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BGCSframeworkforcareofpatientswithgynaecologicalcancerduringtheCOVID-19PandemicBackground

The BGCS suggest the following as a framework for Gynaecological Cancer Centres andGynaecologicalCancerUnitsintheUKtoaidmanagementdecisions.Thisguidanceadherestoprinciples laidout in theNHSdocument,01559, ‘Clinical guide for themanagementofcancerpatientsduringthecoronaviruspandemic’,March2020.

This framework is intended to aid decision-making by Gynaecological Cancer CentrecliniciansandCancerUnitcliniciansandNHSTrusts,intheeventthatthefacilityforcancerservices is compromised due to a combination of factors, including staff sickness, lack oftheatreavailability and supply chain shortagesamongothers. This guidanceencompassesinpatientandoutpatientactivity,diagnosticsandmanagementand isacrossallmodalitiesofanticancer treatment. Inputting together this framework, theworkinggroupgavehighweighting to procedures and treatments with the most robust evidence of benefit, thepotentialforcureorprogressionbeyondoperabilitywheresurvivalwasexpectedtobe>12months,symptomreliefforpatientswithsymptomsnotamenabletoalternativemeasuresand cancer types where cancer cure or survival > 12months would be compromised bydelayintreatment.

Thesituationwith theCOVID-19pandemic isevolvingandwill impactdifferentlyacrossthe UK, depending on local resource availability and scale of the pandemic affectedpopulation.Therefore,thisframeworkisonlyintendedasanaidtosupportMDTsmakingchallenging clinical decisions and to provide examples to fit the national cancerprioritisation categories as outlined in the NHS document 01559. Decisions may varydependentonlocalcircumstances,resourcesandasthepandemicevolves.

GeneralPrinciples

Intheeventofdisruptiontocancerservices,cliniciansmayneedtoprioritisetreatmentforthose most in need. It is important that all decisions taken, are done so withmultidisciplinary team (MDT) input and clearly communicated with patients. Deviationsfrom what would normally be considered standard of care may be appropriate in thecontext of what is safely deliverable during a pandemic. These variations should berecorded in the MDT decision-making and reasons clearly documented. Patients with adiagnosisofcancermustremaintrackedwithinMDT’s,evenifadecisionismadetodefertreatment.MDT’smayneedtoconsideralternatewaysofmeeting,suchasvirtualmeetings.

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Regular communications within the MDT team, working closely with NHS management,timely communication with patients and carers and regular reviews of this progressingsituation will underpin the safe delivery of cancer care for women with gynaecologicalcancer. MDT’s are encouraged to work collaboratively, both regionally and nationally todiscussdecisionsthatareverychallenging.

Patientsandtheirfamiliesshouldbefullyinvolvedindiscussionsaroundwhethertherisksofbeginningorcontinuing theircancer treatmentcouldoutweigh thebenefits,given thatmanypatients,especially thosereceivingsystemic,aremoreat riskofbecomingseriouslyunwelliftheycontractthecoronavirusinfection.

Inparticular,wherepatientsareconsidered‘athighrisk’(e.g.duetoacombinationofage,performancestatus,co-morbidities,cancerload,andfrailty)anindividualiseddecisionmustbe made, with full patient involvement to understand the potential pros and cons ofanticancer treatment versus delaying definitive treatment during the current pandemicsituationanddocumentedbytheMDT.Theneedforperioperative intensivecaresupportshouldbe incorporated intoanydecision-makingprocesses,duetothehighriskofsuchasupportnotbeingavailableduetoemergencycarerequirements.TheincreasedmortalityandmorbidityrisksfromapotentialCOVID-19infectioncausedbyembarking on cancer surgery or anticancer treatments during the pandemic, and theoptions of deferring surgery or non-surgical treatments, should be included in theinformedconsentprocessandclearlydocumented.ModellingbyWilliamsetalsuggeststhatmortalityfromchemotherapyisdoubledinpresenceofCOVID19infection,inthe>50agegroup(https://www.medrxiv.org/content/10.1101/2020.03.18.20038067v1.full.pdf)Treatment escalation plans and resuscitation plans in different scenarios should bediscussedwithpatientsandclearlydocumented.

Whereconservativemethodsoftreatmenthavebeendemonstratedtoshowefficacy–e.g.Levonorgestrol intrauterine system (LNG-IUS/ Mirena) for early stage uterine cancer inpatientswithcomorbidities/elderly/unfitfortreatment,theseshouldbeactivelyconsideredanddiscussedwithpatients.

Greater utilisation of non-surgical options including radical radiotherapy or neo-adjuvantchemotherapymayallowadelayinmajorresectionsurgeryuntilthereisgreateravailabilityof services, such as ITU support.Where decisions about adjuvant treatment need to bemade,prioritisationofwhatisdeliverablesafelylocallymayneedtotakeprecedenceoverasmalladditionalsurvivalbenefit.

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Utilisation of procedures, such as sentinel lymph node assessment, where this haspreviously been audited in the Trust, may enable selected patients to be spared fulllymphadenectomies. The BGCS has previously issued a consensus statement.https://www.bgcs.org.uk/sentinel-consensus-document-for-endometrial-and-cervical-cancer-bgcs/

Enhancedrecoverypathwaysshouldbeemployedto facilitateearlypatientdischargeandminimisetherisktopatientsandtheimpactonthehealthcareservice.

Subject to local arrangements, Cancer Units and Cancer Centres will need tomake jointdecisions on location of cancer surgery so that cancer surgery capacity can be utilisedbetween sites. For instance, patients with uterine cancer who do not need lymph nodeassessmentmayaftercarefuldiscussionandagreementacrosscancercentresandunitsbeperformedatcancerunitsinordertoallowcapacitytobebestutilised.

Outpatientactivity

Hospitalface-to-facevisitsshouldbeminimisedandalternativesforroutinefollow-upsuchas virtual clinics (telephone or videoconference) or patient-initiated follow-up should beconsidered. Pre-assessment visits, including pre-Systemic Anticancer Therapies can beperformedvirtually.Thiscouldbedeliveredbyspecialistnursesinadditiontomedicalstaff,whereappropriate.BGCSguidanceonPatientinitiatedfollowupisavailablehereandcanbemodifiedbasedonavailabilityoflocalresourceandclinicaldecision-making.

Two-weekwaitreferralsforsuspectedcancer

NHSGuidancehasbeenissuedhttps://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/cancer-alliance-information-on-managing-cancer-referrals-19-march-2020.pdf

Two-weekwait (2WW)referralsmayneedtobetriagedattrusts,withtheconsentofthereferringprimarycareprofessional,toprioritisepatientswhoneedtobeseenurgentlyandinvestigated within the 2WW pathway. These deviations from standard 2WW pathwaysshouldbedocumentedandreasonsprovided.Safety-nettingmechanismsshouldbeinplacefor patients whose referrals are downgraded. Consideration of initial virtual clinicappointments (telephone/video) or straight to test strategies can be made in order tominimise patients needing to physically attend hospital and may provide additionalinformation to aid triage decisions. Ideally, virtual appointments should be performed sothat friends/family can also attend, either remotely (e.g. mini videoconference orteleconference),orbewiththepatient,ifthisisfeasibleandinkeepingwithpatientchoice.

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However, the appointment ‘breaking bad news’ may be best done at a face to faceappointmentandwithaccess toCNSsupport.Thiswillenable signposting to servicesandtransparentcommunications.

Post-menopausalbleeding

Triageforthosewithpost-menopausalbleedingbyUSSandvirtualappointmentwithresultsand management plan may need to be considered. Many patients are unlikely to haveaccess to an examination by their GP, so those with a low risk profile, normal cervicalscreening history and an endometrial thickness <4 mm could be managed by patient-initiatedfollowupovera3-6monthperiod.Patientsthatreportcontinuingbleedingduringthe follow-up period can be invited for clinical examination. A record of all of those onpatient-initiatedfollow-upshouldbemaintainedandclinicalreviewconsidered,ifrequired,onceoutsideofthepandemicperiod.

Performing the most definitive investigation at first face-to-face visit (e.g. outpatienthysteroscopy/pipelle),allocatingthemostexperiencedhysteroscopiststotheseclinicswillminimiseneed for further investigationunderGA, since this ismaynotbeavailable foraconsiderable period. Insertion of a LNG-IUS, in those with suspicious findings, at initialhysteroscopy prior to histology being available, may limit face-to-face contact and maymitigate delay of definitive treatment where surgical treatment is constrained due toservicepressures.

Ovariancysts

UseofMRIorIOTAultrasound(simplerulesorAdNEX)todelineatelikelihoodofmalignancyinwomenwithraisedRMI,butclinicallylowriskofmalignancy(e.g.premenopausalwomenwith likely endometriosis) may be utilised to triage patients for surgery. Patients withmassesidentifiedbycarefultriageaslikelybenign,afterMDTdiscussionfordifficultcases,canhavesurgerydeferredby3-6months.ThosewithRMI<200couldbeconsideredforvirtualclinicappointmentsandfollowupduringthepandemicperiod.

Prioritisationofprocedures

SURGERY

Categorisationofpatients

Prioritylevel1aEmergency:operationneededwithin24hourstosavelife,e.g.:surgeryforcomplicationssuchasanastomoticleak;bowelperforation;peritonitis;burstabdomen.Torsionorruptureofsuspectedmalignantpelvicmasses.Heavybleedingfrommolarpregnancyrequiringinitialorrepeatsurgicalevacuationorhysterectomy

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PriorityLevel1bUrgent:operationneededwith72hours,e.g.:surgeryforacutemechanicalintestinal obstruction/impending perforation in a gynaecological cancer patient with anobvioussingletransitionpoint inthe imagingandwhere linesof lifeprolongingtreatmentexist. Life-threateningbleeding fromcervicaloruterinecancer,where there is reasonableexpectation of surgery being curative and conservative measures have failed or areunavailable.Urgentradiotherapymaybemoreappropriateinsomecases.

PriorityLevel2:Electivesurgerywithexpectationstocure,tobeperformedwithin4weeksto save life/progression of disease beyond operability. Further prioritisation within thiscategory should be based on urgency of symptoms,complications (such as localcompressivesymptoms),biologicalpriority(expectedgrowthrate)ofindividualcancers.

Forgynaecologicalcancers,thismayinclude:

Suspectedgermcelltumours,intrauterinebrachytherapyforcervicalcancer,pelvicconfinedmassessuspiciousofovariancancer,earlystagecervicalcancer,highgrade/highriskuterinecancerandresectionofprimaryvulvaltumourinselectedpatients.

PriorityLevel3:canbedelayedby10-12weekswithnopredictednegativeoutcome:

Insomepatients,delayingsurgerytoapointwherethereisgreateravailabilityofintensivecare support may be advisable and of limited impact on the survival outcome frommalignancy.Patientsinthiscategoryincludeearlystage,lowgradeuterinecancerpatientsmanaged conservatively with LNG-IUS and oral progestogens. Patients with low volumecervicalcancercompletelyexcisedatloopexcision.

AdvicespecifictoOvarianCancerPatientswith Ovarian Cancer pose a particular challenge.Whilst treatment for advancedovarian cancer is aimed to delay progression and prolong remission, many patients willachieve long and durable remissions (median survival 4-5 years). However, at firstpresentation, surgery to achieve complete removal of all visible cancer often requiresprolonged surgical time and possiblemulti-visceral resection potentially necessitating ITUsupport and prolongation of postoperative stay; ITU capacity may be unavailable andsurgicaltimelimitedduetoprioritisationofotherservices.

Insituationswhereprimarysurgeryisnotfeasible,theBGCSproposes:

1) Neo-adjuvantchemotherapyeitherwithsingleagentcarboplatinorcarboplatinandpaclitaxel.Considerationshouldbegivento theroutineuseof filgrastimtoreducethe incidence of neutropenia in patients receiving combination therapy. Wherepossible, thisshouldbeconsideredPriority2.Neoadjuvantbevacizumabshouldbeused with caution as it has not been shown to improve survival and may beassociatedwithagreaterriskofbowelperforationinextensivediseaseinvolvingthe

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bowel. In much of the UK, GFR measurements to calculate carboplatin dose arebasedonradionucleotideexcretion.Cockroft-GaultorWrightmethodsofcalculatingGFR should be considered in lieu of radionucleotidemethods at this time. Imageguidedbiopsyfacilitiesmaybeconstrainedduetopressureonradiologyanditmaybe necessary to rely on cytology to confirm diagnosis of malignancy prior totreatment.

2) PatientsscheduledforIntervalDebulkingsurgery(IDS)canbeassessedafter3cycleswith CT scan (+/- diffusion weighted MRI) or consideration of laparoscopy andproceed to IDS, if there isapotential formacroscopic cytoreduction.Patientsmayalso be counselled to continue with chemotherapy and the decision for surgeryreviewedafter6cyclesofchemotherapydependingonresourceavailability.

3) There is no information about the outcome of patients receiving initial surgeryfollowingthecompletionofchemotherapy.Decisionsaboutthisshouldbemadeonanindividualbasisdependingonthevolumeofresidualdisease,symptomsandco-morbidities.

4) In the absence of overall survival benefit from secondary debulking benefit inrecurrent ovarian cancer, these patients should be managed with chemotherapyunlesssurgerywouldrelievesymptoms.Thesepatientswouldbeclassedasprioritylevel3.

Chemotherapyandradiotherapy

In the event of limited chemotherapy capacity clinicians will be advised to follow localguidelinesandthosebasedonNHSEnglandrecommendations.Thiswillrequireadetaileddiscussionwith the patient,which should take into account the benefit of chemotherapyandtheriskofCOVID-19infectionwhilstonchemotherapy.Wherepossiblealternativeandlessresource-intensiveregimens(suchassingleagentcarboplatinorPARPinhibitors)shouldbe considered where appropriate or the use of prophylactic growth factors withcombinationtherapiesmaybewarranted.

Asgeneralprinciples,patientsreceivingcurativeradiotherapyforlocallyadvanceddiseaseshouldbeprioritizedoverpatientsreceivingadjuvanttherapy.Patientswhereadjuvanttherapyislikelytoreducelocalrecurrence,butnotlikelytoprolongsurvival,canbecarefullycounselledandRTwithheld.

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CHEMOTHERAPY

Considerations for Chemotherapy for patients with gynaecological cancer during Covid-19pandemicOvariancancer-Womenwithhighgradeserousandendometrioidovariancancercanbeexpectedto respond well to first line platinum-based chemotherapy and this should be considered highpriority due to significant survival gain and symptomatic benefit. Maintenance bevacizumab issignificantly resource intensive, lacking data on survival advantage and should be considered lowpriority. Where possible chemotherapy for platinum sensitive relapse should be considered forsymptomaticpatientsanddelayed ifpossibleforpatientswithoutsymptomsorwithsmallvolumedisease unlikely to lead to significant pathophysiological complications in the next threemonths.Chemotherapy forplatinum resistantdiseasewouldbe lowpriority, particularly in theabsenceofsymptoms; alternative strategies to manage symptoms should be considered. For any patientsalreadyontreatmentconsiderstoppingearlierthanplanned(therearenodatatosuggest5cyclesof first-line therapyare inferior to6ormore). Ifpatientsareeligible forPARP inhibitors followinggood response to chemotherapy starting oral therapy early after cycle 4 may be considered.Chemotherapy for non-serous, non-endometrioid ovarian cancers and low-grade cancers offerslimited benefit and adjuvant chemotherapy in these patients is of lower priority. Endocrinetherapiesmaybeconsideredwhereappropriateandchemotherapyintherecurrentsettingdeferredwherepossibleclinically.Uterinecancer-Forwomenwithadvanced,high-grade,endometrialcancer,adjuvantchemotherapymay increase thechanceofcureandshouldbeconsidered if resourcesallowordeferred insomecases for up to three months. In lower risk endometrial cancers, the benefit of adjuvantchemotherapyislesssignificantandmaybedeferredoromitted.InwomenwithstageIVdisease,chemotherapymaybeoffered,wherepossible,dependentontheavailabilityofresourcesandtheuseofprophylacticfilgrastimorsingleagentchemotherapymaybewarranted.Endocrinetreatmentmaybeanappropriatealternative. In relapseddisease treatment shouldbeconsideredbasedontheindividual’ssymptomsandriskfactors.Again,endocrinetherapyortreatmentdelayshouldbeconsideredwhereappropriate.Forcervicalandvulvalcancers-Chemoradiotherapyforlocallyadvancedcervical,vaginalandvulvalcancers is a high priority and should be delivered wherever possible as local resources allow.Palliativechemotherapyinmetastaticcervixcancershouldbeconsideredwhereresourcesallowbuttreatmentsecondlineandbeyondisoflimitedbenefitandlowpriority.Firstlinechemotherapyformetastaticvulvalcancershouldbeconsideredbasedonthe individual’ssymptomsandriskfactorsbuttreatmentsecondlineandbeyondisoflimitedbenefitandlowpriority.Chemotherapyforgermcelltumoursshouldbeofferedtoallnewpatientsashighpriority.

NHSErecommendationsforchemotherapyaresummarisedbelow.

Prioritylevel1

·Curativetherapywithahigh(>50%)chanceofsuccess

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·Adjuvant(orneo)therapywhichaddsatleast50%chanceofcureversussurgeryorradiotherapyaloneortreatmentgivenatrelapse

For Gynaecological cancers, this includes chemotherapy for germ cell tumours andGestationaltrophoblastictumours.Concurrentchemoradiationforcervicalcancer.Prioritylevel2

·Curativetherapywithanintermediate(15-50%)chanceofsuccess·Adjuvant(orneo)therapywhichadds15-50%chanceofcureversussurgeryor

radiotherapyaloneortreatmentgivenatrelapseFor Gynaecological cancers, this may include chemotherapy for patients with high gradeserousorendometrioidovariancancer,particularlywhere thepatient isknowntohaveaBRCAmutation,lowvolumediseaseorgoodperformancestatus.Prioritylevel3

·Curativetherapywithalowchance(10-15%)ofsuccess·Adjuvant(orneo)therapywhichadds10-15%chanceofcureversussurgeryor

radiotherapyaloneortreatmentgivenatrelapse·Non-curativetherapywithahigh(>50%)chanceof>1yearoflifeextension

For Gynaecological cancers, this may include chemotherapy for some patients with highgrade serous or endometrioid ovarian cancer, newly diagnosedor first platinum-sensitiverelapse.Womenwithadvanced,high-grade,endometrialcancer.

Prioritylevel4

·Curativetherapywithalow(0-15%)chanceofsuccess·Adjuvant(orneo)therapywhichadds<10%chanceofcureversussurgeryor

radiotherapyaloneortreatmentgivenatrelapse·Non-curativetherapywithanintermediate(15-50%)chanceof>1yearlife

extension

Forexample,chemotherapyforcervicalandendometrialcancerinfirstrecurrencewithgoodperformancestatus,oradvancedpreviouslyuntreateddisease.Somepatientswithplatinumsensitiverelapsedovariancancer.Prioritylevel5

·Non-curativetherapywithahigh(>50%)chanceofpalliation/temporarytumourcontrolbut<1yrlifeextension

Forexample,chemotherapyforplatinumresistantovariancancer,recurrentendometrialcancer.

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Prioritylevel6·Non-curativetherapywithanintermediate(15-50%)chanceofpalliation/temporary

tumourcontroland<1yrlifeextension

Forexample,chemotherapyformetastaticorrecurrentcervicalcancerorendometrialcancerinsecondrecurrence. ConsiderationsforRadiotherapyduringCovid-19pandemicTheremaybereducedradiotherapyavailabilityrequiringprioritisationofpatientsdependingonlocalresourceanddemands.Withthepossibilitythatallcancersurgeryissuspendedthendefinitiveradiotherapywillberequiredtotreatsomeearlystagecancers.Changestocurrentpracticemayberequiredtoreducedepartmentalworkload.Generalmeasurestoconsiderinclude:

• Usingthemostclinicallyappropriatehypo-fractionatedschedule.

• Simplifiedtechniquesforplanningandtreatmentverificationmaybeusedwithappropriateadjustmentoftargetvolumes

• Chemotherapyaccessforchemo-radiotherapytreatmentsshouldbeprioritisedasoutlinedinNHSEnglandChemotherapyPriorityCategory1.

• Anaestheticavailabilitymaybethedeterminingfactorforcapacityforsomeradiotherapysuchasintrauterinebrachytherapy

• Thenumberofintrauterineinsertionsshouldbeminimised,deliveringmultiplefractionsperinsertionifpossible.Simplificationoftechniquemaybenecessarydependingonimagingandplanningavailability

• Consideromissionofadjuvantradiotherapywhenthereisnoorlimitedsurvivaladvantagesuchasadjuvantbrachytherapyforintermediateriskendometrialcancer.

NHSPriorityLevelsforRadiotherapyExtendingthetotaltreatmenttimeofradiotherapycanhaveadeleteriousimpactontumourcontrol.TheRoyalCollegeofRadiologistsdefinestumourswheresurvivalisimpactedbyanydelaysintreatmentascategoryoneandthosewhereshortdelayshavelesseffectascategorytwo.Prioritylevel1:PatientswithRCRcategory1tumourscurrentlybeingtreatedwith(chemo)-RTandBrachytherapyforCategory1tumoursonEBRT

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Forgynaecologicalcancer,thisincludesradicalradiotherapyforcervical,vaginalandvulvalcancers,andintrauterinebrachytherapyforcervicalcancerPrioritylevel2:Urgentpalliativeradiotherapytosavelossoffunction/lifeExamplesincludeurgentpalliativeradiotherapyinpatientswithmalignantspinalcordcompressionwhohaveusefulsalvageableneurologicalfunctionandpalliativeradiotherapytostopbleeding.Prioritylevel3:RadicalradiotherapyforCategory2tumourswhereradiotherapyisthefirstdefinitivetreatmentORPost-operativeradiotherapywherethereisknownresidualdiseasefollowingsurgeryintumourswithaggressivebiologyThisincludesadjuvantradiotherapyforresidualdisease,positiveresectionmarginsornodalinvolvementincervical,vaginal,vulvalandendometrialcancers.Definitiveradiotherapyforuterinetumoursmaybenecessaryforselectedcases.Prioritylevel4:PalliativeradiotherapyforsymptomcontrolThisincludespalliativeradiotherapyformetastaticdiseaseandpelvicmassesPrioritylevel5:AdjuvantradiotherapyThisincludespost-operativeradiotherapyforfullyresectedhigh-riskendometrialcancer.

SupportforwomenWomen undergoing investigation and treatment for gynaecological malignancies usuallyhavethesupportofaclinicalnursespecialist(CNS).TheCNSiscrucialtosupportwomenatthis time, provide information, answer questions and support complexdecisionmaking.Theyhelptonavigatecomplexpathways.Theyareakeypatientadvocateliaisingwithclinicalteamsaboutpatientchoiceandpreferences.However,ashospitalswillbefacingunprecedenteddemandonnursingcare,theCNS'swillinevitablybere-deployedtosupportinpatientclinicalcareonwards.Thisisgoingtobeafrighteningandworryingtimeforwomenwhoarecurrentlyundergoingtreatment,thosewhorelapseandthosenewlydiagnosed.Akeymemberoftheteammaynotbeavailableanddepartmentsshouldconsiderhowsupportwillbeofferedtowomen.The charitable sector has made a significant contribution to the care of women withgynaecologicalcancersandit isanticipatedtheirroleatthistimewillbecrucial.TheBGCSwill be working closely with gynaecological cancer charities to enable women to bestsupportedinthisdifficulttime.

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TheBGCSrecommendsthat:

• WheremorethanoneCNSisavailablethatwardworkisalternatedtoallowoneCNStoworkasaCNS

• CancerunitscouldconsidercrosscoverofCNS'sthroughgenericworkingofCNS’sacrosstumoursites

• TrustsconsiderwhowilltakeCNStelephonecallsi.e.administrativestaff,cancercareco-ordinatorsandhavemechanismsinplaceforaclinicalmemberoftheteamtoreviewandrespondtothese.AlternativessuchasusingemailbyCNSstaffmayallowremoteworkingwherepossible.

• HavesafetynettinginplacesothatpatientscanbecontactedbyaCNSwhennormalserviceresumes

• Departments/Trustsconsidersignpostingpatientstoothersourcesofsupporti.e.thecharitablesector.Suggestionswouldbetocontactclinicalteamswithclinicalconcerns/queries,contactcharitablesectorwithemotionalconcernswhentheCNSisnotavailable.

• Innovativewaysofworkingtoaccesscharitablesectorsupport,withpatientconsentandtrustpermissionstodiscussconcernsmayneedtobeconsidered.

Selfcare

These are challenging times for all those working to provide services for women withsuspectedorconfirmedgynaecologicalcancer.Manywillexperienceanxietyforthemselves,theirlovedonesandpatientsatthesametimeasprovidingmuchneededcare.Astrategytoseekhelpandareadinesstosignpostcolleagueswhenvulnerable,tosupportservices,willbeimportanttoensureourwellbeingduringandafterthispandemic.

DetailedguidanceontheuseofPPEisavailableonhttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/874316/Infection_prevention_and_control_guidance_for_pandemic_coronavirus.pdf Dataonsafetyatinterventionalproceduresisstillemerging(e.g.aerosolisationriskatLaparoscopy)andwillneedtoberegularlyreviewedandpracticechangedtokeephealthcareproviderssafe.