The COVID-19 pandemic has impacted the dynamics of health systems, including limiting activities to prevent and diagnose gynecological cancers in primary care. This study aims to understand the extent of the consequences of the pandemic period on gynecological cancers in terms of diagnosis and prognosis. The method in this research was an integrative review based on the search of publications in PubMed, SciELO, and BVS from January 2020 to June 2023, with three exclusion moments and a final sample of 9 articles. The results indicated avoidance of consultations due to fear of the virus, postponement of evaluation exams, interruptions of screening and vaccination procedures, establishment of non-priority staging, postponement of surgeries, priority to conservative treatments, and decline in diagnoses during the pandemic. It is concluded that the pandemic event impaired women’s health care in the context of gynecological cancers, which calls for measures to adapt to primary and secondary care.

• Genital Neoplasms

• Female

• COVID-19

• Diagnosis

• Neoplasm Staging

• Medical Oncology

Amaral APA, de Azevedo LAR, Nunes MM, Giannecchini GV, Vieira CM (2024) The Impact of Covid-19 on the Diagnosis of Gynecological Cancers in the Post-Pandemic Era: An Integrative Review. Ann Community Med Pract 9(1): 1054.

According to the National Cancer Institute, neoplasms are a public health issue worldwide, ranking among the leading causes of premature death [1]. As the population ages and life expectancy increases, the incidence of cancer has been on the rise, consequently leading to increased morbidity and mortality [1]. Currently, cancer staging holds significant importance in guiding treatment based on the extent of the lesion. The most commonly used system in Western countries is TNM, as recommended by the International Union Against Cancer and the American Joint Committee on Cancer [2].

The public healthcare system’s access to oncology treatment resources is limited, especially in less developed countries [3]. Another limitation is the low access to general tumor diagnostic services, which is also related to lower socioeconomic development [3-5]. When combined with the prospect that cancer will become the leading cause of death in these countries in the future, it becomes a concerning issue in Latin America [5].

The most prevalent tumors in females, excluding skin cancer, are breast cancer and cervical cancer, which fall under gynecological tumors [1,6]. Additionally, other female cancers are notable in the oncological landscape, such as uterine and ovarian cancer. This class is responsible for significant morbidity and mortality and is expected to grow even further [1]. Under the same perspective, it was expected that in Brazil, new cases of gynecological neoplasia would be around 16.35 per 100,000 women between 2020 and 202 [6].

However, at the end of 2019, a new coronavirus was identified as the cause of acute respiratory infections. It spread rapidly, resulting in a pandemic. In January 2020, the World Health Organization declared it a public health emergency of international concern [7]. From that point, it impacted healthcare systems, as resources were redirected, and internal reorganization took place to address COVID-19-related diseases. This primarily affected primary care, limiting activities and reducing the population’s access to healthcare services, especially concerning gynecological cancers, regarding prevention and diagnosis methods [6,7,8]. As for access to healthcare, the impact extended beyond that, also causing reluctance among the population to seek care at healthcare centers [6].

In seeking to quantify the direct and indirect effects of the pandemic, it became evident that there was an impact on the treatment of various types of cancer due to the reorganization of healthcare services [7,8]. Therefore, this study aims to describe the extent of the effects of COVID-19 on patients with gynecological cancer and understand the changes caused in the realm of diagnosis through an integrative review. This is to provide scientific evidence for planning women’s healthcare and mitigate the deficits caused.

This is an integrative review of the literature on the change in the diagnostic pattern of gynecological tumors during the COVID-19 pandemic. Six stages organize the article: formulation of the research question, bibliographic search, data extraction, critical evaluation, analysis and summarization of studies, and synthesis of knowledge.

The research question was based on medical observation and experience, in which it was possible to inquire about a significant and possible change in the staging and number of diagnoses of gynecological cancers in the post-pandemic era to establish a relevance aimed at alerting the population.

The search for studies took place in July 2023 in the databases that make up the Virtual Health Library (VHL), the Scientific Electronic Library Online (SciELO), Medline via PUBMED, and Google Scholar. The search for data on Medline via VHL versus PUBMED presented divergent results. For this reason, both search engines were used to analyze the results. The choice of databases considered the scope and affinity with the theme.

For a broad search in the literature, the strategies combined the controlled descriptors “Female Genital Neoplasms,” “COVID-19,” and “diagnosis” included in the latest version of the Health Sciences Descriptors (DECS), which has an interface with the Medical Subject Headings (MESH). These descriptors were used in Portuguese in the VHL search route and English in PUBMED, combined using the Boolean operator AND. In the SciELO, the same method did not present results, and thus, the strategies for the combination of the controlled descriptors “Neoplasm Staging,” “COVID-19,” and “Gynecology” and their derivatives included in the latest version of the Health Sciences Descriptors (DECS) reformulated interconnected by the Boolean operator AND and OR, respectively.

Original articles, cross-sectional or mixed-methods studies, in English/Spanish/Portuguese, published between January 2020 and June 2023, whose data collection includes the pandemic period and that dealt with the research theme, considering possible justifications and influences on the investigated change, were included.

Publications presented in the form of thesis, dissertation, book chapters, reflections, case reports, preprints, studies with intervention, as well as duplicate publications in the databases, which did not refer to the theme or population of the research or that did not answer the guiding question, were excluded.

There were three moments of exclusion: first, of duplicate publications through the titles, a second stage by reading the title and abstract, and finally, after reading the texts in full. For mapping, the publications were exported to Excel ® software and organized and summarized in a table prepared by the authors. The data summary is presented in a flowchart constructed with the support of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol10 and the report of the results of the articles in tables with descriptive analysis (Table 1).

Table 1: Characterization of the studies. The table summarizes the results of the sample analyzed according to authorship, year of publication, journal, and description of the results.

Ethical aspects were respected, with reliable citations of the authors’ sources and definitions.

Seventy-nine publications were identified in the databases, 38 in Medline via PUBMED, 15 in SciELO, and 26 in the VHL databases (all in Medline). In the first moment of deletion, 23 duplicate publications were removed. In the second moment, after reviewing the title and abstract, 45 articles that did not answer the research question were excluded. Finally, after reading the full article, two publications were excluded because they were not accessible completely, so the rest met the inclusion criteria. The flowchart of the selection of articles is in Figure 1.

Figure 1: The figure shows the process of searching and selecting the articles based on three moments of exclusion and the established criteria.

The sample consisted of 9 articles published between 2020 and 2022, 3 in 2022, 1 in 2021, and 5 in 2020, all in English.

The rapidly expanding COVID-19 pandemic has impacted all areas of daily life, including healthcare, directly interfering with diagnoses by disrupting primary and secondary care [8]. This leads to limited activities, the reassignment of healthcare professionals, and reduced patient access to facilities due to containment measures and fear of contagion [8].

In this context, this study sought to investigate the limitations these interferences caused in diagnosing gynecological tumors during this event. The evidence gathered pointed to a decline in the diagnosis of gynecological cancers during the study period [12,13-16]. It was reported that ovarian cancer was the most affected gynecological cancer by the pandemic [16].

Several justifications for this decrease in medical care were identified, including delays in assessment exams for lower malignancy risks, such as ultrasounds, mammograms, CT scans, diagnostic procedures, and interruptions in routine screenings and prevention measures like vaccination [9,11,13].

Patients also played a role in this event, seeking investigation only after the onset of symptoms rather than through secondary prevention strategies. There was also increased waiting time for appointments after the presence of symptoms due to the fear of contracting COVID [12,13].

Regarding treatment, various delays occurred due to the postponement of treatments in patients testing positive for COVID-19 and for stages deemed non-priority, with oncological surgeries categorized as semi-urgent and priority given to hormonal treatments over surgical procedures [10,11].

There were differences in tumor staging, with some authors reporting a higher rate of advanced-stage cervical and ovarian cancers during the pandemic period [15]. Others said similar stages to pre-pandemic levels and predicted that there would be diagnoses with more advanced stages in the future [12,16].

Some reported a decline in the diagnosis of initial stages of breast cancer, and secondary prevention measures, as mentioned earlier, were postponed [12,15].

The main factors that positively interfered with tumor staging are related to the duration of the study, as it becomes difficult to measure the consequences that are yet to come three years from the start of the pandemic [12]. Another factor relates to the acute event that occurred, leading to an emergency response that caused delays in diagnostic procedures [9, 11,13,14,16,17].

Therefore, it is inferred that the pandemic harmed the diagnosis and treatment of gynecological cancers, causing delays in both. This factor may have led to the neglect of women’s health. Future impacts are still concerning, such as the diagnosis of neoplasms in more advanced stages, which may no longer have treatment alternatives.

To mitigate these consequences, it is crucial for healthcare services, especially primary care, to increase primary prevention and screening strategies for these neoplasms and strengthen primary care to provide more significant opportunities for diagnostic investigations. Additionally, reinforcing secondary care through increased availability of diagnostic exams is essential to compensate for the delays in waiting lists caused by the pandemic.

The present study finds that social distancing requirements have hindered screening routines for breast and cervical câncer [11], HPV vaccination schedules, outpatient screening with HPV cytology/testing, and subsequent referrals for colposcopy [13], as well as procedures such as ultrasound, which determined many conditions to be postponable [9]. Regarding the queries, the practice volume dropped by more than 60%, and delays in care were reported as their biggest concern [16].

Undoubtedly, mortality from COVID-19 infection is significantly higher in patients with gynecologic cancer than in patients without câncer [14]. Due to the precautions to prevent the spread of the virus prescribed worldwide, there was a favor to postponing the surgical condition. Congruent to this panorama, the present study showed that there was, in a global scenario, a significant postponement of the treatment of some conditions already diagnosed, mainly when patients tested positive for COVID-19 [10], in addition to a tendency to prefer conservative treatment, such as hormonal treatment [9]. However, as mentioned, the risk of death increases after a delay of 4 weeks, regardless of the treatment modality, and a delay of more than eight weeks in the surgical treatment of low-grade endometrial cancer was independently associated with worsening 5-year survival [14]. With this article, we can observe the position of societies such as the American College of Surgeons (ACS), which argued that delaying cancer surgeries could cause more harm than good to patients [17], and the Society of Gynecologic Oncology which highlighted the importance of informed consent and mutual decision-making with patients, along with advising patients on the harms of surgical delay compared to COVID-19 cross-infection in the hospital [17].

With the study, it was possible to identify regions already registered with lower diagnoses of such types of cancers in the pandemic period. There was no significant difference in tumor staging compared to previous periods. Although there has been a need for further studies in the area in recent years since, as demonstrated, there are numerous factors that contribute to the diagnostic delay and, consequently, to the worse expectations of staging to the diagnosis, being a warning theme for both primary and secondary care, to mitigate the impact already constituted, but still amenable to interventions.

We acknowledge Dr. Carolina Martins Vieira for supporting us in drafting the manuscript.

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