The COVID-19 pandemic has delayed surgery and other care for patients with urologic cancers. As restrictions ease, clinicians should prioritize patients with high-grade urothelial carcinoma, advanced kidney cancer, testicular cancer, and penile cancer for treatment, according to a recent literature review.
A team led by Christopher J.D. Wallis, MD, PhD, of Vanderbilt University Medical Center in Nashville, Tennessee performed the review to better understand the oncologic risks of delayed intervention in urologic cancer patients and published their management recommendations in European Urology.
Risks for delayed treatment of upper tract urothelial cancer (UTUC) vary by cancer grade and stage. For patients with high-grade UTUC, delaying nephroureterectomy for 12 weeks is associated with worse pathologic outcomes but not poor survival. Patients with suspected UTUC may skip diagnostic ureteroscopy and be worked up with urine cytology and computed tomography urograms.
Among bladder cancer patients, those with muscle-invasive disease are at risk for progression when radical cystectomy is delayed for longer than 12 weeks from diagnosis or completion of neoadjuvant chemotherapy, and should be prioritized for surgery (or trimodal therapy with radiosensitizing chemotherapy). Low-grade non-muscle-invasive bladder cancer (NMIBC) patients are unlikely to suffer harm from a 3- to 6-month delay. High-grade NMIBC patients should receive induction Bacillus Calmette–Guérin (BCG) and a single course of maintenance therapy (6 + 3). Physicians should not skip re-resection in higher-stage (pT1) or higher-risk disease. Use of systemic therapies in patients with metastases should be individualized.
Patients with intermediate- and high-risk prostate cancer (PCa) can defer surgery for 3 to 6 months without a change in outcomes. Neoadjuvant androgen deprivation therapy (ADT) before surgery, while controversial, may be considered. For patients awaiting radiation treatment, neoadjuvant ADT use may be prolonged. Men starting radiation can safely defer treatment for 3 to 6 months and can consider hypofractionation to reduce healthcare visits. Patients with metastatic PCa should start treatment, prioritizing androgen-receptor-targeted therapies over chemotherapy to avoid hospitalizations for side effects such as neutropenia. Glucocorticoid use should be minimized, and longer-duration ADT injections should be considered.
Patients with locally advanced renal tumors of T3 or higher should receive immediate treatment, given the unknown risk of delayed resection and the potential for complications including bleeding and inferior vena cava occlusion. Patients with metastatic kidney cancer may consider vascular endothelial growth factor targeted therapy instead of immunotherapy to reduce the chances of toxicity-related hospitalization or glucocorticoid use.
Patients with testicular and penile cancer patients require prompt treatment. Adverse outcomes have been observed with delays of 3 or more months before inguinal lymphadenectomy in penile cancer patients.
According to Dr Wallis’ team, “it is important to prioritize the timely care of patients for whom delays are most likely to result in adverse outcomes, also taking into account the patient’s age, comorbidities, symptoms, and life expectancy.”
Many patients with urologic cancers have characteristics that put them at higher risk for COVID-19, such as male sex, hypertension, and more than one comorbid condition, they noted. Minimizing nonessential healthcare visits and hospitalizations is an important goal.
Wallis CJD, Novara G, Marandino L, et al. Risks from deferring treatment for genitourinary cancers: A collaborative review to aid triage and management during the COVID-19 pandemic [published online May 3, 2020]. Eur Urol. doi: 10.1016/j.eururo.2020.04.063