COVID-19 and ovarian cancer: ‘A new opportunity to have tough conversations’
Click Here to Manage Email Alerts
The COVID-19 pandemic greatly affected the delivery of cancer care across the U.S. and globally. In response, oncology societies have established guidance for clinicians on how to best manage ovarian cancer during the COVID-19 era.
ASCO launched the Survey on COVID-19 in Oncology Registry with the intention of helping the cancer community learn more about COVID-19 symptoms and severity among patients with cancer. The registry was created to collect baseline and follow-up data throughout the pandemic and into the next year to provide insights into how COVID-19 infections affect the delivery of cancer care and patient outcomes.
“These registries are going to add to our understanding of the impact of COVID-19 in patients with cancer — we are at the tip of the iceberg in learning what we need to learn about COVID-19 and cancer, which appears to be a risk factor for more significant complications from COVID-19,” Merry-Jennifer Markham, MD, FACP, FASCO, interim chief of the division of hematology and oncology and an associate professor in the department of medicine at University of Florida Health, told Healio. “These registries are going to help add to the data and help oncologists, cancer surgeons and radiation oncologists make better decisions for our patients through understanding the unique risk that our patients may have if they develop COVID-19 infection.”
Additionally, ESMO released guidance on the management and treatment of the main solid tumors and hematological malignancies amid the COVID-19 pandemic to adequately inform patients and their family members about the risk/benefit ratio of each treatment intervention, while clinicians are recommended to take into account national therapeutic guidelines or national specialty recommendations in relation to COVID-19.
Restrictions should remain
“It appears that patients with active cancer and/or receiving treatment for cancer are likely to be at higher risk for complications from COVID-19 and the guidance in place for any person would be the same for any patient with cancer — good handwashing, physical distancing and avoiding going out into public unless it is absolutely essential,” Markham told Healio.
Even when social-distancing restrictions are lifted, it is important for patients with cancer to pretend that those restrictions remain in place, Markham added.
“This is truly the safest course of action — to pretend that we are under a shelter in place or stay at home order even when those orders have been lifted,” Markham said. “Wearing a mask in public is also an important step that patients with ovarian cancer should continue to take.”
Cristiana Sessa, MD, consultant for gynecological cancer at the Oncology Institute of Southern Switzerland and deputy chair of the ESMO Guidelines Committee, agreed.
“We recommend keeping all prevention measures, including frequent handwashing, disinfectant use and social-distancing in place — this has all become a new standard of practice,” Sessa told Healio. “Restrictions are important to keep in place as to not increase risks for all our patients, including those with ovarian cancer, as well as their treating clinicians.”
For those patients understandably concerned about visiting the hospital to receive treatments, Sessa said clinicians should put their patients at ease.
“We are now letting our patients know that it is time to start thinking about coming back to the hospital to improve their cancer outcomes,” Sessa told Healio. “When patients are scared and have doubts, it is important for them to be able to contact a professional immediately, and for this reason, we have professionals available via phone or email 24-hours per day to address any patient concerns or anxieties.”
Traditionally, the beginning of any cancer treatment includes a discussion of the potential risks/benefits and goals of treatment. However, it is important that all of patients with ovarian cancer understand the risk of treatment during this specific time, according to Markham.
“What has made the scenario with the COVID-19 pandemic more nuanced is that we are having to take more steps to ensure our patients understand the particular risks and benefits of starting treatment now vs. delaying treatment,” Markham said. “In terms of misinformation during the COVID-19 era, this is a battle in medicine in general. There is a lot of misinformation out there about cancer treatments and potential cures for cancer. The COVID-19 pandemic is no exception and certainly has brought out a lot of untrustworthy information. For this reason, I am quick to point out trusted resources to my patients and inform them of false and dangerous information, such as ingesting or injecting household cleaners, which is certainly misinformation that we want to address head on.”
Treatment during COVID-19
Although the screening process for ovarian cancer has not changed since the COVID-19 pandemic began, the management and treatment of this population of patients has been affected.
“Unfortunately, there are no effective screening measures for ovarian cancer, so COVID-19 has not impacted screening in this patient population — with the exception of patients who have hereditary risk for breast and ovarian cancer,” Markham said. “For women with an increased risk for breast cancer, screening mammography has often been delayed because of COVID-19. This is due to the initial recommendations to delay non-urgent screening procedures as well as surgeries.”
The staging process for ovarian cancer has changed, Sessa said.
“What ESMO has done is prepare special guidelines with recommendations for treatment in the COVID 19 pandemic that can be integrated into the ESMO guidelines for the management of gynecological cancers,” Sessa said. “We tried to establish a priority for patients who may not be able to come to the hospital but who need immediate attention, such as those with acute symptoms of ovarian cancer, those with acute symptoms after a surgery for ovarian cancer or other gynecological tumors. In these particular cases, we recommend seeing the patient and planning the imaging or other investigations needed in a reasonable period of time, within 1 day or 2 days, to solve symptoms and define the stage of disease.
Regarding approved surgeries for patients with ovarian cancer, Markham said some delays have been recommended.
“The guidance that came out from the CDC and other public health officials regarding surgeries was to minimize non-urgent or elective surgeries. However, in general, ovarian cancer surgery is not considered elective,” Markham said. “At my institution, patients with ovarian cancer continue to be seen and operated on in a timely fashion and it has been reassuring to our patients with ovarian cancer that they have been able to continue their treatments.”
With that said, treatment for ovarian cancer should be modified when possible, Markham added.
“All of this comes down to individual patient risk — both for worsening of cancer but also for developing more severe COVID-19 symptoms and complications if patients are exposed,” Markham said. “All decisions about screening, treatment, surgery or other medical visits should be done through shared decision-making on the part of the treating clinician and the patient, based on that patient’s individualized risk.”
Sessa agreed.
“Our priority is value-based. While there may be patients who require more immediate treatment than others, we will continue to care for all patients to ensure the potential for cure,” Sessa said. “If some treatments are delayed, we want to reassure our patients and let them know that we know what we are doing and would never place them at risk for bad outcomes.”
It is also imperative for clinicians to participate in tumor boards where experts discuss individual patient cases via video conferencing and then relay the information to the patient via video conference or during an in-office visit.
“This is such an important moment that requires an in-person discussion to be when possible with all safety measures in place, of course,” Sessa said.
COVID-19 has given clinicians another opportunity to address the goals of care for each individual patient with ovarian cancer, Markham said.
“This is certainly important with any treatment that we offer. We try to incorporate goals of care discussions with all patients, but I know this is not always done at the level it needs to happen,” Markham said. “COVID-19 has given us a new opportunity to have tough conversations with our patients, not because we are worried that they may not get a ventilator, but because it is an important topic to talk about, for everyone, and if we do not take into consideration what a patient’s goals are then we have missed a real opportunity to take better care of our patients.”
References:
- ASCO Survey on COVID-19 in Oncology (ASCO) Registry. https://www.healio.com/news/hematology-oncology/20200413/asco-launches-registry-to-track-covid19-symptoms-severity-among-patients-with-cancer. Accessed June 2, 2020.
- ESMO Management and Treatment Adapted Recommendations in the COVID-19 Era: Epithelial Ovarian Cancer. https://www.esmo.org/guidelines/gynaecological-cancers/gynaecological-malignancies-epithelial-ovarian-cancer-in-the-covid-19-era. Accessed June 2, 2020.
Collapse
Read more about
Click Here to Manage Email Alerts