Management of Gynecologic Cancer During COVID-19 Pandemic: South Asian Perspective

Gynecological Cancer Burden in India

More than 1.3 million Indians are diagnosed with cancer every year and over 800,000 deaths are attributable to this deadly disease. ³ The projected incidence of all cancer among Indian females was 712,758 in the year 2020, accounting to an incidence rate of 103.6/100,000 women, which was higher than for Indian males (679,421 men in the year 2020). Among female cancers, 155,630 cancers will be attributed to gynaecological malignancies which include cancers of the uterine cervix, uterine corpus, ovary, vagina, vulva, and gestational trophoblastic diseases. It was predicted that 1 in 36 Indian women would be diagnosed with a gynaecologic cancer in their lifetime. Breast cancer was the most common cancer among females followed by cervical and ovarian cancers. Majority of cancers are diagnosed as locoregional/locally advanced as seen in 60% cases of cervical cancer. As a result, most patients would receive multimodal cancer directed treatment as first treatment of choice. ⁴

With the new data coming from GLOBOCON 2020, the incidence of new cervical cancer cases was 6,04,127, new ovarian cancers 313,959 and new uterine cancers 414,367 (2.2% of all cancers in females) globally. The mortality was 341,831 (3.4%) from cervical cancer, 207,252 (2.1%) from ovarian cancer and 97,370 (1.0%) from uterine cancer.^3,5 India accounts for 20% of the world’s burden of cervical cancer. ³

Concerns About Patients Suffering from Gynecological Malignancy during COVID-19 Pandemic

COVID-19 had led to immense health-related, economic, and social suffering and harm worldwide. 20% of patients who expired due to COVID-19 in Italy were cancer patients. ⁶ COVID-positive Cancer patients had a 40% mortality rate in China, much higher than any other cancer related cause.^6,7 India was no exception to this tragedy with many facing job losses, financial destabilization, economic shrinkage, and loss of livelihoods, especially women. The situation is compounded in women with cancer, due to the chronic nature of their disease, need for frequent hospital visits, possible immunosuppressive therapies, need for strict follow up, and multidisciplinary approach of treatment to the illness. Though management of cancer cases is not an immediately life-threatening condition, the repercussions of delaying treatment may have serious health outcomes. A cross-sectional survey on perspectives of 310 patients in Lucknow regarding the impact of COVID-19 pandemic on cancer treatment showed a significant adverse impact in 5 domains (financial status, healthcare access, stress, anxiety, depression). The maximum impact was seen in patients earning less than INR 35,000 and living in rural areas. ⁸

Patients with cancer who are admitted, receiving chemotherapy/radiation therapy may be at an increased risk of COVID-19 infection, according to a recent JAMA Oncology report. ⁹ However, most infected patients belonged to lung cancer group and there were no patients with gynecologic cancer in this study. Due to this, experts have suggested revising the goals of treatment, expected benefits of treatment, and avoiding complications of COVID-19 in an immune-compromised cancer patient. Infectious diseases are the second-leading causes of mortality in patients with cancer, whose immune systems are often compromised and COVID can be one such infection during time of pandemic. The cause of their systemic immunosuppressive state can be malignancy or anti-cancer treatments, such as chemotherapy, targeted therapy, and immunotherapy. Most cancer patients are, therefore, asked to avoid non-essential travel to the hospital and urged to take advice online. ¹⁰ A multicentric retrospective study evaluating the effect of COVID-19 on endometrial cancer patients revealed that more patients suffered from advanced stage endometrial cancer in pandemic as compared to pre-COVID era. The total number of endometrial cancer patients who had been offered treatment significantly reduced in pandemic. ¹¹

Challenges Faced by Gynecologic Oncologists, Gynecologists, and Medical Personnel

New gynecologic cancer patients usually need surgery. Surgery during the time of pandemic, especially in high burden areas, may be risky. At the same time, surgery offers one time treatment. Radiotherapy requires multiple visits while chemotherapy suppresses immune system. So, surgery should be considered in the present phase of resetting health services after carefully screening the patient. This needs to be discussed with the patient, before, making any decision. ¹² For follow-up of gynecological malignancy cases, oncologists and their patients need to discuss the necessity of avoiding clinic visits, due to higher risk of morbidity and mortality from COVID-19 and choose telemedicine facility instead if applicable. Another issue of significance is the tough decision for both patients and oncologists to continue immuno-suppressive treatments during this COVID-19 crisis. The patients must be made aware regarding risks pertaining to delaying cancer treatment while emphasizing about its effect on immunity simultaneously. Patient centric approach should be preferred. With the opening of all the gynae-oncologic services currently, balance must be maintained between the old pending cases and newly diagnosed cases. ¹³ Some nations have defined specialized treatment center (includes cancers) and COVID treatment centers separately. They perform screening of all the patients coming to specialized centers to limit cross infection. However, many variations were noted in the method of triage. Patients undergoing surgery were given priority for nasopharyngeal swab testing for COVID-19 while history and contact racing method was adopted for patients planned for chemotherapy/radiotherapy. ¹⁴

Being front-line workers, medical personnel play an important role in effectively treating patients with COVID infection. As of 12^th June 2021, the Indian Medical Association reported that 719 Indian doctors have lost their lives to COVID-19, with the state of Bihar recording the maximum fatalities. In many parts of the world, including India, doctors have worked despite shortage of liquid medical oxygen, inpatient and ICU beds, ventilators, healthcare personnel, personal protective equipment (PPE) kits. Many healthcare workers in India faced discrimination in the society outside hospitals and refused accommodation within the community. ¹⁵ Those dealing with cancer patients had more burn-out due to the unpredictable nature and duration of the pandemic, stoppage of all oncology services including palliative care and dealing with frustrations of cancer patients who faced risk of disease progression.

Education and research related activities were held less often in 2020 compared to pre-pandemic time. ¹⁶ Medical training has been largely impacted by COVID-19 pandemic. With less time spent in training for cancer surgeries and management of cancer patients, oncology students and residents being deployed into managing the pandemic, education and training of future doctors will most likely suffer. In an online survey conducted amongst gynecologists, gynecologic oncologists, surgical oncologists, radiation oncologists, and medical oncologists of Association of Gynecological Oncologists of India (AGOI), 54% respondents felt that alternative learning methods like virtual conferences, online reading material through professional society websites, and limited gathering were necessary to inform medical practices, but expressed concern that there would be few opportunities for professional interaction and networking. ¹²

Determining Surgical Emergency in Gynecologic Cancer Cases

Indication for any surgery is classified as elective/non-urgent, semi-urgent, and urgent/emergent. The Elective Surgery Acuity Scale (ESAS), adapted for gynecologic oncology procedures, may guide surgeons with routine procedural classification and prioritization; the table of advised tiers is mentioned in the document by Society of Gynecologic Oncology (SGO). ¹⁷ Most gynecologic oncology procedural indications will fall into a Tier 3a/b (semi-urgent) category. Tier 3a includes high acuity surgery/healthy patient, potentially life threatening, or when patient is severely symptomatic and requires admission. Tier 3b comprises of high acuity surgery in unhealthy patients. For these two categories, the Society of Gynecologic Oncology (SGO) recommends not to postpone surgery. ¹⁷ They also recommend that if there is high COVID-19 census for any tier, case prioritization might change.

Resource Considerations

Since the onset of the pandemic in 2020, healthcare resources in terms of personnel, hospital beds, PPE kits, medical equipment, etc. have been directed to care of persons suffering from COVID-19 infection. As a result, many health emergencies including periodic screening, diagnosis, and management of cancer have taken a back seat. ¹⁸ Those already diagnosed and on treatment for cancer had faced treatment interruptions due to the pandemic. Women with gynecologic cancers faced many challenges in cancer treatment such as unavailability of operating theatres, chemotherapy units, and radiation services leading to cancelled/postponed surgeries and definitive treatment. Several cancer centers including the National Cancer Institute (NCI, Jhajjar) were converted into COVID-19 care facilities. Healthcare personnel were deployed into caring for persons with COVID infection, were infected or exposed, and quarantined. Health resources like inpatient and ICU beds, ventilators, etc. were diverted to managing COVID patients. ¹⁹

Survivorship was also affected due to lack of follow up visits which may affect early detection of recurrences and subsequent treatment.

An ambidirectional cohort study conducted across 41 cancer centers in India between 1^st March 2020 and 31^st May 2020 (inclusive of the nationwide lockdown period), it was seen that there was reduction in registration of new patients (54%), follow-up visits (46%), hospital admissions (36%), chemotherapy admissions (37%), major surgeries performed (49%), minor surgeries performed (52%), radiotherapy services (23%), pathological diagnostic testing (38%), radiology services (43%), and palliative care referrals (29%). Public and charitable hospitals had larger reductions in patient numbers compared to private hospitals. ¹⁶

A survey of challenges faced by Indian cancer patients by a multispecialty hospital in Bihar identified several factors preventing optimum care. The main challenges included lack of availability of teleconsultation slots for consultation, chemotherapy slots, deferral of surgery, tumor boards, radiotherapy dates, transportation problems, unavailability of psychological and peer group support services, nutritionist advice, difficulty in maintaining precautionary measures against COVID transmission, restriction of family/attendants at the hospital and visa issues. Almost 91.7% patients reported an increase in anxiety levels, associated with fear of contracting COVID infection, progression of cancer due to treatment delay, death and loss of jobs leading to financial crisis. ²⁰

The decision of continuing elective surgeries during pandemic should be made after considering manpower and infrastructure available at organization. Local authorities looking after readiness of a facility in managing COVID patients should share information about scarcity of resources regularly. These resources include protective gear for providers and patients. ¹⁷ With this mutual sharing of information, apt decision can be taken, with idea of its potential impact on delaying crucial gynae-oncologic procedures/limiting the hospitals capacity to pandemic response. One needs to balance the risk of delay of surgery against the immediate availability of resources for COVID-19 patients, while operating upon cases with a high likelihood of postoperative ICU or ventilator requirement. These problems are being encountered more frequently currently with the opening of all the non-COVID services almost everywhere. The judicious allocation of resources during this phase of recovery, resumption and renewal of gynae-oncology services is the need of the hour. ²¹

Acceptable Delay in Gynecologic Cancer Surgery

No delay is acceptable psychologically, however, from an oncologic perspective, up to 3-8 weeks delays might be considered for select cancer cases if the risks of COVID-19 exposure are deemed high enough. Referral to regional centers, if possible, is a feasible alternative. If semi-urgent cases are no longer operated upon or managed at an institution, patients requesting appointments should be carefully prioritized to identify patients requiring early management. It is important to note that patients with advanced or high-grade cancer conditions, if delayed for long, may develop symptoms worsening or progression of disease. If a case is delayed, re-evaluation at every 2– 4-week intervals is necessary. Finally, it is prudent to prioritize patients beforehand, who need to be operated first. Priority should be given to highly curable, early-stage, and those with advanced gynecologic malignancies who require surgery or with symptoms necessitating surgical palliation. ¹⁷

In an Indian study looking at mortality rates in cancer patients with COVID, Mehta et al reported a case fatality rate of 14.52%. The risk of dying was associated with presence of severe symptoms at presentation and coexisting morbidities, especially diabetes and cardiovascular diseases. Recent anti-cancer therapy (including surgery, radiotherapy, chemotherapy, targeted therapy and immunotherapy) within a month prior to COVID infection appeared to have no influence on mortality rates. ²² The median duration to negative RT-PCR test in cancer patients after COVID infection was 16 days in 88 Indian patients with solid organ cancers. ²³

To understand the effect of delaying cancer treatment in view of avoiding COVID infection, a Markov-model-based analysis was conducted for women at risk of cervical cancer in India. It was seen that there was a lifetime increase of about 795 to 2160 (2.52-3.80%) cervical cancer related deaths due to delay in treatment ranging from 9 weeks to 6 months, respectively. The model also predicted that 88 to 238 COVID related deaths would be prevented for the same time period, but this would result in an excess 18,159-53,626 life-years and 16,808-50,035 disability adjusted life-years being lost due to cervical cancer. The study concluded that cancer related mortality may be higher than COVID related mortality for Indian women due to delays in treatment. ²⁴

In a modelling study by COVIDSurg initiative, it was estimated that almost 48728 surgeries were being cancelled per week. This translated into 59.7% of cancer surgeries being cancelled in India over a 12-week period. ²⁵

Modification in Management of Specific Cancers- Worldwide

Several international societies have laid down general guidelines on managing different gynaecological malignancies to help clinicians with the decision-making process during the COVID pandemic. Surgical procedures have been critically analysed for their risks of spreading infection. Risk of laparoscopic surgery concerning pneumoperitoneum in the setting of COVID-19 must be weighed against risk of laparotomy. ²⁶ A proof-of-concept study by Bogani et al demonstrated that SARS-CoV2 has the potential to disseminate via smoke from surgery and get transmitted in surgical smoke and aerosols generated by abdominal fluid. ²⁷ However, some studies advocate minimally invasive surgeries in favor of open surgeries due to lesser post-operative complications, lesser duration of hospital stay, and lesser spread of COVID-19 in in-patients’ wards. Laparoscopy could be considered if benefits outweigh the risks with utmost attention to the safety of health personnel.^28,29 The uncertainty regarding open/laparoscopic approach was demonstrated by a survey where one out of four surgeons reported that they restricted laparoscopic procedures and opted for open surgeries. ³⁰ Currently, only half of the surgeons are using any specific protection gear with merely one-third adopting respirator masks during open/laparoscopic surgeries. ³⁰

Endometrial Cancer

For patients with early-stage endometrial cancer of low and intermediate preoperative European Society of Medical Oncology (ESMO) risk, hysterectomy with bilateral salpingo-oophorectomy combined with a sentinel lymph node sampling is recommended. Surgery can be postponed for 1 to 2 months in low-risk endometrial cancers (FIGO IA stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy).^12,13,33 For patients of high ESMO risk, the MSKCC (Memorial Sloan Kettering Cancer Center) algorithm combining PET-CT and sentinel lymph node biopsy, should be used to avoid pelvic and lumbar-aortic lymphadenectomy. ¹⁸ In management of endometrial carcinoma, postponing surgery in early stage disease, hysterectomy with or without salpingo-oophorectomy excluding lymphadenectomy, and exploring medical treatments were some modifications adopted by Italian gynaecological oncologists.^10,28

For the details regarding existing guidelines and proposed modifications in the treatment plan pertaining to cervical, endometrial and ovarian cancer, refer to Table 1.

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Table 1.

Existing Guidelines And Modifications In Gynae-Oncologic Cancers.

S.no	Gynecological cancer	Existing guidelines	Modifications suggested pertaining to Covid-19 pandemic
1.	Cervical cancer	CIN2/CIN3: LEEP/Conization FIGO IA1 (without LVSI): Conization/Trachelectomy/Simple hysterectomy FIGO IA1 (with LVSI): Surgical hysterectomy plus assessment of lymph nodes (includes sentinel lymph node) FIGO IA2: Modified radical hysterectomy and pelvic lymphadenectomy/sentinel lymph node assessment. FIGO IB1: Radical hysterectomy with bilateral lymphadenectomy. Modified radical hysterectomy may be considered. IB2, and IIA1: Both surgery (radical hysterectomy with bilateral lymphadenectomy) and radiotherapy could be chosen as primary treatment modality depending on patients’ preferences and available resources.19,24 IB3 AND IIA2: Concurrent chemoradiation (CRT) based on platinum have better survival rates as surgery followed by postop radiotherapy. FIGO IIB-IVA: Chemoradiotherapy (CRT) /Neoadjuvant chemotherapy followed by surgery or RT#/tailoring RT as per surgical staging or PET-CT19,24 *Fertility sparing surgeries could be offered. *Laparoscopic/robotics surgeries could not be considered preferrable as compared to open surgery in FIGO stage IA2, IB, and IIA. Patients should be counselled about risks and benefits.33,34	RT and concomitant CRT should be considered as the first line therapy wherever applicable. 32 Lymph node dissection should be considered on a case-to-case basis. 15 Surgery after concomitant CRT should be done only if residual disease is present. 32 Risks vs benefits of adapting modifications should always be individualized and discussed with the patient.
2.	Uterine cancer	FIGO I, II (occult disease): Extra-fascial total hysterectomy with bilateral salpingo-oophorectomy, ± pelvic lymphadenectomy FIGO II (overt disease): Radical/modified radical hysterectomy, bilateral salpingo-oophorectomy, Bilateral pelvic lymphadenectomy, and selective aortic node dissection/neoadjuvant therapy followed simple hysterectomy/pelvic radiotherapy and intracavitary brachytherapy in inoperable patients medically17,23 FIGOIII: surgery followed by postoperative EBRT and/or chemotherapy, Non-resectable disease: Pelvic irradiation, with or without chemotherapy/neoadjuvant chemotherapy followed by laparotomy FIGO IV: Cytoreductive surgery/Neoadjuvant chemotherapy followed by interval bulking surgery/pelvic radiotherapy.33,36	Surgery is always the first choice for early stage cancers. Laparoscopy could be considered. 35 . For early stage disease, postponement of the procedures for 1-2 months might be offered. For advanced stage disease, medical treatment should be the first line of management.Sentinal lymph node sampling/MSKCC algorithm should be used to avoid lymphadenectomy.35, Risks vs benefits of adapting modifications should always be individualized and discussed with the patient.
3.	Ovarian cancer/fallopian tube/peritoneal	For early stage disease staging laparotomy(TAH +/− BSO, peritoneal wash cytology, multiple biopies from undersurface of diaphragm, peritoneum, pelvic side walls etc., infracolic omentectomy, selective pelvic and paraortic lymphadenectomy, For advanced stage: Primary debulking/interval debulking/neoadjuvant chemotherapy/secondary cytoreduction/second look surgeries. 37	Neoadjuvant chemotherapy should be preferred over cytoreductive surgery. The chemotherapy for 4 cycles could be extended to 6 cycles. 2 cycles of chemotherapy should be given at least post-operatively. Risks vs benefits of adapting modifications should always be individualized and discussed with the patient.

Management of Gynaecologic Cancer During COVID-19- Indian Scenario

The management of gynecologic cancers during the pandemic is a complex situation, with no ‘one size fits all, strategy. While treading in this unfamiliar and perilous times, it is necessary to have a multidisciplinary approach involving all the treating physicians, support staff, patient and their family in making a treatment plan. It is imperative that the benefit of starting early treatment is weighed against the risk of contracting COVID infection and vice versa. A case-to-case discussion should be done to choose the best treatment approach that is suitable for the patient’s ideas and goals.

Covid-19 Positive Gynecologic Cancer Patients

It is now increasingly being recognized that carcinogenesis is a form of immune dysfunction, where immune cells fail to identify and control nascent tumour cells in a process called ‘immunosurveillance’. ⁴⁸ This has been further reinforced by the fact that there is a high incidence of tumours in immunodeficient individuals. ⁴⁹ Immunocompetency of patients with cancer is further depleted as a result of treatment like extensive cytoreductive surgeries, radiation therapy, and chemotherapy. A weakened immune system predisposes cancer patients to infection, particularly with COVID-19 virus. It has been seen that such infection is likely to persist for a long time and lead to increased rates of morbidity and mortality. In a study of more than 5 million patients with COVID (of which 2.8% were cancer patients), it was seen that patients with cancer had a higher mortality rate compared to those without cancer. The mortality rate was 1.6% in patients without cancer, 5.0% for patients with cancer with no recent treatment, and 7.8% for cancer patients on active treatment. It was seen that this risk was higher in patients with metastatic solid tumors and hematologic cancers. Patient receiving chemotherapy and immunotherapy were particularly at a higher risk of worse outcomes. ⁵⁰

SGO recommends that whenever possible, one must avoid operating on known COVID-19 positive patients or those with flu-like symptoms and unknown COVID-19 status, unless the case is emergent/urgent. ¹⁷ The National College of French Gynecologists and Obstetricians Guidelines say if a patient with a gynecologic cancer presents with COVID-19, surgical management should be delayed for at least 15 days. ³² Vulvar Cancer multidisciplinary team from Italy recommended that any diagnostic/surgical /medical treatment should be postponed in Covid-19 positive symptomatic patients. In case of emergent need of palliative treatment in acute, severe, and extremely urgent patients, least invasive therapy should be given. Even in Covid-19 positive asymptomatic patient, initiation of treatment is risky with adverse outcomes. The multidisciplinary discussion should be held, and treatment should be withheld till negative laboratory report is obtained. In cases having aggressive disease/severe symptoms where Covid-19 positive status persists with no symptoms, multidisciplinary tumor board should decide the lines on which treatment should be initiated considering least invasive therapy. In patients turning Covid-19 positive after the start of treatment, the decision to complete, discontinue, or postpone the initiated treatment should be decided based on multidisciplinary discussion, presence/absence of Covid-19 symptoms, general condition of patient, stage of disease, and time required for treatment completion. The discontinued treatment could be started again after two negative laboratory reports > 24 hours apart/subsidence of symptoms since last 3-7 days. ³⁵

The guidelines for giving chemotherapy in the background of an infection say that in case of any infection, be it COVID-19 or otherwise, one should wait until the infection is resolved to resume chemotherapy. Doctors should be able to test every patient (symptomatic or asymptomatic) before beginning chemotherapy to ascertain regarding infective status ideally as incubation period of virus is 5 days. ¹⁸

Many centers are adopting the universal testing screening policy in current times for renewal of gynecological oncology services.

What does International Guideline say regarding management of Gynecologic Cancer patients

The Society of Gynecologic Oncology states that precise triage is essential to maintain harmony between existing resources and protecting staff and patients. Decisions regarding proceeding with semi-urgent and elective surgeries need participation of state health department and hospital system levels at ground level. ¹⁷ Informed consent and mutual decision making with patients, along with counseling patients about the harms of surgical delay as compared to in hospital COVID-19 cross infection, is important while planning procedures with proper documentation. Determinations regarding cancer surgery are based on local/projected resources, emergence of COVID-19 in community, patient and tumor factors and expected outcomes from delays. This guideline also clearly delineates urgent (immediate), semi-urgent (1-4 weeks) and non-urgent (>4-12 weeks) gynecologic oncology surgeries as mentioned earlier in the article. ¹⁷

The International Gynecological Cancer Society (IGCS) advocates restricting number of physicians and healthcare providers involved in providing out-patient services to restrain exposure to everyone. ²⁶ They also recommend delaying all routine services/follow-up visits or changing to telemedicine/web-based consultation until crisis has resolved and it is advised to return to resumption of routine services. Patients should use teleconsultation and electronic correspondence in case of any important issues. Patients should be counselled to postpone unnecessary interventions/routine investigations and imaging if that is not absolutely required, for example, in patients who are free of symptoms/not showing relapse or progression. ¹⁷

The American College of Surgeons (ACS) has also issued guidance for triage of patients for cancer surgery in general. ⁵⁶ However, many cancer surgeries cannot be considered as elective. If decision for surgery is taken, it requires multiple hospital visits and treatment related low immunity; these risks need thoughtful consideration. At the same time, the risks of postponing any surgery or chemotherapy also need evaluation. The American College of Surgeons (ACS) have categorized most gynecologic cancer cases as semi-urgent (i.e., non-elective) surgeries, second only to trauma cases and surgical emergencies in order of their importance. The ACS advocated that delaying cancer surgeries could cause more harm rather than benefits to patients. ⁵⁶

There is some guidance from the Centre for Disease Control (CDC), USA, that ‘elective surgeries' may be rescheduled, if possible. ⁵⁷

Mental Health of Gynecologic Cancer Patients

The anxiety, uncertainty and stress arising due to conflicting decisions regarding cancer management, whether to undergo surgery or postpone it, the fear of relapse and recurrence, loss of life due to non-accessibility of health services during pandemic, all these factors have taken toll of mental health of cancer patients. It is a dreadful situation for oncologists and more so for cancer patients. Cancer patients should refrain themselves from the myths and misinformation that is being widely circulated on WhatsApp, Facebook, and other social media platforms. The misinformation, related to COVID-19 and cancer, can do more harm than good to a patient mentally. The proliferation of false information has led to depression, suicidal tendencies, and fear in vulnerable populations and expanding the heavy emotional burden of this disease for those who could least bear it. Patients are encouraged to avail of appropriate cancer organizations, including the World Health Organization (WHO) for definitive information. ⁵⁸

Building up coping mechanisms during this crisis, is quintessential. At this time, family support is most important for cancer patients, but if someone in the family gets sick, cancer patients must start social distancing, wearing gloves and masks, sleeping in a different room if possible, and wiping down the areas with regular hands washing with soap or with alcohol wipes if available.

Limitations of the current review

The situation regarding gynae-oncology practices and COVID-19 is an ever changing one. Though the authors tried to give a comprehensive review, however, the data and guidelines regarding impact of COVID-19 on gynae-oncology keep emerging. Also, the current review is a narrative review, rather than a detailed systematic review.

Conclusion

The COVID-19 pandemic has been tackled for now but with the emergence of new strains and anticipation of multiple waves over a period, it had left an unforgettable impact on cancer patients and their caregivers along with oncologists who are helpless on deciding whether “to treat or not to treat”. Oncologists must think critically and prepare a guideline as per regional considerations to deal with gynecologic cancer patients during the time of health emergencies and how to manage gynecological cancers, as these patients are more prone for adverse outcomes. Very real ethical dilemmas abound for cancer clinicians bearing the hopes and dreams of their patients, who deserve empathy but also a realistic insight into their situation. The implementation of recommended international guidelines for the management of gynecologic cancers should take precedence. Each modification from standard approach should be approved by multidisciplinary team depending on patients’ condition and locoregional circumstances. The resetting of gynae-oncology services will need the novel ways to ensure standard care to cancer patients while minimizing their risks to COVID-19 at the same time.