- In most cases, minimal harm is expected with delays of 3-6 months, especially when estimating the risk: benefit ratio within mind the mortality related to COVID-19.
- Telemedicine should always be prioritized as well as laboratory monitoring rather than in-clinic visit to avoid exposures.
- About staging, surveillance and timing of treatment:
- For low risk cancer (very low, low and favorable intermediate risk according to NCCN), further staging or surveillance may be delayed until deemed safe.1
- For high risk cancer (unfavorable intermediate, high and very high risk according to NCCN) further staging or treatment may also be defer to a certain extent.1,2
- Patients with rapid PSA doubling <4 months, the risk: benefit ratio of potential cure must be weighed against risk of COVID-19 exposure and subsequent risk after therapy unique to each center and patient.2
- First post-treatment (surgical or RT) monitoring may be delayed until deemed safe.1
- About RT (radiation therapy):
- Use of ADT can safely delay the need to start radiotherapy for multiple months.2
- If RT is deemed safe, regimen with fewer fractions should be used (5-7 fractions).1,2
- Prophylactic whole pelvic radiation therapy may be harmful as early reports suggest it increases the risk of grade IV lymphopenia (RTOG 9413).1
- Brachytherapy may not be a good option as it relies on anesthesia staff and PPE most of the time2
- For symptomatic patients (obstruction or bleeding), conservative measures should be prioritized until deemed safe to proceed to surgery or RT. This include clean intermittent catheterization, medical therapy and ADT.1
- About ADT (androgen deprivation therapy):
- Formulation of 3, 4 or 6 months are preferred to 1-month injections.1,3
- ADT may be avoided if PSA doubling time is >9 months.1
- Neoadjuvant ADT may be an interesting option to differ definitive RT and may be given for 4-6 months as necessary.1
These recommendations are not formal rules, as limited data is available. Its goal is to provide a framework of thinking.
Sources:
- Management of Prostate Cancer During the COVID-19 pandemic: Recommandation of the NCCN. Consulted on April 09, 2020. https://www.nccn.org/covid-19/
- Zaorsky N.G., Yu J.B., McBride S.M., Dess R.T., Jackson W.C., Mahal B.A., Chen R., Choudhury A., Henry A., Syndikus I., Mitin T., Tree A., Kishan AU., Spratt D.E. (March 24, 2020). Prostate Cancer Radiotherapy Recommendations in Response to COVID-19. ASTRO, Advances in Radiation Oncology (2020). https://doi.org/10.1016/j.adro.2020.03.010
- Lalani A., Chi N.K., Heng D.Y.C, Kollmannsberger C.K, Sridhar S.S, Blais N., Canil C., Czaykowski P., Hotte S.J., Iqbal N., Soulières D., Bossé D., Alimohamed N.S., Basappa N.S., Mukhergjee S.D., Winquist E., Wood L.A., North S.A. (April 05, 2020). Prioritizing systemic therapies for GU malignancies during COVID-19. Can Urol Assoc J 2020l Epud ahead of print. https://doi.org/10.5489/cuaj.6595