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EAU Annual Congress 2021

EAU 2021: State-of-the-Art Lecture: Safe and Optimal Management of MIBC in the Time of SARS-COV-2

(UroToday.com) Professor James Catto discussed the safe and optimal management of muscle-invasive bladder cancer (MIBC) in the time of COVID-19 pandemic at the European Association of Urology (EAU) 2021 virtual annual meeting’s plenary session on advanced bladder cancer. Based on data from the COVID-19 dashboard at Johns Hopkins University from June 15, 2021, the COVID-19 pandemic has globally resulted in more than 176 million cases, more than 3.8 million deaths, and more than 2.3 billion vaccine doses administered.


Early data from the pandemic from the COVIDSurg Collaborative1 assessing 1,128 patients (n=294, 26.1% with SARS-CoV-2 infection) suggested that 30-day mortality was associated with male sex (OR 1.75, 95% CI 1.28-2.40), age 70 years or older versus younger than 70 years (OR 2.30, 95% CI 1.65-3.22), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (OR 2.35, 95% CI 1.57-3.53), malignant versus benign or obstetric diagnosis (OR 1.55, 95% CI 1.01-2.39), emergency versus elective surgery (OR 1.67, 95% CI 1.06-2.63), and major versus minor surgery (OR 1.52, 95% CI 1.01-2.31). Indeed, many of these factors are inherent to our bladder cancer population.

Subsequently, several publications showed that there was an immediate drop-off in urologic procedures being performed at the beginning of the pandemic in an attempt to ration hospital resources, ventilators, PPE, etc, particularly in areas (ie. Italy) hit hard early in the COVID-19 pandemic. A UK modeling study assessed the effect of delays in cancer referrals during the COVID-19 pandemic, suggesting that a reduction in 10-year net survival from a 3-month delay for bladder cancer would significantly negatively impact survival as compared to patients with prostate or kidney cancer:2

EAU_COVID-19.png

As such, Dr. Catto highlights that during different waves of the pandemic we have had to change priorities and strategies for managing patients, specifically in wave 1 avoiding surgery until COVID-19 improved, in wave 2 operating on patients despite COVID-19, and wave 3 learning to manage surgery around COVID-19:

Catto.png

During wave 1 of the pandemic, case selection in order to prioritize the risk of disease progression with limited OR space/resources was paramount. Several papers were published to guide these management decisions, including an opinion piece by thought leaders in the field3 and the EAU Guidelines Office Rapid Reaction Group.4 Based on priority levels, the EAU Guidelines Rapid Reaction Group provided recommendations to guide prioritization for radical cystectomy for MIBC, neoadjuvant chemotherapy, etc:

neoadjuvant_chemotherapy.png

In waves 2 and 3 (and beyond), we have learned from our initial experiences, incorporating telemedicine and telemonitoring, stratifying patient selection, however, the full impact on the mental health of our patients and decisions in care remains to be fully determined:5

telemedicine.png

Dr. Catto posed the question, how should we manage MIBC in July 2021? First, decision-making should take into account local prevalence and burden on health jurisdictions. At the beginning of the pandemic the majority of the burden was in China, with a subsequent shift to Western countries, and now primarily in South America and Asian countries. Secondly, one must take into account the percentage of the local population that is fully vaccinated. Third, individual patients are certainly the key drivers of decision-making for treatment, as we know that patients older than 60 years of age, those with medical comorbidities, and those with cancer are at higher risk of COVID-19 complications/death. With respect to MIBC treatment options and the COVID-19 pandemic, there are pros and cons to primary treatment with either radical cystectomy or radiotherapy as highlighted in the following figure:

Catto_2.png

Dr. Catto then highlighted several considerations for treating MIBC patients moving forward:

  • COVID free pathways: A recent collaborative effort assessed the impact of a COVID-19-free surgical pathway (complete segregation of the operating room, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19), noting that pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% versus9%; aOR 0.62, 95% CI 0.44 to 0.86) [6]. Additionally, the postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% versus3.6%; aOR 0.53, 95% CI 0.36 to 0.76). At Dr. Catto’s home institution of Sheffield University, there is a priority for vaccination (at least 7 days prior to surgery), limiting hospital preadmission, nasal swab, and PCR testing at least 3 days prior to admission (with isolation between testing and admission), and avoiding public transportation to the hospital.
  • If COVID-19 positive, delay surgery if possible: Data from the COVIDSurg Collaborative suggests that previous SARS-CoV-2 infection is associated with increased odds of pulmonary complications compared to no infection (10.7% [12/122] versus 3.6% [16/448], aOR 3.84, 95% CI 1.51-9.74).7 When split by time from swab to surgery, both pulmonary complications and mortality were lowest at least 4 weeks after notification of a positive swab test, thus suggesting that COVID-19 positive patients should delay surgery for at least 4 weeks.
  • Reduce hospital contact time: In order to achieve this, patients should be admitted on the same day as surgery and discharged as soon as possible. Additionally, patients may consider enrolment in prehabilitation and all patients should be placed on ERAS protocols post-operatively.
  • Neoadjuvant chemotherapy: Dr. Catto notes that the data is less clear with regards to the use of neoadjuvant chemotherapy during the COVID-19 pandemic and that the best option is to engage in shared decision-making with individual patients. Important aspects to discuss include (i) factors that may affect their risk of becoming severely ill with COVID-19, (ii) uncertainty whether systemic anticancer treatment increases the risk of becoming severely ill with COVID-19, (iii) possible greater risk of poor outcomes for patients with hematological cancers from COVID-19, and (iv) possible greater risk of poor outcomes from COVID-19 with immunosuppressive systemic anticancer treatments. If the patient has COVID-19, if possible, patients should defer systemic anticancer treatment at least 10 days after a positive test, and until any significant symptoms have resolved.

Dr. Catto concluded his presentation with the following take-home messages:

  • COVID-19 is here to stay, but vaccination is helping
  • We should consider best choices with respect to individual patient risks, safety of local pathways, and local COVID-19 prevalence and vaccination rates
  • It is crucial to design and adhere to COVID-19 free pathways and to defer treatment when patients are COVID-19 positive
  • Hospital contact and length of stay should be reduced with the use of ERAS protocols and telemedicine
  • Chemotherapy is safe to use if managed suitably

Presented by: James W. F. Catto, MD, PhD, Sheffield University, Sheffield, UK

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2021 European Association of Urology, EAU 2021- Virtual Meeting, July 8-12, 2021.

References:

  1. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020 Jul 4;396(10243):27-38.
  2. Sud A, Torr B, Jones ME, et al. Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: A modelling study. Lancet Oncol. 2020 Aug;21(8):1035-1044.
  3. Stensland KD, Morgan TM, Minzadeh A, et al. Considerations in the triage of urologic surgeries during the COVID-19 pandemic. Eur Urol 2020 Jun;77(6):663-666.
  4. Ribal MJ, Cornford P, Briganti A, et al. European Association of Urology Guidelines Office Rapid Reaction Group: An Organization-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era. Eur Urol 2020 Jul;78(1):21-28.
  5. Wallis CJD, Catto JWF, Finelli A, et al. The impact of the COVID-19 pandemic on Genitourinary Cancer Care: Re-envisioning the Future. Eur Urol 2020 Nov;78(5):731-742.
  6. Glasbey JC, Nepogodiev D, Simoes JFF, et al. Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study. J Clin Oncol. 2021 Jan 1;39(1):66-78.
  7. COVIDSurg Collaborative. Delaying surgery for patients with a previous SARS-CoV-2 infection. Br J Surg. 2020 Nov;107(12):e601-e602.