Short title: Cervical cancer in COVID-19 period
Abstract
SARS-CoV-2 infection outbreak has
been going on for nearly a year since December 2019. With the
implementation of national risk management policy, SARS-CoV-2 infection
has been effectively controlled in China. In the absence of a SARS-CoV-2
vaccine, the second wave of COVID-19 may still break out due to frequent
personnel exchanges around the world. The Colposcopy and Cervical
Lesions of the Chinese Association of Obstetricians and Gynecologists
(CCNC) collected management experience in the diagnosis and treatment of
cervical lesions and cancers at different risk stages during the
COVID-19 pandemic. In order to evaluate feasible treatment options at
different risk levels, a comprehensive management strategy for cervical
cancer screening, diagnosis and treatment has been developed. The
implementation of this expert consensus can help doctors in hospitals
and regions around the world to carry out different degrees of
protection according to the risk of SARS-CoV-2 infection, including
cervical vaccination, cervical cancer screening, abnormal treatment of
screening results, and treatment of precancerous lesions or lower
genital tract cancer.
With the release and implementation of this expert consensus, we will be
more confident to adopt different principles in the face of different
degrees of COVID-19 pandemic. While ensuring the safety of medical staff
and patients, it can also ensure that the diagnosis and treatment of
cervical cancer is carried out as planned during the COVID-19 pandemic.
WHO announced that the elimination mission of cervical cancer will not
be delayed due to the COVID-19 pandemic.
Background
The novel coronavirus causes acute infectious disease. It is designated
as a Class B infectious disease by Class A management under the Law of
the People’s Republic of China on the Prevention and Control of
Infectious Diseases. During the outbreak, it is necessary to implement
hierarchical emergency prevention and control according to the National
Emergency Plan for Public Emergencies [1]. According to the
properties of the emergency, the extent of harm, and the scope of the
public health emergency, four levels of emergency have been defined:
particularly serious (grade I), serious (grade II), major (grade III),
and general (grade IV).
Cervical cancer screening and the diagnosis and treatment of cervical
lesions are important long-term projects for the prevention and
treatment of cervical cancer in China. However, proper management of
cervical cancer screening and the diagnosis and treatment of cervical
lesions during the COVID-19 pandemic is a challenge.
Experts from the Professional Committee for
Colposcopy and Cervical Lesions of
Chinese Obstetricians and Gynecologists Association (CCNC) have
formulated a comprehensive management strategy for cervical cancer
screening and the diagnosis and treatment of cervical lesions during the
COVID-19 epidemic based on the Law of the People’s Republic of China on
the Prevention and Control of Infectious Diseases, the Frontier Health
and Quarantine Law of the People’s Republic of China Governing
Foreign-Related Matters (2018 Edition), the Contingency Rules of
Paroxysmal Public Health Events [2], the National Emergency Plan for
Public Emergencies, the New Coronavirus Pneumonia Diagnosis and
Treatment Plan (Trial 8 Edition) [3], and the Management of
Gynecology Patients during the Coronavirus Disease 2019 Pandemic:
Chinese Expert Consensus [4].
Protection of personnel in colposcopy outpatient clinics
during the epidemic
The prevention and control of disease in the gynecological outpatient
services during the epidemic period follows the guidance of the
Management of Gynecology Patients during the Coronavirus Disease 2019
Pandemic: Chinese Expert Consensus.
The following are the recommendations for colposcopy outpatient clinics
during the epidemic:
Protection of medical professionals in outpatient clinic for
colposcopy and lower genital tract diseases
Although there is evidence that the risk of coronavirus in the lower
genital tract is low, medical professionals still have the risk of
exposure to coronavirus infection during the diagnosis and treatment of
lower genital tract diseases.
Medical professionals must strictly follow the guidance of the Common
Medical Protective Products Use for the Prevention and Control of Novel
Coronavirus Infection Guidelines (Trial) [5]. It remains uncertain
whether COVID-19 can be transmitted via aerosols. It is suggested that
the smoke exhaust device should be turned on during the electrosurgical
operation for lower genital tract lesions, such as LEEP, laser, etc. To
reduce the amount of surgical smoke, electrical surgery energy equipment
can be set at a low-power level and continuous use can be reduced.
Moreover, the use of electrosurgical instruments for hemostasis can be
reduced.
It should be noted that the principle of disease treatment should not be
violated due to the risk of the virus caused by smoke.
Specimen handling and transportation
Fixed specimen collection areas for vaginal secretions and cytology and
biopsy specimens should be set up and disinfected regularly. Specimens
should be placed in an isolated leak-proof transport box and transported
by specialized personnel. Specimen delivery personnel and pathology or
laboratory receiving personnel should wear standard protective clothing
that meets the risk level and should avoid direct contact with
specimens. After specimen transfer, personnel should clean and disinfect
immediately. It is necessary to establish a record of personnel and
specimen registration for traceability and transmission. Patients or
family members are not permitted to deliver specimens to the hospital.
Medical waste disposal
The treatment of medical waste is based on the following principle:
Separate the infectious medical waste generated during the diagnosis and
treatment of patients infected with SARS-Cov-2 virus from general
medical waste. The working area should be cleaned every day, and the
medical garbage should be cleaned up more than twice a day. Medical
waste, including protective equipment for medical personnel and
disposable articles (cotton swabs, vaginal dilators, gauze, biopsy
forceps, sanitary articles), should not overflow the medical garbage
can, which should be cleaned at least once every 1–4 h. Red
“infectious waste” signs should be printed or pasted on the waste
bags, and the temporary storage time should not exceed 24 h.
All medical waste must be strictly handled in accordance with the
Medical Waste Management Regulations [6] and the Management and
Technical Guidelines for Emergency Disposal of Medical Wastes during the
COVID-19 Pandemic (Trial) [7].
Tertiary prevention of cervical cancer during the COVID-19
epidemic
During the COVID-19 epidemic period, the management of HPV vaccination,
cervical cancer screening, and the diagnosis and treatment of cervical
lesions should be adjusted according to the level of emergency and the
management policies announced by the government. Relevant institutions
need to manage and evaluate the delays in screening, diagnosis, and
follow-up of cervical cancer caused by the COVID-19 epidemic.
Appropriate measures and management should be taken to maintain the
annual cervical cancer screening and treatment population.
Whenever the epidemic situation of COVID-19 is effectively controlled,
HPV vaccination, cervical cancer screening, and patient management
should be gradually resumed in accordance with the Expert Consensus on
Issues Related to Cervical Cancer Screening and Management of Cervical
Abnormalities: Chinese Expert Consensus [8,9] and the Application of
Colposcopy: Chinese Expert Consensus [10].
In areas where cervical cancer screening is suspended, relevant
institutions should establish data management for patients with delayed
screening and for those who need to be recalled for treatment, and
update them regularly. For those who have been scheduled but have not
been screened, cervical cancer screening tasks should be resumed
gradually after the risk of the COVID-19 epidemic has been downgraded.
For patients with cervical abnormalities, follow-up files should be
established, and the condition and possible treatment plan should be
relayed to patients by telephone or Internet. When the risk of the
COVID-19 epidemic has been downgraded, patients should be informed and
appointments for examination and treatment should be scheduled.
In regions that restart organized screening, risk control plans are
still needed, which should focus on population control, body temperature
testing, tourism history, and close contact history in high-risk areas.
It is suggested that medical staff still need to take a high level of
self-protection measures. The transportation and examination of
specimens should follow the epidemic prevention measures.
To ensure the quality control of HPV self-sampling screening, a video or
file of the self-sampling operation must be taken as an operation
specification in the HPV self-sampling screening tracking implementation
area. Those who have not had an HPV vaccination need to make an online
appointment when the risk level of the epidemic has been reduced. Those
who have received part of the HPV vaccine can postpone the next
vaccination, but it should not exceed 12–15 months after the first
vaccination [11].
Establish a database of patients with abnormal screening results to
record information about all patients who need to be checked but have
been delayed due to the epidemic, so that the diagnosis and treatment
can be planned for when the risk of the COVID-19 epidemic has been
downgraded.
Telemedicine consultation can be strengthened for preliminary assessment
and guidance for patients. Telemedicine consultation, medical records,
or image data (such as colposcopy and/or pathology images) can be
uploaded and interpreted remotely. This will ensure that patients
continue to receive standard clinical care while reducing the risk of
overcrowding in hospitals.
For patients with precancerous lesions or lower genital tract cancer
confirmed by histology, the risk of disease progression should be
comprehensively evaluated, and the next diagnosis or treatment should be
arranged as soon as possible during the epidemic period (Table.1).
High-risk areas: particularly serious (grade I)
- For vaccination: HPV vaccination should be stopped.
- For screening: organized cervical cancer screening should be stopped.
When the risk level of COVID-19 is reduced, it is recommended that the
opportunistic screening should be prioritized for high-risk groups,
and then the organized screening of cervical cancer should be resumed.
- For cervical abnormalities by screening: Routine colposcopy should be
stopped and only emergency patients should be treated. If colposcopy
evaluation is necessary, both patients and medical staff should
implement adequate protection.
- For precancerous lesions or lower genital tract cancer confirmed by
histology: surgery or related invasive treatment should be postponed.
If surgical treatment is necessary, patients with invasive or
suspected cancer should be given priority. Both patients and medical
staff need to implement adequate protection.
Medium-risk areas: serious (grade II) and major (grade III)
- For vaccination: Vaccination can only be implemented after being
approved by the director of the medical and health institution
according to the epidemic risk assessment.
- For screening: Opportunistic screening of the high-risk population
should be the main task, and organized screening should only be
carried out after the approval of the relevant medical and health
institutions.
- For cervical abnormalities by screening: Hierarchical management
should be carried out according to the risk of cervical cancer and
cervical lesions. Plan to schedule patients for colposcopy or
follow-up. For patients with suspected cancer (SCC, AGC FN, AIS, ACC)
after screening, it is recommended to arrange colposcopy within 2
weeks. Patients with high-risk screening results [HPV16/18(+), ASCUS
and HPV16/18(+), LSIL and hrHPV(+), ASC-H, HSIL, AGS-NOS] should be
evaluated and diagnosed by colposcopy within 4–6 weeks after
obtaining the screening results. Patients with low-risk screening
results [hrHPV(+) with HPV16/18(−) and cytological NILM or ASCUS,
ASCUS +hrHPV (−), LSIL + hrHPV(−)] with no clinical symptoms or
specific risk factors can be postponed for colposcopy within 6–8
weeks.
- For precancerous lesions or lower genital tract cancer confirmed by
histology: For invasive cervical, vaginal, and vulvar cancer confirmed
by histology or suspected by diagnosis, further evaluation or
treatment should be arranged within 2–4 weeks. For highly
intraepithelial lesions of the cervix, vagina, and vulva (HSIL/-IN3,
AIS), it is recommended that the treatment should be carried out
within 3 months. For conservative cases of HSIL/− in2 in the lower
genital tract, treatment or evaluation can be delayed for 6 months.
For low-grade intraepithelial lesions of the lower genital tract:
Further evaluation should be postponed for 6–12 months. The first
follow-up should be completed within 6 months after surgical treatment
and no more than 12 months after surgery. Follow-up should include
cytology and HR-HPV (HPV self-sampling can be used if conditions
permit). Follow-up results and corresponding medical advice can be
relayed by telephone, internet, or telemedicine. Abnormal results
during follow-up should be treated according to the abnormal
management process of screening results.
Low-risk areas: general (grade IV)
- For vaccination: normal vaccination.
- For screening: While resuming cervical cancer organized screening, the
number and intensity of opportunistic screenings should be
strengthened to reduce the risk of cervical cancer caused by delayed
screening during the epidemic period.
- For cervical abnormalities by screening: The evaluation and follow-up
of colposcopies not completed during the epidemic should be completed
according to the results of the high- to low-risk screening results of
patients.
- For precancerous lesions or lower genital tract cancer confirmed by
histology: Patients should be treated and managed in accordance with
the Application of Colposcopy: Chinese Expert Consensus [10].
Psychological counseling for patients with cervical lesions
during the epidemic
During the epidemic, patients with cervical lesions may have different
degrees of psychological problems, such as fear, anxiety, depression,
etc., due to the delay or interruption of diagnosis and treatment. It is
recommended that medical institutions and medical staff use telephone,
WeChat, telemedicine, etc. to carry out disease explanation and
psychological counseling for patients to reduce their psychological
pressure. Appropriate treatment and follow-up plans should be arranged
based on the risk of disease and the epidemic situation.
Continuing education for professionals during the epidemic
During the outbreak, the medical association or continuing education
courses must meet the requirements of the local health management
department. Professional committees or medical institutions at all
levels should make extensive use of network video communication (such as
webinars) to ensure the updating of professional theoretical knowledge
and the cultivation of clinical skills.