During the COVID-19 pandemic, urologists caring for patients with prostate cancer (PCa) have needed to weigh the benefits of routine care against the potential risks for viral spread.
In Prostate Cancer and Prostatic Diseases, Tunkut Doganca, MD, of Acibadem Taksim Hospital in Istanbul, Turkey, and colleagues compiled and discussed current guidance to prevent the spread of COVID-19 among patients with PCa and their healthcare team. All nonurgent in-person clinic visits should be postponed in favor of telemedicine communication, unless the patient suffers from active symptoms, requires wound care, or presents with newly diagnosed advanced PCa, they stated. Patients with newly diagnosed cN1 or metastatic PCa, however, may require an in-person visit. Here is a brief overview of their discussion of priority care.
Prostate Biopsy
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The American Urological Association (AUA) recommends a risk-based approach to biopsy during the pandemic, the reviewers pointed out. For men with a PSA level greater than 20 ng/mL, PSA doubling time of less than 6 months, and digital rectal examination (DRE) suggestive of T3 disease, AUA suggests a biopsy delay of up to 3 months and a transperineal approach to avoid fecal exposure. Biopsy may be delayed for 3 to 6 months in other cases. If DRE suggests locally advanced disease or the patient is symptomatic, then perform a biopsy within 6 weeks.
For patients with symptoms of metastasis, the European Association of Urology (EAU) recommends imaging for staging within 6 weeks. If metastasis is confirmed, postpone biopsy and start androgen deprivation therapy (ADT).
Prostate Cancer Treatment
Patients with very low, low, and favorable intermediate-risk disease can reasonably postpone further staging, active surveillance, confirmatory testing, monitoring, and treatment, for 6 to 12 months, according to the reviewers.
For men with unfavorable intermediate-risk PCa, surgery may be delayed for 6 to 12 months without the use of neoadjuvant ADT. With respect to radiation therapy, neoadjuvant ADT can be used (for up to 6 months, per EAU) with external beam radiation therapy (EBRT) that is preferably hypofractionated and without fiducial marker or rectal spacer insertion. Brachytherapy also needs to be avoided to prevent infection. Prophylactic whole pelvic radiation therapy should generally be skipped during the pandemic.
Patients with high-risk or very high-risk PCa may have further staging, but guidance varies on this point. Surgery may be delayed for 3 to 6 months (without neoadjuvant ADT). Radiation therapy with neoadjuvant ADT can be employed instead, as discussed above.
Men with cN1 disease require treatment within 6 weeks. ADT plus EBRT may be best option during the pandemic, the reviewers wrote. Patients with low-volume metastatic PCa also may consider ADT with delayed EBRT.
Men with metastatic hormone-sensitive PCa can be treated with ADT plus androgen receptor axis-targeted therapy. Physicians should use the longest possible cycle frequency schedules of LHRH agonist to limit in-person healthcare visits. Chemotherapy, immunosuppressive drugs, and steroids should be avoided because of their effects on the immune system.
Patients with metastatic castration-resistant PCa should also avoid chemotherapy in favor of androgen receptor axis-targeted therapy when not previously used, and skip immunosuppressive drugs and steroids. Bone-only metastases should be treated with radium-223. Doctors should avoid using agents to prevent skeletal-related events that require hospital visits.
Recommendations for Surgical Planning
Surgery should be postponed whenever possible during the pandemic, according to the reviewers. All candidates should undergo preoperative testing for COVID-19, including chest imaging. COVID-19-positive patients should not have surgery unless absolutely emergent, in which case an isolated operating room and negative pressure room should be used and all other hospital-mandated precautions followed.
Operating on patients with negative COVID-19 test results still requires safety measures. Laparoscopic and robotic surgery carry the potential risk for aerosolization of the SARS-CoV-2 coronavirus, the cause of COVID-19, and spillage with pneumoperitoneum. To prevent spread, electro-surgery units should be set at the lowest possible settings. Limit cautery plume creation and uncontrolled CO2 release. Keep insufflation pressure to the lowest acceptable level.
For robot-assisted laparoscopy, the authors advise using intelligent integrated insufflation systems. Laparoscopic suction devices should be connected to a device with an ULPA or HEPA filter. Prior to specimen extraction, closure, trocar removal, or conversion to open surgery, evacuate all pneumoperitoneum using the filtration system. For further detailed information, the reviewers suggested consulting advice from the Society of Robotic Surgery, published in BJU International.
Dr Doganca and colleagues cautioned that their review should not be perceived as rigid guidelines established from high-level evidence, but rather as reasonable perspectives on the risk to benefit ratio of PCa treatment in specific clinical scenarios. As the pandemic evolves, recommendations may change.
Reference
Obek C, Doganca T, Argun OB, Kural AR. Management of prostate cancer patients during COVID-19 pandemic. Prostate Cancer Prostatic Dis. 23:398-406. Sep;23(3):398-406. doi:10.1038/s41391-020-0258-7
