Every cancer case presents differently, but Dr. Morgans and Dr. Schaeffer together provide their insight and reflect on the NCCN guidelines in regard to the treatment of localized disease during this crisis.
Localized prostate cancer treatment
1. Should patients who are on the borderline (favorable, intermediate-risk) of treatment for active surveillance (unfavorable intermediate risk with a Gleason 3+4 or a 4+3 or a lower grade 3+4 or 3+3) be considering active surveillance? Is active surveillance something that should be expanded to patients with higher risk?
A patient’s risk group is non-negotiable, no matter the status of the pandemic, Dr. Schaeffer stated. One’s diagnosis, and how aggressive their cancer is are still the most important factors for driving treatment decisions, but how and when treatment options are delivered may have to slightly shift to accommodate the new state of the world.
Schaeffer says that treatment plans should not necessarily change. For example, in the case of Gleason 4+3 prostate cancer, “We should not second guess what is an appropriate treatment for you,” but he added, “We can critically review what would be appropriate timing for you for that treatment.”
Low- and very low-risk prostate cancers are good candidates for active surveillance, and surveillance programs can usually be delayed for multiple months without added risk. For people with favorable, intermediate-risk prostate cancer, some tests can be put on hold for three to six months. However, patients with high-risk prostate cancer will usually be advised to continue their treatment plan. For example, Dr. Schaeffer notes that if a patient previously decided with their physician to take a radiation-based approach and is thus required to receive androgen deprivation therapy before they can be slated to get radiation, they must still get their ADT shot during this time. Fortunately, it is possible to safely administer this shot at home, Dr. Schaeffer said.
For treatment schedules including upcoming surgeries, Dr. Schaeffer suggests talking with your individual provider about the severity of COVID-19 in your area. This is in order to help safely reschedule the procedure, as hospitals face unprecedented, but varying, capacities due to COVID-19.
Finally, Dr. Schaeffer highlights a study from Johns Hopkins that looked at patients across risk groups. The goal of the study, as Dr. Schaeffer explained, was to determine "Is there a difference if you delay treatment in the overall final pathology? Is there a difference in the chances of recurrence or metastasis?" The study saw no difference, Dr. Schaeffer said. This means that delaying therapy will not necessarily cause detriment to your overall care regimen and prognosis.
2. How should we be thinking about prostate-specific antigen (PSA) screening given all that's going on in terms of COVID-19? Some people may wonder: my family history is such that I should think about this or my primary care physician visit is coming up and I'm now of age to consider PSA screening. What would you advise for those folks?
Annual checkups for healthy individuals can be safely deferred for three to six months. The main reason why 12 months is the baseline for regular PSA screening in the US is due to the nature of annual checkups — waiting an extra few months will not make the test futile. In areas of intense COVID-19 infection, it is not advisable to go in for your screening PSA blood test right now, and the test can be safely deferred until the pandemic lessens in your local region. It is important to be aware if you are due for a PSA screening, but “you should never compromise your health today for something that you're trying to screen for and look for in the future,” Dr. Morgans said, adding that the test can happen at 15 or 18 months after your last checkup.
Both Dr. Morgans and Dr. Schaeffer note in the video that elective interventions can, and usually should, be delayed. But, they say, keep in mind that if you are having an urgent problem, the emergency room is still open to you and you should contact your care term. Numbness, severe back pain, weakness or tingling in the legs, bleeding, and obstruction are all symptoms that can come with prostate cancer, or other cancers, and should be treated with the same urgency that they would be under normal conditions.
3. How necessary is the first PSA check after my radical prostatectomy? Is this something that I need to get now? Is it something I can delay? What should I do in terms of thinking of postop management after one of these surgeries?
For an individualized answer to this question, it is advisable to reach out to your provider through your patient portal. However, it is important to note that the main point of this post-op PSA test is to check if “the cancer is at bay,” Dr. Schaeffer said, so the answer will depend on the severity of a given diagnosis. Ask your doctor if it is okay to delay your blood test by a month or two months. There is no right answer for every patient; for some, the results of the blood test are crucial and thus worth leaving home and going to the clinic to get blood drawn. Others could delay by upwards of six months without issue.
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
Video: NCCN Localized Prostate Cancer Patient Treatment Considerations During the COVID-19 Pandemic - Edward M. Schaeffer
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 Metastatic Castration-Resistant Prostate Cancer Patient Treatment Considerations During the COVID-19 Pandemic - Edward M. Schaeffer and Alicia Morgans