Endometrial cancer is considered a disease with good prognosis, since most patients are diagnosed at an early stage of the disease. However, physicians have started delaying non-urgent procedures in order to face the growing need for assistance of COVID-19 patient. This study reports a significant impact of the COVID-19 outbreak on the patterns of presentation and treatment of endometrial cancer patients.
Endometrial cancer (EC) is one of the most common gynaecological cancers in developed countries. Generally, EC is considered a disease with good prognosis, since most patients are diagnosed at early stage of disease. Regular visits and prompt assessments in patients with new-onset symptoms have improved the early detection of uterine malignancies. However, over the last year, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) respiratory disease (coronavirus disease 2019, COVID-19) has spread worldwide. In order to flatten the growth curve and face the growing need for assistance of COVID-19 patients, physicians have started delaying non-urgent procedures. This has partly translated into a risk of late diagnosis and treatment procrastination, with significant negative impacts on the outcomes of cancer patients. Emerging data suggest that the COVID-19 outbreak might influence patterns of disease presentation, compromising the possibility of early access to care for patients with malignancies. However, until now, no studies have specifically evaluated the real impact of COVID-19 on the attitudes, practice, and workflow in oncology. Therefore, this study evaluated whether diagnostics and treatment patterns of EC patients have change before and during the pandemic.
This was a multi-institutional retrospective study coordinated by the IRCCS Foundation, which involved 54 high-volume centres in Italy. It collected medical records of consecutive patients with newly diagnosed EC treated in Italy before (period 1: from March 1, 2019, to February 29, 2020) and during (period 2: from April 1, 2020, to March 31, 2021) the COVID-19 outbreak. Cases treated in March 2020 were excluded to minimise possible bias. Eligible patients were adults (≥18 years old) with a confirmed histological diagnosis of EC, regardless of the type of treatment. Data concerning surgical procedures, peri-operative details, adjuvant therapy, and follow-up evaluations were recorded in computerised databases and updated on a regular basis. During the two study periods, there were no significant differences in the facilities available for patient care. The primary endpoints were 1) prevalence of patients affected by International Federation of Obstetrics and Gynecologists (FIGO) stage >I disease at presentation, and 2) prevalence of adjuvant therapy indication in the two periods. The secondary endpoints were changes in EC management during the COVID-19 outbreak. Data were statistically analysed.
In total, medical records of 5,164 EC patients were retrieved: 2,718 and 2,446 women treated in period 1 and period 2, respectively. The prevalence of endometrioid FIGO grade 1, 2, and 3 was consistent over the study period (p=0.855). However, the prevalence of non-endometrioid EC was lower in period 1 than in period 2 (15.6% vs. 17.9%; p=0.032). During period 2, patients were more likely to be treated for advanced-stage disease (FIGO stage >I), with a high rate of patients with FIGO stage III–IV disease (12.8 vs. 14.3%, and 4.7 vs. 6.8%, in periods 1 and 2, respectively). Surgery was the mainstay of treatment before and during the COVID-19 pandemic (p = 0.356). The adoption of minimally invasive surgery was consistent in the two study periods (p=0.976). Before and after COVID-19 pandemic (periods 1 and 2), sentinel node mapping, sentinel node mapping plus backup lymphadenectomy, and lymphadenectomy (pelvic and/or para-aortic) were performed in 37.0 vs. 42.5%, 8.9 vs. 10.2%, and 26.0 vs. 26.1% of the patients, respectively. Nodal assessment was omitted in 27.3% and 21.2% of the patients treated in period 1 and 2 (p<0.001). Conversely, the prevalence of patients undergoing sentinel node mapping (with or without backup lymphadenectomy) increased during the COVID-19 pandemic (46.7 vs. 52.8% in period 1 and 2; p<0.001). Overall, 1,280 (50.4%) and 1,021 (44.7%) patients had no adjuvant therapy in period 1 and 2, respectively (p<0.001). The adoption of vaginal brachytherapy as adjuvant treatment remained stable in the study periods (11.9% vs. 11.1%; p=0.325). Adjuvant therapies indication increased during the COVID-19 pandemic (p<0.001), in particular the use of adjuvant radiotherapy (26.8% vs. 30.7%; p=0.001) and chemotherapy (25.1% vs. 30.1%; p<0.001), alone or in combination.
Compared with the pre-pandemic period, patients with endometrial cancer were more likely diagnosed with advanced-stage disease (FIGO stage >I) during COVID-19 pandemic, with a consequently higher indication for adjuvant therapies. Although further prospective evidence is necessary to corroborate the results, the data suggest that the COVID-19 pandemic had a significant impact on the characteristics and patterns of care of EC patients. These findings highlight the need to implement healthcare services during the pandemic.