisations recommended the suspension of elective surgeries. It is still controversial whether the gynaecologic oncology surgical procedures to be performed in this unprecedented time should be laparoscopic or laparotomic.What do the results of this study add? The malignant and premalignant gynaecological oncology surgeries should be safely performed laparoscopically or by laparotomy in the COVID-19 pandemic.What are the implications of these findings for clinical practice and/or further research? Gynaecologic oncology surgeries can be safely performed by attaching appropriate personal protective equipment procedures with pre-operative COVID-19 PCR testing in the COVID-19 era.

Perspectives of Gynecologic Oncologists on Minimally Invasive Surgery During COVID-19 Pandemic: A Turkish Society of Minimally Invasive Gynecologic Oncology (MIJOD) Survey.

BACKGROUND: To evaluate gynecologic oncologists' trends and attitudes towards the use of Minimally invasive surgery (MIS) in active period of the COVID-19 pandemic in Turkey. METHODS: Online national survey sent to members of Turkish Endoscopy Platform consisting of six sections and 45 questions between the dates 1-15 June 2020 in Turkey to explore their surgical practice during the pandemic in three hospital types: Education and research hospital/university hospital, state hospital and private Hospital. Participants were gynecologic oncologists who are members of Turkish Endoscopy Platform. RESULTS: Fifty-eight percent of participants canceled all operations except for cancer surgeries and emergent operations. About a quarter of participants (28%) continued to operate laparoscopically and/or robotically. For the evaluation of the suspected adnexial mass (SAM) 64% used laparotomy and only 13 % operated by laparoscopy (L/S). For the management of low-risk early-stage endometrial cancer only fifth of the participants preferred to perform L/S. For endometrial cancer with high-intermediate risk factors more than half of participants preferred complete staging with laparotomy. For advanced stage ovarian cancer, one-fifth of the participants preferred to perform an explorative laparotomy, whilst 15 % preferred diagnostic laparoscopy to triage the patients for either NACT or cytoreductive surgery. On the contrary 41 % of participants chose to have cytology by paracentesis for neo-adjuvant chemotherapy (NACT). Gynecologic oncologists with >10 years L/S experience used MIS more for SAM. Furthermore, experienced surgeons used L/S more for endometrial cancer patients. In busy COVID hospitals, more participants preferred laparotomy over L/S. CONCLUSION: Use of MIS decreased during the pandemic in Turkey. More experienced surgeons continued to perform MIS. Surgical treatment was the preferred approach for SAM, early-stage endometrial cancer.  However, NACT was more popular compared to radical surgery.

The safety of major gynaecologic cancer surgery without routine preoperative COVID-19 testing in the COVID-19 era: a multicentre, retrospective, case-control study.

Our goal was to address the safety of major gynaecologic cancer surgery without routine preoperative COVID-19 testing in the COVID-19 era. The databases of seven gynaecologic cancer centres were searched in order to identify all consecutive gynaecologic cancer patients undergoing major surgery between March 11, 2020 and May 15, 2020 for this retrospective, case-control study. The case group consisted of patients with histopathologically confirmed gynaecologic cancers, and each case was matched with two counterparts who had undergone primary surgery before the COVID-19 pandemic. The case and the control groups were compared in terms of length of hospital stay, admission to the intensive care unit (ICU), intraoperative and postoperative complications.During the study period, 154 women with gynaecologic cancer undergoing major surgery were identified. Although the case group had more co-morbidities compared to the control group (103/154 vs. 178/308, respectively; p = .04), the median length of hospital stays, the rate of ICU admission, intraoperative complication rates and postoperative complication rates were similar in the two groups. Gynaecologic cancer surgery may be performed safely in the COVID-19 era with similar rates of ICU admission, intraoperative and postoperative complications compared to the patients operated before the COVID-19 pandemic.IMPACT STATEMENTWhat is already known on this subject? Many societies have announced their guidelines about the surgical management of gynaecologic cancer patients during the COVID-19 pandemic. However, most of them are not evidence-based and mostly on expert opinions.What do the results of this study add? The main findings of this retrospective, case-control study indicate that the short-term (30 day) outcomes of gynaecologic cancer patients undergoing major surgery in the COVID-19 era are similar to those who had been operated before the COVID-19 pandemic. The length of hospital stays, the rates of admission to the ICU, intraoperative and postoperative complications were comparable between women undergoing major gynaecologic cancer surgery in the COVID-19 era and the women who had been operated before the pandemic.What are the implications of these findings for clinical practice and/or further research? We can suggest that definitive surgery may be performed for gynaecologic cancer patients in the COVID-19 era if the resources permit and appropriate precautions such as social distancing, isolation and the use of personal protective equipment are taken.

Sleep Disorders Prior to Adjuvant Radiation Therapy for Gynecological Malignancies.

BACKGROUND/AIM: Many patients with gynecological malignancies receive postoperative radiotherapy, which can lead to fear and sleep disorders. We aimed to identify the prevalence of and risk factors for sleep disorders. PATIENTS AND METHODS: Sixty-two patients assigned to radiotherapy for gynecological malignancies were retrospectively evaluated. Seventeen characteristics were analyzed for associations with pre-radiotherapy sleep disorders including age, Karnofsky performance score, Charlson comorbidity index, history of additional malignancy, family history of gynecological cancer, distress score, emotional, physical or practical problems, tumor site/stage; chemotherapy, treatment volume, brachytherapy, and the COVID-19 pandemic. RESULTS: The prevalence of pre-radiotherapy sleep disorders was 46.8%. Sleep disorders were significantly associated with Charlson comorbidity index ≥3 (p=0.012), greater number of physical problems (p<0.0001), and advanced primary tumor stage (p=0.005). A trend was found for greater number of emotional problems (p=0.075). CONCLUSION: Pre-radiotherapy sleep disorders are common in patients with gynecological malignancies, particularly in those with specific risk factors. Patients should be offered early psychological support.

Gynecologic oncology treatment modifications or delays in response to the COVID-19 pandemic in a publicly funded versus privately funded North American tertiary cancer center.

OBJECTIVE: To compare gynecologic oncology surgical treatment modifications and delays during the first wave of the COVID-19 pandemic between a publicly funded Canadian versus a privately funded American cancer center. METHODS: This is a retrospective cohort study of all planned gynecologic oncology surgeries at University Health Network (UHN) in Toronto, Canada and Brigham and Women's Hospital (BWH) in Boston, USA, between March 22,020 and July 302,020. Surgical treatment delays and modifications at both centers were compared to standard recommendations. Multivariable logistic regression was performed to adjust for confounders. RESULTS: A total of 450 surgical gynecologic oncology patients were included; 215 at UHN and 235 at BWH. There was a significant difference in median time from decision-to-treat to treatment (23 vs 15 days, p < 0.01) between UHN and BWH and a significant difference in treatment delays (32.56% vs 18.29%; p < 0.01) and modifications (8.37% vs 0.85%; p < 0.01), respectively. On multivariable analysis adjusting for age, race, treatment site and surgical priority status, treatment at UHN was an independent predictor of treatment modification (OR = 9.43,95% CI 1.81-49.05, p < 0.01). Treatment delays were higher at UHN (OR = 1.96,95% CI 1.14-3.36 p = 0.03) and for uterine disease (OR = 2.43, 95% CI 1.11-5.33, p = 0.03). CONCLUSION: During the first wave of COVID-19 pandemic, gynecologic oncology patients treated at a publicly funded Canadian center were 9.43 times more likely to have a surgical treatment modification and 1.96 times more likely to have a surgical delay compared to an equal volume privately funded center in the United States.

The impact of the COVID-19 coronavirus pandemic on the surgical management of gynecological cancers: Analysis of the multicenter database of the French SCGP and the FRANCOGYN group.

INTRODUCTION: The coronavirus SARS-CoV-2 (COVID-19) pandemic has put tremendous pressure on the French healthcare system. Almost all hospital departments have had to profoundly modify their activity to cope with the crisis. In this context, the surgical management of cancers has been a topic of debate as care strategies were tailored to avoid any delay in treatment that could be detrimental to patient wellbeing while being careful not to overload intensive care units. The primary objective of this study was to observe changes in the surgical management of pelvic cancers during the COVID-19 pandemic in France. MATERIAL AND METHODS: This study analyzed data from the prospective multi-center cohort study conducted by the French Society for Pelvic and Gynecological Surgery (SCGP) with methodological support from the French (FRANCOGYN) Group. All members of the SCGP received by e-mail a link allowing them to include patients who were scheduled to undergo gynecological carcinologic surgery between March 16th 2020 and May 11th 2020. Demographic data, the characteristics of cancers and the impact of the crisis in terms of changes to the usual recommended coarse of care were collected. RESULTS: A total of 181 patients with a median age 63 years were included in the cohort. In total, 31 patients had cervical cancer, 76 patients had endometrial cancer, 52 patients had ovarian or tubal cancer, 5 patients had a borderline tumor of the ovary, and 17 patients had vulvar cancer. During the study period, the care strategy was changed for 49 (27%) patients with postponed for 35 (19.3%) patients, and canceled for 7 (3.9%) patients. Surgical treatment was maintained for 139 (76.8%) patients. Management with neoadjuvant chemotherapy was offered to 19 (10,5%) patients and a change in surgical choice was made for 5 (2,8%) patients. In total, 8 (4,4%) patients tested positive for COVID-19. Data also shows a greater number of therapeutic changes in cases of ovarian cancer as well as a cancelation of a lumbo-aortic lymphadenectomy in one patient with cervical cancer. Hospital consultants estimated a direct detrimental impact of the COVID-19 pandemic for 39 patients, representing 22% of gynecological cancers. CONCLUSION: This study provided observational data of the impact of the COVID-19 health crisis on the surgical management of gynecological cancers.

[Impact of COVID-19 pandemic on breast and gynecologic cancers management. Experience of the Surgery Department in the Nice Anticancer Center]. / Impact de la pandémie de COVID-19 sur les prises en charge pour cancer du sein et gynécologique.

INTRODUCTION: During the COVID-19 pandemic, the containment measures and the recommendations of several societies in oncology may have impacted the request for initial care for cancers. METHODS: In this monocentric retrospective study, the number and the characteristics of patients received for a first consultation for a breast or gynecologic tumor were compared between the containment period and a control period. The times from diagnosis to treatment and the type of initial care were compared too. RESULTS: During the outbreak, 91 patients were seen for a new request, versus 159 during the control period, a decrease of 43.5 %. Patients were older (62.9 versus 60.9 years old) but this difference was not significant. Tumor stage was not modified. Concerning senology, the time from the biopsy to the first consultation was 5.5 days longer during the outbreak (difference statistically insignificant). Among the 51 patients requiring a surgical treatment during the outbreak, 16 (31.48 %) were postponed after the end of the containment measures. After all, the average time from the consultation to the treatment was not modified. No modification of type of treatment was observed. DISCUSSION: At the height of the pandemic, benefits and risks of the cancer treatment had to be daily balanced against the risk of exposition to the COVID-19. The evaluation of practices for cancer care is essential to understand the real impact of COVID-19 outbreak on global cancer management, so as to get prepared to further crises.

Maintaining surgical care delivery during the COVID-19 pandemic: A comparative cohort study at a tertiary gynecological cancer centre.

BACKGROUND: Surgery is the cornerstone of gynecological cancer management, but inpatient treatment may expose both patients and healthcare staff to COVID-19 infections. Plans to mitigate the impact of the COVID-19 pandemic have been implemented widely, but few studies have evaluated the effectiveness of these plans in maintaining safe surgical care delivery. AIM: To evaluate the effects of mitigating plans implemented on the delivery of gynecological cancer surgery during the COVID-19 pandemic. METHODS: A comparative cohort study of patients treated in a high-volume tertiary gyneoncological centre in the United Kingdom. Prospectively-recorded consecutive operations performed and early peri-operative outcomes during the same calendar periods (January-August) in 2019 and 2020 were compared. RESULTS: In total, 585 operations were performed (296 in 2019; 289 in 2020). There was no significant difference in patient demographics. Types of surgery performed were different (p = 0.034), with fewer cytoreductive surgeries for ovarian cancer and laparoscopic procedures (p = 0.002) in 2020. There was no difference in intra-operative complication rates, critical care admission rates or length of stay. One patient had confirmed COVID-19 infection (0.4%). The 30-day post-operative complication rates were significantly higher in 2020 than in 2019 (58 [20.1%] versus 32 [10.8%]; p = 0.002) for both minor and major complications. This increase, primarily from March 2020 onwards, coincided with the first peak of the COVID-19 pandemic in the UK. CONCLUSIONS: Maintaining surgical throughput with meticulous and timely planning is feasible during the COVID-19 pandemic but this was associated with an increase in post-operative complications due to a multitude of reasons.

COVID-19 free oncologic surgical hub: The experience of reallocation of a gynecologic oncology unit during pandemic outbreak.

INTRODUCTION: During the SARS-CoV-2 pandemic, the majority of healthcare resources of the affected Italian regions were allocated to COVID-19 patients. Due to lack of resources and high risk of death, most cancer patients have been shifted to non-surgical treatments. The following reports our experience of a Gynaecologic Oncology Unit's reallocation of resources in a COVID-19 free surgical oncologic hub in order to guarantee standard quality of surgical activities. MATERIALS AND METHODS: This is a prospective observational study performed in the Gynaecologic Oncology Unit, on the outcomes of the reallocation of surgical activities outside the University Hospital of Bologna, Italy, during the Italian lockdown period. Here, we described our COVID-19 free surgical oncologic pathway, in terms of lifestyle restrictions, COVID-19 screening measures, and patient clinical, surgical and follow up outcomes. RESULTS: During the lockdown period (March 9th - May 4th, 2020), 83 patients were scheduled for oncological surgery, 51 patients underwent surgery. Compared to pre-COVID period, we performed the same activities: number of cases scheduled for surgery, type of surgery and surgical and oncological results. No cases of COVID-19 infection were recorded in operated patients and in medical staff. Patients were compliant and well accepted the lifestyle restrictions and reorganization of the care. CONCLUSIONSONCLUSIONS: Our experience showed that the prioritization of oncological surgical care and the allocation of resources during a pandemic in COVID-19 free surgical hubs is an appropriate choice to guarantee oncological protocols.

Perioperative SARS-CoV-2 infection among women undergoing major gynecologic cancer surgery in the COVID-19 era: A nationwide, cohort study from Turkey.

OBJECTIVE: The objective of this study was to determine the rate of perioperative SARS-CoV-2 infection among gynecologic cancer patients undergoing major surgery. METHODS: The database of the Turkish Ministry of Health was searched in order to identify all consecutive gynecologic cancer patients undergoing major surgery between March 11, 2020 and April 30, 2020 for this retrospective, nationwide, cohort study. The inclusion criteria were strictly founded on a final histopathological diagnosis of a malignant gynecologic tumor. COVID-19 cases were diagnosed by reverse transcriptase- polymerase chain reaction testing for SARS-CoV-2. The rate of perioperative SARS-CoV-2 infection and the 30-day mortality rate of COVID-19 patients were investigated. RESULTS: During the study period, 688 women with gynecologic cancer undergoing major surgery were identified nationwide. The median age of the patients was 59 years. Most of the surgeries were open (634/688, 92.2%). There were 410 (59.6%) women with endometrial cancer, 195 (28.3%) with ovarian cancer, 66 (9.6%) with cervical cancer, 14 (2.0%) with vulvar cancer and 3 (0.4%) with uterine sarcoma. The rate of SARS-CoV-2 infections confirmed within 7 days before or 30 days after surgery was 46/688 (6.7%). All but one woman was diagnosed postoperatively (45/46, 97.8%). The rates of intensive care unit admission and invasive mechanical ventilation were 4/46 (8.7%) and 2/46 (4.3%), respectively. The 30-day mortality rate was 0%. CONCLUSION: In the COVID-19 era, gynecologic cancer surgery may be performed with an acceptable rate of perioperative SARS-CoV-2 infection if the staff and the patients strictly adhere to the established infection control measures.

[Guidelines for surgical management of gynaecological cancer during pandemic COVID-19 period - FRANCOGYN group for the CNGOF]. / Prise en charge chirurgicale des cancers gynécologiques en période de pandémie COVID-19 ­ Recommandations du Groupe FRANCOGYN pour le CNGOF.

INTRODUCTION: Recommendations for the management of patients with gynecological cancer during the COVID-19 pandemic period. MATERIAL AND METHOD: Recommendations based on the consensus conference model. RESULTS: In the case of a COVID-19 positive patient, surgical management should be postponed for at least 15 days. For cervical cancer, the place of surgery must be re-evaluated in relation to radiotherapy and Radio-Chemotherapy-Concomitant and the value of lymph node staging surgeries must be reviewed on a case-by-case basis. For advanced ovarian cancers, neo-adjuvant chemotherapy should be favored even if primary cytoreduction surgery could be envisaged. It is lawful not to offer hyperthermic intraperitoneal chemotherapy during a COVID-19 pandemic. In the case of patients who must undergo interval surgery, it is possible to continue the chemotherapy and to offer surgery after 6 cycles of chemotherapy. For early stage endometrial cancer, in case of low and intermediate preoperative ESMO risk, hysterectomy with bilateral annexectomy associated with a sentinel lymph node procedure should be favored. It is possible to consider postponing surgery for 1 to 2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For high ESMO risk, it ispossible to favor the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) in order to omit pelvic and lumbar-aortic lymphadenectomies. CONCLUSION: During COVID-19 pandemic, patients suffering from cancer should not lose life chance, while limiting the risks associated with the virus.

COVID-19: gynecologic cancer surgery at a single center in Madrid.

OBJECTIVES: While numerous medical facilities have been forced to suspend oncological surgery due to system overload, debate has emerged on using non-surgical options on cancer cases during the pandemic. The goal of our study was to analyze, in a retrospective cohort study, the results of gynecological cancer surgery and evaluate postoperative complications in a single center in one of the most affected areas in Europe. METHODS: We retrospectively analyzed the records of patients who were referred between March 2020 and May 2020 for primary surgical treatment of breast, endometrial, ovarian, cervical, or vulvar cancer. RESULTS: The study included a total of 126 patients. Median age was 60 years (range 29-89). Patients were referred with breast (76/126, 60.3%), endometrial (29/126, 23%), ovarian (14/126, 11.1%), cervical (5/126, 4%), or vulvar cancer (2/126, 1.6%). Polymerase chain reaction (PCR) test for detection of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) was only conducted in 50% of cases due to the low availability of tests during the first phase of our study, and was indicated only in suspected cases according to the healthcare authorities' protocol. Median hospital stay was 1 day (range 0-18). Excluding breast surgery, laparoscopy was the most used procedure (43/126, 34.1%). 15 patients had a postoperative complication (15/126, 11.9%); only in 2 patients (2/15 13.3%) were there reports of Clavien-Dindo grade 3 or 4 complications. 6 patients tested positive for COVID-19 following a PCR diagnostic test, and these surgeries were cancelled. CONCLUSIONS: Adequate protective measures in the setting of COVID-19 free institutions enabled the continuity of cancer surgery without significant compromise of the safety of patients or healthcare workers.

When to Operate, Hesitate and Reintegrate: Society of Gynecologic Oncology Surgical Considerations during the COVID-19 Pandemic.

The COVID-19 pandemic has challenged our ability to provide timely surgical care for our patients. In response, the U.S. Surgeon General, the American College of Srugeons, and other surgical professional societies recommended postponing elective surgical procedures and proceeding cautiously with cancer procedures that may require significant hospital resources and expose vulnerable patients to the virus. These challenges have particularly distressing for women with a gynecologic cancer diagnosis and their providers. Currently, circumstances vary greatly by region and by hospital, depending on COVID-19 prevalence, case mix, hospital type, and available resources. Therefore, COVID-19-related modifications to surgical practice guidelines must be individualized. Special consideration is necessary to evaluate the appropriateness of procedural interventions, recognizing the significant resources and personnel they require. Additionally, the pandemic may occur in waves, with patient demand for surgery ebbing and flowing accordingly. Hospitals, cancer centers and providers must prepare themselves to meet this demand. The purpose of this white paper is to highlight all phases of gynecologic cancer surgical care during the COVID-19 pandemic and to illustrate when it is best to operate, to hestitate, and reintegrate surgery. Triage and prioritization of surgical cases, preoperative COVID-19 testing, peri-operative safety principles, and preparations for the post-COVID-19 peak and surgical reintegration are reviewed.

Clinical Characteristics of COVID-19 After Gynecologic Oncology Surgery in Three Women: A Retrospective Review of Medical Records.

From a large medical center in Wuhan, the epicenter of the 2019 novel coronavirus disease (COVID-19), we report clinical features and prognosis for three women diagnosed with COVID-19 after gynecologic oncology surgery and hospitalized in January 2020. The incidence of COVID-19 was 0.77% (3 of 389) of total hospitalizations and 1.59% (3 of 189) of patients undergoing surgeries in the ward. The infection of severe acute respiratory syndrome coronavirus 2 may be related to the older age, comorbidities, malignant tumor, and surgery in gynecologic hospitalizations. By February 20, 2020, only two of the three patients had met the clinical discharge criteria. Given the long and uncertain incubation period of COVID-19, screening for the virus infection should be carried out for all patients, both preoperatively and postoperatively. Postponement of scheduled gynecologic surgery for patients in the epidemic area should be considered.