Pandemic Led to Surgical Delays in Gynecologic Cancers, and Worse Outcomes

NEW YORK — The first wave of the pandemic caused care disruptions that resulted in worse health outcomes among gynecologic cancer patients undergoing surgery, according to a prospective, international cohort study.

Among nearly 4,000 gynecologic cancer patients worldwide, only 0.6% reported a SARS-C0V-2 infection within 30 days of surgery between March and August 2020, a “reassuringly” low rate, reported Elaine Leung, PhD, of the University of Birmingham in England.

These rates were lower compared to other cancers in this international cohort, she said in a presentation at the International Gynecologic Cancer Society (IGCS) annual meeting here.

However, early pandemic disruptions caused surgery delays and cancellations, with 20% of patients experiencing changes in their care management.

Overall, 8% of the patients ultimately did not have a procedure that was meant to be curative and life-prolonging, and 11% of the patients waited more than 8 weeks for a procedure, including 16% of those with ovarian tumors, Leung said.

Delays and cancellations had an impact on morbidity and mortality, she said.

In patients who did not have a planned operation, 2.7% died within 3 months of the initial decision to operate. Additionally, women who had a delayed operation had a significantly higher risk of the composite adverse outcome of unresectable disease or disease progression, emergency surgery, or death compared to those who did not have a delayed procedure (22.4% vs 18%, respectively; P=0.024).

“Despite all the concern of healthcare and hospitals being sites of COVID spread, that was not what was seen in this study,” said IGCS discussant Kevin Holcomb, MD, of Weill Cornell School of Medicine in New York City.

But, Holcomb added, “the pandemic was extremely disruptive,” resulting in care interruptions and adverse outcomes.

“In future healthcare emergencies, which unfortunately I believe there will be, we have to really surge resources to the women requiring the most complex surgeries, to avoid delays in those planned procedures,” he said.

In this prospective, international study, which was also published recently in the American Journal of Obstetrics and Gynecology, the researchers aimed to evaluate the magnitude of adverse outcomes linked to the disruption of gynecologic surgical care during the beginning of the COVID-19 pandemic.

Patients were included only if they were supposed to have a curative, life-prolonging surgery, and those without a fixed plan for surgery were not included in the analysis.

The primary outcome of the study was 30-day postoperative SARS-CoV-2 infection rate after elective surgery, and secondary outcomes included 30-day mortality rate and the pandemic’s impact on changes in care.

Leung’s group included 3,973 gynecologic cancer surgery patients treated from March to August 2020 across 55 countries. Around 60% of study participants were from Europe and Central Asia, and just under three-quarters were from high-income countries. Around 46% of study participants had uterine cancer, 37% had ovarian cancer, 12% had cervical cancer, and 6% had vaginal or vulvar cancer.

The 30-day mortality rate was 0.8%, and the overall complication rate was 19.3%.

There were 22 cancer patients infected with SARS-CoV-2 in this cohort. Patients infected with SARS-CoV-2 had a poorer performance status compared to those who did not, the researchers found. Additionally, COVID-infected patients stayed longer in the hospital compared to those who were not infected (9 vs 4 days, respectively), and also had a higher complication rate (64% vs 19%) and higher mortality rate (18% vs 0.7%).

Leung noted that delayed or cancelled operations were more likely to occur in low- or middle-income countries, or in areas that had a full lockdown.