Routine and nonessential healthcare services came to a nearly complete halt in many places throughout the United States as a result of the coronavirus disease 2019 (COVID-19) pandemic. Hospitals and medical practices discontinued or substantially curtailed provision of all but the most necessary procedures. Fearing infection with the novel coronavirus that causes COVID-19, many patients avoided contact with the healthcare system. Caseloads dropped precipitously across physician specialties.
Physicians who manage patients with prostate cancer (PCa) have not been spared. Urologists, for example, have had to postpone performing prostate biopsies and radical prostatectomies (RPs) except in the most urgent cases. In interviews with Renal & Urology News, urologists and medical oncologists across the nation explained their PCa caseloads, which plummeted for a few months early in the pandemic, have rebounded substantially even in areas that were severely impacted by COVID-19 outbreaks.
New York City
Those hard hit places include New York City, which quickly emerged as the nation’s pandemic epicenter. As early as April 1, for example, the city’s health department reported a total of 45,707 confirmed COVID-19 cases and 1374 deaths.1 Those numbers soared to 164,505 and 13,000, respectively, by April 30, and further swelled to 229,980 and 19,042, respectively, as of August 30.1 Patients with COVID-19 overwhelmed hospitals. All but the most urgent medical procedures were postponed. Physicians with Integrated Medical Professionals, parent company of Advanced Urology Centers of New York and Advanced Radiation Centers of New York, an independent group with headquarters in Farmingdale, New York, and a clinical affiliate of The Mount Sinai Health System in New York, New York, can attest to how COVID-19 hampered PCa care.
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Prior to the pandemic, urologists in the group performed around 1000 prostate biopsies a quarter, said urologist Deepak A. Kapoor, MD, the group’s chairman and chief executive officer. For a few months after the pandemic struck, the number of these biopsies plunged to only a few per week, he said.
Dr Kapoor pointed out that prostate biopsies can result in sepsis, the most significant complication of the procedure, as well as bleeding and urinary retention. Patients may require hospitalization if these problems occur. This would mean using hospital resources when they were badly needed to care for COVID-19 patients. “As a result, we felt that it was our moral obligation to not do elective prostate biopsies,” he explained. “As a consequence, many of those biopsies were delayed.”
However, the group is now ramping up prostate biopsies, Dr Kapoor said. He estimates that his group is at 75% to 80% of the prostate biopsy volume they had before the pandemic. A return to normal biopsy caseloads was delayed in part because patient anxiety about contracting COVID-19 kept individuals from undergoing the procedure, he said. Another factor was the availability of procedure room time “because we still try to do biopsies transperineally, our ability to do the procedure is a little bit restricted,” Dr Kapoor related.
Dr Kapoor said his group moved quickly to establish safety protocols. During the second week of March, the group formed a COVID-19 task force that had representatives from every specialty and service department. “We pulled together as a team in amazing collective fashion in a very short period of time to create protocols that would enable us to continue to function clinically while keeping our employees and our patients safe … and most importantly, out of the hospital.”
“Our goal during the pandemic was to keep our patients out of the hospital because if you have a trip to the hospital you’re in big trouble,” said Ann E. Anderson, MD, the group’s director of pathology. Not only would patients be at risk of contracting COVID-19, they might not have a bed or stretcher available to lie on, she said.
Dr Anderson and her pathology colleagues developed a virtual laboratory methodology whereby physicians could order laboratory tests via telemedicine. This way, patients could go to diagnostic testing sites in their community rather than have to travel to one of the group’s offices.
The group was able to increase caseloads largely because of COVID-19 testing, Dr Anderson said. “We were extremely proactive in COVID testing during the height of the pandemic for our staff,” she said. “That was a very big boost to the staff morale and the company’s ability to provide care for the patients.”
Longer-Duration Hormonal Injections
During the height of the pandemic in New York City, Dr Kapoor related, some patients with PCa who were faced with postponement of RPs opted instead to have radiation therapy rather than delay treatment. Other patients with PCa were given androgen deprivation therapy (ADT) as a stopgap measure until they could undergo RP, Dr Kapoor said. For patients with advanced PCa, urologists gave 6-month, rather than 3-month, injections of hormonal therapy to increase the interval between patient visits. The only patients with PCa for whom care changed little during the pandemic were those with castration-resistant disease. As they are high-risk patients, “we had no choice but to bring them in on a regular basis to make sure they were adequately followed,” Dr Kapoor said.
Telehealth played a big part in cutting down on the number of face-to-face encounters with patients, he said. His group went from having no telehealth encounters on March 12 to nearly 2000 telehealth encounters a week by the end of March. “I don’t know what we would have done had we not been able to at least communicate with those patients virtually,” he said.
The expanded use of telehealth was enabled in large part by the Centers for Medicare and Medicaid Services (CMS), which issued waivers that gave greater flexibility in the use of this modality and established payment parity between telehealth and regular in-person clinical care for Medicare patients.
‘Semblance of Normalcy’
UroPartners, LLC, a large urology group practice that serves the Chicago area, experienced a 70% decline in patient visits early during the pandemic, but the situation has improved substantially, said the group’s president and chief executive officer, Richard Harris, MD, who also is president of the Large Urology Group Practice Association (LUGPA). In-office visits bounced back much faster than he expected, he said. “We’re back up to 98% of our pre-COVID numbers,” Dr Harris explained, adding that his group figured out how to work around the difficulties posed by the pandemic so they could keep everybody safe while providing care. He credits telehealth for enabling providers in his group to “stay in the loop” with many patients. “The ability to do telemedicine has had a profoundly positive impact on our ability to treat these patients,” Dr Harris said.
Dr Harris said his group’s surgicenter is handling more cases than ever because many patients do not want to undergo procedures in a hospital for fear of COVID-19. As elsewhere, RPs were put off for a couple of months, but the number of these procedures began rising around May or June.
“I think most people are getting back up to speed as far as patient care,” said Dr Harris. “It’s not quite business as usual. I don’t know that it’s ever going to be until we have a vaccine or this [virus] has gone away. But at least we’re back to some semblance of normalcy.”
Pacific Northwest
PCa care also appears to be rebounding in the Washington State and the Pacific Northwest in general, according to Daniel W. Lin, MD, professor and chief of urologic oncology at the University of Washington in Seattle, where he also is director of the Institute for Prostate Cancer Research. The COVID-19 outbreak in Washington State — which had 74,320 confirmed COVID-19 cases and 1905 related deaths as of August 302 — was not as severe as in New York City, but during the height of the outbreak from mid-March to the end of April the “center basically stopped doing biopsies for routine elevated PSA,” Dr Lin explained. The same was true for most, if not all, of the Pacific Northwest. “Patients, we think, probably were not hurt by a few-month delay,” he said.
Discontinuation of prostate biopsies for several months, however, has led to a decline in new PCa diagnoses, he noted.
There was a period of a few months when many hospitals nationwide were discouraging or postponing surgeries and radiation therapy for lower-risk PCa, not only to protect patients and staff from COVID-19 transmission, but also out of concern about running out of PPE and other resources that might be needed for live-saving COVID-19 care. At the University of Washington, some robotic RPs for low-risk PCa were postponed because of concern about using up resources.
Still, patients have been reluctant to make medical visits, and this has devastated primary care practices, according to Dr Lin. “Patients are fearful of seeing their healthcare provider. They are not seeking general medical care, and thus are not getting screened for prostate cancer.” This fact has led to a decrease in patient referrals to urologists because of elevated PSA.
Even though Oregon, another Pacific Northwest state, had a relatively mild COVID-19 outbreak (with 26,554 and 458 confirmed cases and deaths as of August 303) compared with New York City and some other cities, COVID-19 altered medical care.
“We had a statewide halt on nonessential medical procedures that ended on May 1,” said medical oncologist Tomasz M. Beer, MD, professor of medicine at the Oregon Health & Science University (OSHU) in Portland, where he is deputy director of the OHSU Knight Cancer Institute. “During that time, prostate biopsies and even prostatectomies except for very aggressive cases were viewed as nonessential cases. But medical treatment for advanced cancer was universally treated as essential. We did not delay any hormonal therapy or chemotherapy or immunotherapy. And we did not delay participation and treatment in clinical trials. We were able to continue most of our clinical research.”
Routine visits for prostate cancer screening had largely been put on hold during March through May, and even men with elevated PSA may have delayed seeing urologists to arrange for a biopsy, Dr Beer said. Men who had a low-grade cancer found on a prepandemic biopsy may have held off on treatment because they know there generally is no urgency with these tumors. But caseloads are essentially back to what they were before the pandemic. “We’re all real busy again now,” he said.
Physicians at the institute transitioned many patient encounters to a virtual setting, Dr Beer said. “We see a lot of our patients by video [or] by phone if they have no access to video. But if they need injections or infusions or imaging or blood tests, we have facilities set up to accommodate that, and they’ve continued to receive their treatment as scheduled.”
As a result of the COVID-19 crisis, Dr Beer explained that physicians made adjustments in specific PCa treatments. For example, during the pandemic, most patients on hormonal therapy were switched to 6-month injections from 1-, 3-, and 4-month injections to decrease the number of patient visits.
Miami-Dade County
In one of the newest COVID-19 hotspots, Florida’s Miami-Dade County (which as of August 30 had 156,038 and 2399 confirmed COVID-19 cases and deaths, respectively4), the outbreak prompted changes in how physicians at Sylvester Comprehensive Cancer Center in Miami provided PCa care as early as April.
“For a couple of weeks to a month beginning around mid-April, everything almost shut down completely,” said urologic oncologist Sanoj Punnen, MD, associate professor of urology at the University of Miami’s Miller School of Medicine. “We’ve had to restructure a lot of what we do.”
Prior to the pandemic, he saw patients from 8 AM to 5 PM, but now he sees them from 8 AM to noon, with priority given to patients he “really needs to see in person for any acute issues and procedures.” Clinic staff schedule appointments to ensure patients do not wait around with others. Patients wait in their cars until they receive a phone call telling them a clinic room is available for their appointment. His afternoons in clinic are spent conducting telehealth visits for patients he does not need to see in person. As a result of how his clinic functions, patients generally do not experience delays in care, he said. “If a patient needs a biopsy, he can get it done pretty much as [if] we were at full capacity,” Dr Punnen said.
A Busy Period for Medical Oncologists
Even in Minnesota, which was not especially hard hit by the pandemic, physicians had to alter their usual care of patients with PCa as a precaution, notably in March and April, according to Arpit Rao, MBBS, an assistant professor in the Division of Hematology, Oncology and Transplantation at the University of Minnesota in Minneapolis. Dr Rao leads the genitourinary oncology clinical research program and the oncology quality and safety team for M Health Fairview system. According to Dr Rao, some patients facing delayed RP or radiation therapy were placed on a few months of ADT as a therapeutic bridge until they could receive definitive treatment. The medical oncology department became busier during the pandemic, Dr Rao said, a trend he suspects is due in part to postponed PCa surgeries. Given the delay, men sought consultations with medical oncologists “just to make sure they’re exploring all the options,” he said.
“Before the pandemic, we had probably 16 to 20 patients in a day of clinic,” Dr Rao said. “During the pandemic, the volume has been 20% to 30% higher.”
For patients with metastatic PCa, he took steps to space visits farther apart when the pandemic hit. “I used to see everybody about once a month for oral novel antiandrogen therapy; now I see them every 6 to 8 weeks at this point,” Dr Rao said. “Whereas we used to get imaging every 3 months, now it’s every 4 to 6 months. Whether that’s going to have long-term consequences remains to be seen. But in the short term, we haven’t really experienced any significant increases in complication rates.” For some patients already on ADT, he switched from 3-month to 6-month injections to decrease the number of patient visits.
Surgeries Resume ‘At Full Pace’
Although the pandemic led to an RP backlog, the situation has begun to normalize, according to Dr Rao. “We have been able to resume surgeries at full pace, as before the pandemic,” he said.
He kept in touch with many patients via telehealth, which he found useful but not optimal in some cases. “After the pandemic started, 80% of our visits were virtual,” he explained. “The pandemic offered us a glimpse into the future of oncology care and allowed us to understand the characteristics of patients and services that can be safely and effectively transitioned to a telehealth model, and of those for whom the traditional care model would continue to be the best approach.”
Telehealth is a major part of how City of Hope, a comprehensive cancer center in Duarte, California, is managing patients with PCa during the pandemic. “COVID-19 has led many patients to be hesitant to come see their doctors due to perceived fear of exposure to the novel coronavirus,” said medical oncologist Yung Lyou, MD, PhD. As a result, patients undergoing chronic PSA surveillance or who were not on any active treatments that require a clinic visit — such as leuprolide injections or chemotherapy infusions — have asked to be converted to telehealth encounters.
“While City of Hope had a telemedicine program prior to the pandemic, the current situation prompted us to rapidly accelerate our planned telemedicine program expansion,” he said.
Reassuring Patients by Phone
Increased use of telehealth was just one of the effects of the COVID-19 outbreak. Dr Lyou said he had to reassure patients by telephone that his institution had strict infection-control measures in place to prevent COVID-19 transmission. “Many of my patients have felt anxious,” he said, “so I have had to make quite a few phone calls to inform them that at City of Hope, where the focus is primarily cancer patients, we take very strict precautions to limit the spread of COVID-19 within our facility. For example, I detail how all staff and patients are screened with a detailed questionnaire and temperature check prior to admission into the cancer center. Also, everyone is required to wear a mask and if they show up without one, we will issue a medical grade facemask at the door.”
Dr Lyou said physicians and other staff at City of Hope have been fortunate in that their leadership has maintained adequate levels of personal protective equipment (PPE) for everyone. Additionally, drive-through COVID-19 testing is readily available on the Duarte campus, with an approximately 4-hour turnaround time. “We perform in-house COVID-19 screening prior to all surgical procedures or hospital admissions,” Dr Lyou said. “These measures have greatly helped to limit our COVID-19 infection rates.”
To lower the risk of COVID-19 transmission, the City of Hope medical center limits the number of visitors. “In the pre-COVID era, we used to see patients with their family members or caregivers,” he said. “However, due to COVID-19 visitor restrictions, with few exceptions, only the patient is allowed to enter the clinic for visits. As a workaround, we have been using telephone or videoconferencing with the other family members while we see patients to ensure everyone is included in the medical decision making [process].”
Dr Lyou said he has had to educate patients with PCa about their risk of contracting COVID-19. One of the most common questions I get asked is, ‘As a prostate cancer patient, do I have a higher risk for COVID-19 compared to the general population?’”
He informs patients on chemotherapy that they may be at higher risk for infection because their treatment causes myelosuppression, but explains to ADT recipients that no definitive evidence exists showing that ADT causes immunosuppression. “As a result, they are most likely at the same risk as someone in their age group without prostate cancer,” he said.
Ramifications of Delayed Care
Whether the delays in care caused by the pandemic will have an effect on PCa outcomes is unclear. Urologists and oncologists generally agree that deferring such medical procedures as prostate biopsies and prostate surgery for a few months will likely have no significant effect on oncologic outcomes in patients with low-risk PCa. As Dr Kapoor pointed out, PCa is generally a slow growing cancer compared with other genitourinary malignancies. “Frankly, I am much more worried about my patients with renal cell carcinoma and my patients with bladder cancer who may not have been able to come in than I am worried about the patients with prostate cancer,” he said.
Nevertheless, he said, “It would be naive to believe that there were some patients whose pathology didn’t advance.”
Although the pandemic interrupted routine follow-up care such as PSA tests and prostate biopsies for patients on active surveillance, Dr Harris said, most of these patients have low- or very low-risk cancer, “so a month or two probably isn’t going to make any difference as far as outcomes or changes in their disease pattern.”
Dr Punnen observed that patients with PCa usually do not need acute care, even those with metastatic disease on ADT. “If they miss receiving their ADT injection by a month or so, “it’s probably not going to have a huge impact,” Dr Punnen said.
Dr Rao pointed out, however, that many men are skipping primary care visits and not having PSA tests that could detect subclinical PCa. “They may end up presenting with locally advanced disease,” he said. Men with advanced PCa and asymptomatic bone metastases, especially those with aggressive disease, may progress to symptomatic disease and present with cancer-related complications as a result of putting off follow-up care for a few months, he said.
Prostate Cancer Research
As with patient care, the pandemic has had an effect on PCa research, but to varying degrees across the United States. At the Sylvester Comprehensive Cancer Center, clinical research slowed “because obviously research isn’t given the same priority as clinical care,” Dr Punnen said. Many research coordinators are still working from home, and that has had an impact on clinical trial accrual. “We don’t really have the resources to get [patients] enrolled in trials and follow through with care,” Dr Punnen said. “As a result, I don’t think we’re seeing the accruals that we normally would.” He added, however, that the situation is “getting better week by week, and we’re almost back to where we used to be.”
The pandemic curtailed much of the PCa research at the University of Washington, which had to suspend a number of clinical trials because of concern about exposing patients to the COVID-19 coronavirus, Dr Lin said. These studies included dose-finding phase 1 trials and phase 3 trials where a “nonexperimental equivalent” treatment is available, he said. One of these phase 3 trials is SWOG 1802, which is being conducted at sites throughout the United States. The trial is comparing standard systemic therapy alone (the nonexperimental equivalent) with standard systemic therapy plus definitive treatment (RP or radiation) of the primary tumor (the experimental therapy) in patients with metastatic PCa.
The pandemic has had less of an effect on clinical research at OSHU. “By and large, we were able to both continue to treat patients on study and continue new enrollments into treatment studies,” Dr Beer said. Investigators discontinued some non-treatment studies in which there was no clear benefit to patients. Earlier in the pandemic, they stopped projects that involved gathering patient samples solely for laboratory research and had no direct effect on patient care, but these projects have since resumed, he said.
At the University of Minnesota, COVID-19 had minimal effect on PCa research, according to Dr Rao. “I think we’ve been very successful at keeping the pace of clinical research going,” he said, adding that his institution’s research program has actually grown in terms of enrollment.
“We’ve been able to publish, we’ve been able to contribute to [U.S. Food and Drug Administration] approvals despite the pandemic,” Dr Rao said. “But there have been challenges. At one point, we were basically doing twice as much paperwork to get every single enrollment. Enrollments were halted university-wide, and you had to convince 3 tiers of research personnel to get a patient into a clinical trial.”
He added, “Our patients have been very committed to clinical research. Many of them have been committed knowing full well that the research could benefit future patients. That’s altruism at its finest.”
Regardless of COVID-19 outbreak severity, the pandemic has forced physicians in many parts of the United States to cut back substantially on PCa-related procedures at least for a few months, resulting in a backlog of cases. The situation appears to be brightening, however. Even in places hard hit by COVID-19, physicians say they have been whittling away at their backlogs and returning to the clinical care they provided before the pandemic. It is too early to ascertain whether the delays in care caused by the pandemic will adversely affect patient outcomes long-term, but physicians generally agree that deferring prostate biopsies and definitive PCa treatment for a few months, at least for patients with low-risk PCa, will not significantly alter clinical outcomes. As healthcare services return to normal in many places, the pandemic rages on in various regions of the United States as investigators work on developing a COVID-19 vaccine and identifying safe and effective treatments.
References
- COVID-19: Data. New York City Health Department website. https://www1.nyc.gov/site/doh/covid/covid-19-data.page. Updated August 30, 2020. Accessed August 31, 2020.
- United States Washington Overview. Johns Hopkins University & Medicine Coronavirus Resource Center website. https://coronavirus.jhu.edu/region/us/washington. Updated August 30, 2020. Accessed August 31, 2020.
- United States Oregon Overview. Johns Hopkins University & Medicine Coronavirus Resource Center website. https://coronavirus.jhu.edu/region/us/oregon. Updated August 30, 2020. Accessed August 31, 2020.
- United States Florida Overview. Johns Hopkins University & Medicine Coronavirus Resource Center website. https://coronavirus.jhu.edu/region/us/florida. Updated August 30, 2020. Accessed August 31, 2020.
