How Do Doctors Manage Ovarian Cancer in the Time of COVID?

No matter at what stage of ovarian cancer a woman is diagnosed, her goals and her doctor’s goals are the same: to stop, or at least slow the cancer and extend her life. But just as many women contemplate their next move, COVID-19 is complicating the decision-making process.

Women with cancer are at particularly high risk for infection, both due to their disease and its treatments. Protecting them while the virus spreads is essential.

“We’re in this unprecedented time,” says Dr. Karen Zempolich, gynecologic oncologist at St. Mark’s Hospital in Salt Lake City, Utah. “How do we make decisions about how to proceed with cancer care in the setting of a pandemic?”

One way in which doctors have protected their most vulnerable patients during this time is by conducting some visits via telemedicine, rather than in person. Another is to change the order of treatment, which is why many cancer doctors have had to ask the question: Surgery first, or chemotherapy?

Which Comes First: Surgery or Chemo?

Just about everyone who is diagnosed with ovarian cancer goes down the same treatment pathway, which involves some combination of debulking surgery to remove all visible traces of the cancer, and chemotherapy.

For most women, the surgery-first approach is optimal. After surgery, they’ll get chemotherapy to get rid of any cancer cells that remain. But in some cases, doctors give chemotherapy first—called neoadjuvant chemotherapy—to shrink the tumor and make it easier to remove.

Usually, the factors that go into the decision of whether to have surgery or chemotherapy first are the patient’s health, how far the cancer has spread, and the likelihood of the surgeon being able to remove all the cancer without causing significant side effects, like the need for a colostomy bag. “Now I would add that another factor is COVID,” Dr. Zempolich says.

The Switch to Chemo First

When the new coronavirus first began spreading across the country, gynecologic oncologists met virtually to discuss the safety of putting their ovarian cancer patients through surgery when in some cities, hospitals were filling up with COVID-19 patients. “I would say that we leaned towards chemotherapy upfront a little more than we might otherwise,” Dr. Zempolich says.

For women who start with neoadjuvant chemotherapy, the typical routine is to get a combination of two different chemo drugs given through an IV every three weeks. Each one of these treatment periods is called a cycle. Generally, the treatment involves about three cycles of chemo, followed by tests to see whether the cancer has regressed.

As the initial COVID wave passed, doctors began to revert back to their original treatment strategy. “We’ve shifted back as the surge of [COVID] is now much better understood,” Dr. Zempolich says.

Does Treatment Order Change the Outcome?

One question that may be in the forefront of women’s minds as they contemplate having chemotherapy first is, “Will it affect my survival?”

Fortunately, the answer seems to be no. Whether you have chemotherapy first and then surgery, or surgery first and then chemotherapy, “Both of those have equal survival,” Dr. Zempolich says.

“So whether surgery is delayed because of COVID or because of medical conditions or extent of disease, and chemotherapy is chosen, I feel very confident that really, that will not have a negative impact on how well we’re going to cure a patient,” she adds. “It just has to be tailored to the situation, the patient, and these days, the time that we live in with the COVID pandemic.”

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