Clinical and surgical assistance in prostate cancer during the COVID-19 Pandemic: implementation of assistance protocols

Lara Rodriguez Sanchez , Xavier Cathelineau , Alexis M. Alva Pinto, Ángel Borque-Fernando, Maria Jesús Gil, 4, Chi-Hang Yee , Rafael Sanchez-Salas.

International Braz J urology, Vol 46, supplement 1 July 2020.

ABSTRACT

Purpose: Propose an approach of prostate cancer (PCa) patients during COVID-19 pandemic.

Material and Methods: We conducted a review of current literature related to surgical and clinical management of patients during COVID-19 crisis paying special attention to oncological ones and especially those suffering from PCa. Based on these publications and current urological guidelines, a manual to manage PCa patients is suggested. Results: Patients suffering from cancer are likely to develop serious complications from COVID-19 disease together with an increased risk of postoperative morbidity and mortality. Therefore, the management of oncological patients should be taken into special consideration and most of the treatments postponed. In case the procedure is not deferrable, it should be adapted to the current situation. While the shortest radiotherapy (RT) regimens should be applied, surgical procedures must undergo the following recommendations proposed by main surgical associations. PCa prognosis is generally favourable and therefore one can safely delay most of the biopsies up to 6 months without interfering with survival outcomes in the vast majority of cases. In the same way, most of the localised PCa patients are suitable for active surveillance (AS) or hormonal therapy until local definitive treatment could be reconsidered. In metastatic as well as castration resistant PCa stages, adding androgen receptor targeted agents (abiraterone, apalutamide, darolutamide or enzalutamide) to androgen-deprivation therapy (ADT) could be considered in high risk patients. On the contrary, chemotherapy, immunotherapy and Radium-223 must be avoided with regard to the consequence of hematologic toxicity and risk of COVID-19 infection because of immunodepression.

Conclusions: Most of the biopsies should be delayed while AS is advised in those patients with low risk PCa. ADT allows us to defer definitive local treatment in many cases of intermediate and high risk PCa. In regard to metastatic and castration resistant PCa, combination therapies with abiraterone, apalutamide, darolutamide or enzalutamide could be considered. Chemotherapy, Radium-223 and immunotherapy are discouraged.

Keywords: Prostate cáncer, COVID19, Pandemic.

The coronavirus outbreak has been without a doubt one of the most devastading world health emergency in the last century affecting a great percentage of population around the world and influenced the way we address our clinical practice. In this article the authors present an adaptation of the scientific evidence available to treat the most common urological cancer (prostate cancer). Paradoxically the population with the highest prostate cancer incidence is also the age group most likely to suffer severe disease from SARS-COV-2.

Commentary

Is probably a success in the therapeutics’ recommendations in the literature review performed by the authors for the different prostate cancer groups the base treatment is the androgen deprivation therapy (ADT) delaying and avoiding patients visits to the Hospital, at this point is very important to mention according to M.Montopoli et al (1) the prostate cancer patients receiving ADT therapy appear to be partially protected from SARV-COV 2 infection and their infection could be less severe, the mechanism described is the TMPRSS2 is a member of the family of type II Trans-membrane serine proteases that are in multiple physiological and pathological processes including cancer and viral infections. Recent studies report that SARV-COV2 binds to angiotensina-converting enzyme 2 (ACE2) for cell entry following by cleavage of the S protein by TMPRSS2 whose transcriptions is regulated by the androgen receptor this mechanism is also linked the increased susceptibility of men to develop SARS-COV-2 severe infection compare to women.(2)

In the M. Montopoli paper patients with cancer diagnosis including all types of cancers develop more severe disease 69.3% required hospitalization against 47 % in no cancer group (1). In the sub-analysis of the prostate cancer group according to the treatment modalities namely ADT and non ADT, only 4 patients out of 5273 receiving ADT developed a SARS-COV-2 infection with no one died. This data support the beneficial effects of ADT treatment in prostate cancer patients reducing probability to develop SARS-COV-2 infections and with less severe infections outcomes(1). In the other hands going through the pandemic oscillations peaks during this year is difficult to predict accurately when we will be able to apply definitely radical treatment to our patients.

I could not end this Journal club without thanking the authors involved in this manuscript for their valuable scientific contribution supported in the best evidence and accurately adapted to the current pandemic.

Dr. Leonardo Tortolero Blano

References

1. Montopoli M, Zumerle S, Vettor R, et al. Androgen-deprivation therapies for prostate cancer and risk of infection by SARS-CoV-2: a population-based study (N = 4532). Ann Oncol. 2020;31(8):1040-1045. doi:10.1016/j.annonc.2020.04.479.
2. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. 2020; 395:565-74
3. Gillessen S, Attard G, Beer TM, Beltran H, Bjartell A, Bossi A, et al. Management of Patients with Advanced Prostate Cancer: Report of the Advanced Prostate Cancer Consensus Conference 2019. Eur Urol. 2020; 77:508-47
4. Ribal MJ, Cornford P, Briganti A, Knoll T, Gravas S, Babjuk M, et al. European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era. Eur Urol. 2020: S0302-2838, 30324-9.
5. Bhowmick NA, Oft J, Dorff T, Pal S, Agarwal N, Figlin RA, Posadas EM, Freedland SJ, Gong COVID-19 and androgen-targeted therapy for prostate cancer patients.Endocr Relat Cancer. 2020 Sep;27(9):R281-R292. doi: 10.1530/ERC-20-0165.