A total of 255 participants from four international societies representing 30 different countries in the European and Middle East and North-Africa regions completed the questionnaire. The completion rate among the respondents was 89%. The majority (n=177, 71.7%) of participants were gynaecological oncologists from university hospitals (n= 162, 65.6%) with at least an Intensive Care Unit with cardiopulmonary support available at their institutions (188, 76.1%). Most respondents were highly experienced physicians (161, 65%) with more than 11 years of experience in their respective fields (Mean ± SD; 16.9 years ± 9.9), and the majority were in consultant leadership positions (167, 67.6%). The participants were mostly affiliated with certified cancer centres (163, 66.0%) and the majority had work volumes beyond 30 treated cases per year for ovarian, cervical and endometrial cancers (49.8%, 31.1%, and 59.0%, respectively) (Table 1).
Table 1: The characteristics of the participants
Parameter
|
n (%)
|
Type of Institution
|
|
University Hospital
|
162 (65.6)
|
District General Hospital
|
42 (17.0)
|
General Practice
|
13 (5.3)
|
Private Practice
|
23 (9.3)
|
Other
|
15 (6.1)
|
Cancer Centre
|
9 (3.6)
|
Specialist Hospital
|
4 (1.6)
|
Nursing Home
|
1 (0.4)
|
Medical Supplier
|
1 (0.4)
|
Certified Cancer Centre
|
|
Yes
|
163 (66.8)
|
No
|
81 (33.2)
|
Level of ICU
|
|
ICU with cardiopulmonary support
|
188 (76.1)
|
ICU with ECMO support
|
54 (21.9)
|
Intermediate Care Unit
|
52 (21.1)
|
None
|
5 (2.0)
|
Ovarian Cancer Cases Treated Yearly
|
|
1 – 10
|
38 (16.2)
|
10 – 20
|
36 (15.3)
|
20 – 30
|
44 (18.7)
|
>30
|
117 (49.8)
|
Cervical Cancer Cases Treated Yearly
|
|
1 – 10
|
62 (26.5)
|
10 – 20
|
62 (26.5)
|
20 – 30
|
35 (15.0)
|
>30
|
75 (32.1)
|
Endometrial Cancer Cases Treated Yearly
|
|
1 – 10
|
22 (9.4)
|
10 – 20
|
29 (12.4)
|
20 – 30
|
45 (19.2)
|
>30
|
138 (59.0)
|
Perform Elective Surgery
|
|
Yes
|
155 (62.8)
|
No
|
66 (26.7)
|
NA
|
26 (10.5)
|
Type of Elective Surgeries Performed
|
|
Gynaecological Cancer Surgery
|
132 (96.4)
|
Benign Surgery
|
5 (3.6)
|
Cases for Gynaecological Cancer Surgery
|
|
Curative
|
121 (49.0)
|
Palliative
|
39 (15.8)
|
Emergency
|
105 (42.5)
|
All Indications
|
80 (32.4)
|
Diagnostic
|
1 (0.4)
|
None
|
1 (0.4)
|
Running clinics
|
|
Gynaecological Oncology
|
134 (54.3)
|
Second Opinion
|
46 (18.6)
|
Follow-Up
|
57 (23.1)
|
Therapy Monitoring
|
54 (21.9)
|
Other
|
4 (1.6)
|
Colposcopy
|
2 (0.8)
|
Urgent appointments
|
1 (0.4)
|
Breaking bad news
|
1 (0.4)
|
ECMO: Extracorporeal membrane oxygenation, ICU: Intensive Care Unit, NA: not announced
Surgical Interventions
During the pandemic period, most respondents continued to perform elective surgeries (155, 62.8%), almost exclusively for oncological cases (132, 96.4%). Of which curative cases (121, 49.0%) and emergencies (105, 42.5%) were the most prioritized. Generally, there was a significant reduction in operative capacity during the pandemic period with one third (61, 37.2%) of respondents stating a reduction between 75% – 100% of their operative capacities (combined benign and oncology cases). Additionally, benign cases tended to be reduced between 75 – 100% in 45.4% of respondents while oncology cases saw a reduction within the range of 0 – 25% in 71.4% of participants.
On average, patients had to wait up to 5 weeks longer for their elective surgery appointments during the pandemic as compared to previous years (mean wait time in weeks ± SD; 5.2 ± 8.3). For patients requiring radiotherapy treatment, the mean waiting time was 4.5 ± 2.4 weeks, while patients subjected to radio-chemotherapy had a mean waiting time of 9.6 ± 19.6 weeks.
Among our combined cohort, the most adopted triaging techniques were anamnestic data (125, 50.6%), followed by COVID-19 swab tests (124, 50.2%). The use of serology was documented in only a minority of participants (20, 8.1%). Triage modalities utilized by respondents are demonstrated in Figure 1. Patients positive for COVID-19 were frequently present in the institutions of 22.2% of respondents (n = 48). However, regular COVID-19 testing of healthcare staff was mostly conducted under symptomatic settings (101, 47.0%).
Shortages due to COVID-19 were pronounced among our respondents. Difficulties in providing medical care were demonstrated in 34.4% (n = 74). Additionally, when operating on a patient with unknown COVID-19 status, classical surgical masks were utilized to conserve resources (71, 40.1%). Moreover, 34.1% of respondents did not have access to a separate operating room for patients tested positive with COVID-19. The majority of participants report that their respective institutions have developed SOPs for the perioperative management of gynaecological cancers in COVID-19 settings (104, 59.0%).
When looking at the main gynaecological cancers treated among all participating centres, prioritization of all cancer types (ovarian, cervical, and endometrial) was given to primary cases in the early stages with good ECOG status Figure 2. Interestingly, 43.4% of clinicians stated they had changed their decision-making process regarding offering surgical treatment to their patients in light of the pandemic, as compared to 50.0% who had not changed their processes. About 51.0% of the surveyed respondents stated that in cases where surgery would be indicated, they were more likely to treat ovarian cancer cases with neoadjuvant chemotherapy instead of surgery as a result of the pandemic. This was not the case for endometrial or cervical cancer cases, where more than 70% of respondents stated they did not have an increased tendency to administer neoadjuvant treatment.
Radiation Therapy and Radiochemotherapy
For patients requiring radiation therapy or radiochemotherapy respondents stated only a minority of cases required active postponement of treatment considering the COVID-19 pandemic (15.8% and 10.8%, respectively). However, 20.5% respondents stated they did need to change or adapt the radiation regimens, in which fractionation was the aspect to be frequently altered (20, 55.6%). Regimen alteration was mostly adopted in cases with palliative intent (39, 15.8%), followed by cases with curative intent (27, 10.9%), and cases which require symptomatic control (26, 10.5%).
Outpatient Clinics
More than half of the respondents stated they continued to run their outpatient clinics as usual (142, 76.3%), of which, more than half of the running clinics were gynaecological oncology outpatient clinics (134, 54.3%). Patients were followed up, kept well-informed regarding guidelines and risks of COVID-19 mainly though telephone calls (160, 64.8%), E-mails (61, 24.7%), and video conferences (15.4%). Social media channels were not reported to be used at that initial phase.
General Information and Triaging
About 62% of respondents expressed their concerns regarding triaging and prioritising patients for treatment during the pandemic period. Nearly 85.0% of participants stated that they did discuss these concerns within their internal team structures. Furthermore, approximately 76% of the entire cohort demonstrated lack of awareness with regards to the clinical pathways for patients with COVID-19 and gynaecological malignancies. While most respondents were open to receive supplementary information or training through webinars (29, 11.7%), conferences (20, 8.1%), or tumour boards (19, 7.7%), about half of the entire cohort rejected the need to receive professional support to deal with the ethical issues associated with patient management during the COVID-19 pandemic.
Clinical Trials
More than half of the respondents experienced an overall reduction in their study and trial activities as compared to the pre-COVID-19 era (45, 54.9%). About 35.5% stated they continued to run ongoing clinical trials during the pandemic period, compared to 64.5% who stopped their clinical trials and 19.7% who halted recruitment of new patients. The majority also continued to provide maintenance therapy (including PARP-inhibitors, Bevacizumab and hormonal therapies as indicated) to their patients during the pandemic (194, 78.5%).
The majority of the trials that continued to run during the pandemic were Phase III trials (Figure 3). Respondents stated that the main criteria for prioritizing which trials to continue running were trial costs and the size of the trial as shown in Figure 4 A.
About 47.3% disclosed that the pandemic has negatively impacted their financial structure and support for clinical trials. Of those, one quarter (21, 60.0%) evaluated the severity of this impact as being moderate. Subsequently, the majority stated they did not have relevant support from their central administrative bodies (51, 70.8%) or the government (57, 79.2%) to preserve their trial activities. In addition, governmental guidelines for the conduction of clinical trials within the COVID-19 era were severely lacking (28, 51.4%) Figure 4 B.
In terms of respondents’ practices to trials within a COVID-19 context, 20.3% routinely screened for COVID-19 patients. Most of which was oriented around Phase II and III clinical trials (13.4%, both). The presence of COVID-19 positive patients was reported by 18.9% of respondents (n = 14). In such cases, stopping or delaying the intervention was the most commonly adopted mitigation strategy (7, 50.0%).