Outcomes of Gynecologic Cancer Surgery During the COVID-19 Pandemic: An International, Multicenter, Prospective CovidSurg–Gynecologic Oncology Cancer Study

Abstract

ABSTRACT The logistic strain on the health care system during the COVID-19 pandemic disproportionally affected women with gynecologic cancers and surgical care delivery. Surgeries were being delayed or replaced by systemic or palliative care options with less favorable outcomes. The true impact of pandemic-related modifications to clinical management of surgical gynecologic cancer patients remains unknown. This international prospective cohort study aimed to analyze the clinical and surgical outcomes of patients with gynecologic cancer who had or were planned to have first-line treatment during the COVID-19 pandemic. This study was part of an umbrella study exploring the impact of COVID-19 in surgical patients across all solid cancer types and multiple specialties (GlobalSurg-CovidSurg Consortium). All hospitals that included patients discussed for surgery regardless of whether they were operated on or not were included in this study. Patients who were planned for curative or life-prolonging surgery or underwent surgery for gynecologic cancer during the COVID-19 pandemic were included. Patients were followed up from the time of multidisciplinary team decision for surgery for the next 3 months, representing the first peak period of the pandemic. The primary outcome was the incidence in pandemic-related changes in care, whereas secondary outcomes included perioperative morbidity and mortality, wait time before surgery, postoperative hospital stay time, proportion of patients not operated on with progression to incurable disease or death, and a composite adverse outcome to measure the potential impact of any treatment delays or adjustment. A total of 3973 patients from 227 centers across 52 countries were included, of whom 3784 (95.2%) ultimately underwent surgery. The majority of patients had uterine or ovarian cancer (n = 3270 [82%]) and were from high-income countries (n = 2906 [73%]). A total of 189 operations (7.9%) were canceled. Although the median time from multidisciplinary team decision to surgery was 3 weeks, 11.2% (424/3784) of patients underwent surgery more than 8 weeks later. Among ovarian cancer patients with stage III/IV disease and a significant delay (>8 weeks) of surgery, 83.6% had neoadjuvant chemotherapy compared with 21% for those who did not experience a delay (P < 0.0001). The overall 30-day postoperative complication rate was 19.3%, and the postoperative COVID-19 infection rate was 0.6%. The length of stay was significantly longer for COVID-19–infected patients (median, 8.5 vs 4 days; P = 0.0001). When evaluating the entire cohort, a total of 20.7% (823/3973) had their standard of care adjusted because of the pandemic. Patients in low- and middle-income countries (P < 0.0001), areas under full lockdown (P < 0.0001), with worse performance status (P < 0.0001), more comorbidities (P = 0.0242), higher American Society of Anesthesiologists grade (P = 0.010), ovarian cancer (P < 0.001), and stage 3 or 4 diseases (P < 0.0001) were more likely to have their operations more than 8 weeks after the MTD decision. There was no significant difference in 30-day mortality among those with delayed operations; however, a significant difference was observed for the adverse composite outcome owing to delay including unresectable disease or disease progression, emergency surgery, and death (95/424 [22.4%] vs 601/3360 [17.9%]; P = 0.024). The results of this study demonstrate that despite a very low risk of perioperative COVID-19 infection, a significant portion of gynecologic cancer surgical patients had treatment plan modifications associated with early negative impact.