4. Exploration of alternative therapy
Whilst the ability to perform operative interventions is restricted, MDT’s need to consider the use of alternative therapies in order to manage gynaecological malignancies. Alternative therapies such as the levonorgestrel intra-uterine system have been used in patients with early endometrial cancer when surgical intervention is not possible(4,6,15). These options should be considered more widely whilst the availability of definitive treatment is reduced. Where surgical intervention is possible, minimally-invasive surgery should be the gold standard (3). For intermediate or high-risk endometrial tumours, consideration should be given to vaginal hysterectomy with bilateral salpingo-oophorectomy or minimally invasive surgery with sentinel lymph node biopsy as this reduces recovery time, thus reducing patient exposure and use of resources(6).
For early ovarian tumours, minimising surgery for those women considered to be at high risk of malignancy (RMI>200) is suggested to remove the primary tumour and to obtain a histological diagnosis, however those women deemed to be at a lower risk of cancer (RMI<200) can be deferred until deemed safe to continue (15). Following this, staging can be completed with imaging or future definitive surgery with the consideration of commencing neoadjuvant therapy (3,6) or prolonging current chemotherapy prior to definitive surgery (3,4,6,15). Evidence suggests that the outcomes associated with primary surgery versus neoadjuvant chemotherapy are similar and as such presents as a viable option (16). The risks of surgery to both the patient and resources need to be considered and weighed against the risk of immunosuppression associated with chemotherapy. It has been suggested that mortality from chemotherapy is at least doubled in the presence of COVID-19 (17).
Where possible, women should be managed with spinal anaesthesia, such as in the management of cervical cancer, whereby options such as wide conisation, trachelectomy and vaginal hysterectomy can be considered depending on stage of disease. Alternatively, these patients should be managed with radiotherapy(6,15). In some institutions, all women with cervical cancer are advised to be treated with chemoradiotherapy as first line(3). Equally with vulval cancer, many patients can be postponed as their lesions may be indolent, however, those patients that cannot be deferred can largely be managed with spinal anaesthesia with preference to undertake sentinel lymph node biopsy if required in order to reduce morbidity and length of admission associated with complete groin node dissection. If the tumour requires extensive surgery with reconstruction, neoadjuvant chemoradiotherapy is advised(6).
Trophoblastic tumours should be managed without delay, however low-risk women (FIGO <6) can have their methotrexate injection administered at home, whilst high-risk women are advised to continue their treatment as planned(3).