Patient Q&As: NCCN Metastatic Castration-Resistant Prostate Cancer Patient Treatment Considerations During the COVID-19 Pandemic - Edward M. Schaeffer and Alicia Morgans

After the National Comprehensive Cancer Network (NCCN) released new guidelines directing cancer care during the COVID-19 crisis, Alicia Morgans, MD, MPH, and Edward Schaeffer, MD, PhD, addressed patient concerns and questions surrounding their treatment options during this uncertain time. Dr. Schaeffer is the Chair of the Department of Urology and a Professor of Urology at the Feinberg School of Medicine at Northwestern, where Dr. Morgans is an Associate Professor of Medicine in the Division of Hematology and Oncology. This FAQ summarizes the answers they shared regarding cases of metastatic or advanced prostate cancer.

Beyond addressing specific treatment approaches, both Dr. Morgans and Dr. Schaeffer emphasized the importance of maintaining a good relationship with your healthcare provider during this uncertain time, as only your doctor can speak to your specific case. During this uncertain time, maintaining clear lines of communication with family members or caregivers is also essential. Also, while some procedures and treatment plans may be postponed or reoriented in light of the situation, if you are facing an immediate, emergent issue related to your cancer or health in general. 

Metastatic prostate cancer treatment

1. There are people that are worried that they missed the Lupron® shot by two weeks or maybe they are going to miss their Lupron® or ADT shot. What would you say to patients about that?

Lupron® shots are designed to turn off the production of testosterone in the testicles. These injections last for differing amounts of time depending on dosage, so the time point at which the last shot will wear off differs from patient to patient, Dr. Morgans said. Also, the effect of the last shot’s expiration will differ between age-groups. For example, young men may start producing testosterone again shortly after the shot reaches its expiration, while older men may have weeks before their testosterone production picks up again.

Dr. Schaeffer says that if you are scheduled to receive a shot soon, ask if you can get a longer duration dose. While no one knows for sure how long the pandemic will last, if you are prescribed a six-month or four-month shot now, you will have more flexibility going forward.

2. The treatment and management of advanced prostate cancer has progressed so rapidly over the last several years that most patients or many patients are not just on, a shot that blocks their testosterone, they're on more advanced medications. Do you have any special tips or tricks or things that these patients should be asking their providers, if, for example, they're on abiraterone? "I ask that one in particular because many patients are worried that they're on the steroid that they take with it and they're worried about being immunosuppressed and having a higher chance of getting these infections".

During the conversation, Dr. Schaeffer flagged a patient's concern surrounding advanced medications like abiraterone. Since this medication is taken with a steroid, does it cause immunosuppression? Dr. Morgans said that the dose of the prescribed steroid, prednisone, is very low and is only taken to replace an individual's native, or naturally occurring, level of cortisol. For this reason, that steroid does not really have an immunosuppressive effect.

However, in terms of patients taking these advanced medications, Dr. Morgans added that it is important to continue to get tests including liver function tests on a relatively normal basis. Blood pressure checks may also be necessary.

3. What are your thoughts about the use and initiation of docetaxel or other chemotherapy-based regimens for prostate cancer? In your practice, are you trying to look at alternatives to doing that because they are immunosuppressive regimens?

Docetaxel and cabazitaxel are chemotherapies that are immunosuppressive in nature. While providers are currently trying to give other treatment options, some patients will have to continue on or start chemotherapy regimens during this time. However, Dr. Morgans indicated that if there are other options that make sense and can control the disease, oncologists will use them. She added that chemotherapy is a key tool for prostate cancer treatment under normal conditions, but in this case, it will be replaced if possible. If there are no other alternatives, NEULASTA® (pegfilgrastim) injection can be prescribed along with the chemotherapy to boost the immune system.

Patients on chemotherapy should keep a distance from others and wash their hands to avoid infection. Even with those precautions, patients receiving chemotherapy can get infections from their own native flora, so if you fear you have an infection, do not hesitate to go to the emergency room. Hospitals are saving beds for cancer patients for this very reason.

Dr. Schaeffer added that in this context it is important to “establish, solidify, and strengthen your relationship with your care provider.” Since things change on a day-to-day basis, it is necessary to have a good relationship so you can have individual questions answered as soon as possible.

4. If I'm getting radiation for localized disease, should I interrupt my treatment course to pause while we have this COVID-19 pandemic?

The general consensus among radiologists is that it is not advisable to abruptly and prematurely halt radiation treatment, Dr. Schaeffer says, adding that he spoke to radiologists about this topic. If you have aggressive cancer, you must also keep in mind that you will need ADT before, during, and after radiation-based treatment, but you can try to delay the initiation of radiation therapy if possible.

If radiation therapy is necessary, then radiation oncologists emphasize the benefit of shortened, more compact treatment cycles. In most cases, fewer, higher dose treatments are effective and completely appropriate, especially as it minimizes contact during this time of social distancing. Dr. Morgans added that palliative radiation can also continue but in short courses, such as three to five fractions. However, both note that this is another topic that should be discussed individually with your care provider.

Written by: Catherine Ryan, Brown University, Providence, Rhode Island

Please consult your healthcare provider with individualized questions. For more information, please read the recommendations from the NCCN: Management of Prostate Cancer During the COVID-19 Pandemic

Related Content:
Video: NCCN Metastatic Castration-Resistant Prostate Cancer Patient Treatment Considerations During the COVID-19 Pandemic - Edward M. Schaeffer and Alicia Morgans
Download: Care of Prostate Cancer Patients During the COVID-19 Pandemic: Recommendations of the NCCN
Visit: Centers for Disease Control and Prevention - COVID-19
View: COVID-19 and Genitourinary Cancers Videos
Read: Patient Q&As: NCCN Localized Prostate Cancer Patient Treatment Considerations During the COVID-19 Pandemic - Edward M. Schaeffer