BGCS framework for care of patients with gynaecological cancer during the COVID-19 pandemic The British Gynaecological Cancer Society (BGCS) are a group of clinicians with a specialist interest in gynaecological cancer. They have recommended a framework of guidelines to help clinical staff decide how cases of ovarian cancer should be treated and managed during the current public health crisis. The aim of the guidelines is to maintain NHS services for ovarian cancer patients as far as possible at a time when the risk to patients of certain treatments is increased due to COVID-19. These guidelines will affect patients going into hospital for surgery and those being treated with chemotherapy and maintenance therapies. Patients having treatment for recurring ovarian cancer will also be affected. Patients may no longer have access to a clinical nurse specialist (CNS) as many are being redeployed. Patients may have to communicate with various other members of their multi-disciplinary team (MDT). However, your team will always explain treatment choices to you, the risks and benefits of treatments available and their possible outcomes. They will also discuss the risks of COVID-19 infection. The guidelines are not compulsory but are there to help clinicians when they are making decisions for individuals, at that specific moment in time, within the demands of local services. . Surgery for ovarian cancer Patients who are diagnosed with ovarian cancer are admitted to hospital and usually have surgery that aims to remove as much of the visible cancer as possible. This can take a lot of operating time and often requires a high level of intensive care unit support and can lead to a prolonged post-operative in-patient stay. The current crisis has led to increased demand for these services so intensive care beds may be unavailable and surgery time may be limited. If primary surgery is not possible because of these circumstances the BGCS recommends that ovarian cancer patients are treated with chemotherapy, either carboplatin alone or carboplatin and Taxol. This may also include treatment via injection to stimulate blood cells for improved immunity. Patients may be asked to do this injection at home. All gynaecological cancer patients will be placed into a group that meets their clinical needs: Group 1 Patients who require emergency surgery in 24 hours to save life, and those who need urgent surgery within 72 hours. Group 2 Patients who need surgery to be performed within four weeks. Ovarian cancer patients needing primary surgery are expected to be in this group. Ovarian cancer patients will be further prioritised by their symptoms, complications and the rate at which their cancer is spreading. Patients needing debulking surgery (removal of both ovaries, both fallopian tubes, womb, cervix and omentum) can be assessed for surgery after three cycles of chemotherapy (three sessions, one every 21 days). Current evidence supports delayed debulking after three cycles of chemotherapy, so surgery may go ahead then if it is possible to deliver safely and if intensive care beds are available. Some patients may still be advised to continue with further chemotherapy before their surgery. Decisions about surgery after the completion of chemotherapy will also take into account how much of the cancer is left to remove, what symptoms the patient has and their general health. Ovarian cancer patients experiencing a recurrence will be treated using chemotherapy and will not be able to have secondary debulking surgery although they may be offered surgery to relieve symptoms. Group 3 Patients whose surgery can be delayed by 10 to 12 weeks with a limited impact on their health outcomes, until more intensive care support is available.Patients where the risk from surgery during the COVID crisis outweighs the benefit. . Chemotherapy for ovarian cancer Clinicians will follow local guidelines and take account of the benefits of chemotherapy and the patient’s risk of COVID-19 infection during treatment. Where possible less resource-intensive treatments should be considered, such as carboplatin only chemotherapy or using PARP inhibitors. Patients with high grade serous and endometrioid ovarian cancer are expected to respond well to first line platinum based chemotherapy (such as carboplatin) and should be a high priority to receive this. Avastin (bevacizumab) as a maintenance therapy should be considered low priority because it requires high resources and lacks clear data on survival benefits. Chemotherapy for patients with platinum sensitive relapsed ovarian cancer (cancer that has come back more than six months after first line chemotherapy) should be considered for patients with symptoms if it is not possible to delay treatment. Chemotherapy for patients with platinum resistant disease (cancer that has returned less than six months after first line treatment) would be low priority. Patients already being treated with chemotherapy may be asked to stop early, from cycle 5 rather than cycle 6. Patients eligible for PARP inhibitors after responding well to chemotherapy may be asked to start these early, after cycle 4. Chemotherapy for non-serous, non-endometrioid and low grade serous ovarian cancer has limited benefits and will be low priority. Hormonal therapies will be considered when appropriate. Chemotherapy for ovarian cancer is placed within six groups: Group 1 Curative therapy with a high chance of success (greater than 50 per cent – more than half)., Therapy that adds at least a 50 per cent chance of cure compared to surgery alone, or treatment given at relapse. Group 2 Curative therapy with a 15 to 50 percent (one in six to over half) chance of success. Therapy adding a 15 to 50 per cent chance of cure compared to surgery alone, or treatment given at relapse. This group may include patients with high grade serous or endometrioid ovarian cancer, particularly those who are BRCA positive. Group 3 Curative therapy with a 10 to 15 per cent (one in 10 to one in six) chance of success. Therapy which adds a 10 to 15 per cent chance of cure compared to surgery alone, or treatment given at relapse. Non-curative therapy with a greater than 50 per cent chance of extending life by more than one year. This group may include some patients with high grade serous or endometrioid ovarian cancer. Group 4 Curative therapy with a 0 to 15 per cent (nil to one in six) chance of success. Therapy that adds less than a 10 per cent (one in 10) chance of cure compared to surgery alone, or treatment given at relapse. Non-curative therapy with a 15 to 50 per cent (one in six to a half) chance of extending life by more than one year. This group includes chemotherapy for platinum sensitive relapsed ovarian cancer. Group 5 Non-curative therapy with a greater than 50 per (more than a half) chance of temporarily controlling the cancer but extending life by less than one year. This group includes chemotherapy for platinum resistant ovarian cancer. Group 6 Non-curative therapy with a 15 to 50 per cent (one in six to a half) chance of temporary tumour control and extending life by less than one year. Treatment with PARP inhibitors for relapsed ovarian cancer Platinum based chemotherapy is standard treatment for patients with platinum sensitive relapsed ovarian cancer. Some BRCA positive patients at their first platinum sensitive relapse can be treated with a PARP inhibitor as a safer alternative to chemotherapy as this can be taken at home. PARP inhibitors are funded by NICE during the COVID-19 crisis. Other BRCA positive patients and those who aren’t affected by the BRCA mutation may be advised to use platinum based chemotherapy followed by a PARP inhibitor as a maintenance therapy. . Outpatient appointments These will aim to be delivered via telephone or other remote methods wherever possible. Improving cancer treatments and services during the COVID crisis The NHS is working to establish sites or areas within hospitals which are COVID-free so that cancer treatment can be given there. Progress on this depends on the presence of COVID-19 in the locality. Cancer services are moving to increase their capacity and return to the pre-COVID levels of two week wait cancer referrals. The benefits of chemotherapy and the risks of COVID-19 infection during treatment need to be discussed in detail with all cancer patients. You may be asked to consider possible alternative treatments that reduce hospital attendance, such as single agent carboplatin chemotherapy or using PARP inhibitors which can be taken at home. . Support Ovarian cancer patients would normally have the support of a clinical nurse specialist (CNS). However, as hospitals face a demand for nursing care due to the COVID-19 crisis CNS’s are likely to be deployed away from cancer services. BGCS made a number of recommendations to continue CNS support at some level where possible. They also suggest providing details of cancer support charities. The Ovacome Support Service is available Monday-Friday 10am-5pm. Call Freephone 0800 008 7054 Email [email protected] Instant messaging via our website ovacome.org.uk You can text us on 07427 390 504. You can Skype us at ovacome.support In addition, to offer further support during the public health crisis, we have introduced Staying Connected, our new remote support service. This will include informative videos, interviews, and interactive video sessions where you can speak to experts directly and ask them your questions. We’ll also be running group sessions where you can speak with others affected by ovarian cancer. Please contact us via any of the methods above or look on our Staying Connected page for further information.