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).