Like other medical specialists, urologists have had to defer performing elective procedures and limit in-person patient encounters to only urgent clinical issues to prevent transmission of coronavirus disease 2019 (COVID- 19) and to free up resources to care for patients stricken with the disease. Meanwhile, fearing the virus, patients have held off going to doctors for routine care and screening as well as emergency departments for more immediate concerns. These consequences of the pandemic have created a backlog of urologic procedures and could set the stage for a surge in new genitourinary cancer cases because of delays in diagnostic work-ups of signs and symptoms that lead to cancer diagnoses.

“There may well be a transient spike in the diagnosis of new malignancies given that patients deferred all types of screening care for an interval and, specifically, many prostate biopsies were put off,” said Mara R. Holton, MD, CEO and President of Anne Arundel Urology in Annapolis, Maryland. “More significantly, there is real concern that the delay in accessing care will persist, as a result of, amongst other things, overwhelming volume and logistic difficulties, patients’ potential reluctance to return to the doctor, resurgence of virus and subsequent repeat stay-at-home orders, along with changes in insurance and other financial consequences related to the pandemic. These longer delays could certainly lead to higher stage and progression of disease by the time of diagnosis.”

Dr Holton said she anticipates that urologists in her group will be facing “a tremendous backlog” of cases as a result of elective surgeries that had been postponed during the peak of COVID-19 restrictions.

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“These run the gamut from robotic prostatectomies to vasectomies; essentially anything that was not truly deemed ‘emergent’ was subject to a delay,” Dr Holton said. “In our state, the stay-at-home order was in place for about 7 weeks so, for some types of procedures, literally hundreds were deferred. Addressing this backlog is a priority for our practice, and we are working to optimize our resources with staffing, location, and coordinating with our hospitals to get these done expediently.”

“I definitely think that many patients are choosing to defer visits for standard- of-care procedures such as PSA screening or evaluation of pain and blood in the urine,” said Sumanta Pal, MD, a medical oncologist and Co-Director of the Kidney Cancer Program at City of Hope, a comprehensive cancer center in Duarte, California. “I anticipate that there will likely be a big spike in cases that we see in the clinics once quarantine measures are lifted, and my greatest fear is that many of these will be advanced cases that could have been prevented with earlier intervention.”

“We may see patients presenting with more advanced cancers,” said urologist Brian Stone, MD, who is in private practice at Jasper Urology in Jasper, Alabama. In response to state-imposed restrictions, his practice had to decrease patient flow by limiting their workload to urgent cases. This affected patients with elevated PSA levels who had been referred for evaluation or were already scheduled to undergo biopsies, thereby possibly delaying prostate cancer diagnoses. He and his colleagues have been using magnetic resonance imaging (MRI)-ultrasound fusion technology for several years and addressed this delay by using that technique to screen patients who had high PSA levels and insurance coverage for the procedure “so at least we could stratify patients based on a PIRAD score and risk.” They typically would biopsy patients with high PIRAD scores (4 or 5).

Judd W. Moul, MD, Professor of Surgery in the Division of Urologic Surgery at Duke Cancer Institute in Durham, North Carolina, said “there is going to be pent up demand once primary care doctors start seeing patients again for check-ups and once patients are not scared to go to the ER and to the doctor for various complaints.”

The Duke Cancer Institute has a strong working relationship with the Duke Primary Care Network, which is a source of referrals. Although physicians in the network have not been on the front lines of routine care since around March, and North Carolina has not been hit hard by COVID-19, the pandemic has affected the institute’s caseload.

“Our referrals for elevated PSA have pretty much dried up temporarily,” Dr Moul related. “This is leading now to less prostate biopsies now in mid- May, and fewer men coming in for newly diagnosed prostate cancer.”

In addition, “bread-and-butter” urologic consultations, such as those for cases of hematuria and incidental renal masses, are down temporarily, Dr Moul said. “This will gradually change as healthcare opens back up, but it is not just like turning the spigot back on,” he said.