NCCN Localized Prostate Cancer Patient Treatment Considerations During the COVID-19 Pandemic - Edward M. Schaeffer

Edward (Ted) Schaeffer provides the urologist's perspective while answering patient questions on treatment considerations for localized prostate cancer in light of the COVID-19 crisis. Dr. Schaeffer provides insights into the National Comprehensive Cancer Network (NCCN) new patient guidelines on April 1, 2020.  


Edward M. Schaeffer, MD, Ph.D., Chair, Department of Urology, Feinberg School of Medicine, Program Director, Genitourinary Oncology Program, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA.

Alicia Morgans, MD, MPH Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois.

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Alicia Morgans: Hi, this is Alicia Morgans, Associate Professor of Medicine and GU Medical Oncologist at Northwestern University. I am so excited to have here with me today, a friend and colleague, Dr. Ted Schaeffer, who is the Chair of the Department of Urology at the Feinberg School of Medicine and the Director of the GU Oncology Program at the Robert H. Lurie Comprehensive Cancer Center at Northwestern University where I am honored to work with him each day. Thank you so much for being here to speak with me about this COVID-19 pandemic and the implications for prostate cancer care. Thank you so much, Dr. Schaeffer.

Edward Schaeffer: Yeah, thanks for taking the time out of your busy schedule to chat about, I think, this very important issue. As most of the listeners know, both Dr. Morgans and I have a passion for taking care of men and their families with prostate cancer. Our country and our world have really been taken by storm with this widespread, rapidly progressive virus, this Coronavirus. This has really changed the landscape of how we are caring for patients in the here and in the now. Alicia and I, who have offices very close to each other, thought this would be a great opportunity to really answer patients' questions about their prostate cancer, and how to think about, and manage, and structure their prostate cancer in this particular unprecedented time in America and in the world.

And so, thanks for joining me, Alicia, and thanks for hosting us. Do you want to just give your general overview of your perspective in the U.S., in Chicago, in the setting of Coronavirus in your particular clinical practice, Dr. Morgans?

Alicia Morgans: Sure, and thank you for that. I think that we care for men with prostate cancer and, of course, their families. The majority of men that I see in my practice have biochemical recurrent prostate cancer or have more advanced prostate cancer. Although there are definitely patients that I see, who I'm giving hormonal therapy for concurrent with their radiation, or maybe some hormonal therapy combinations in a post-prostatectomy situation if they had some high-risk features. But most of the patients that I see are men who have recurrent disease or metastatic disease, and there are lots of fears and tension around what they should do for their disease in this setting.

We've converted a majority of our visits, whenever medically feasible, to telehealth. This is not unique to Northwestern. This is actually happening across the United States. So that we can care for people, check their labs, check up on them, and give them guidance without having to have them into our clinics, where they may be exposed potentially to COVID-19 because they've come into a healthcare setting.

We recognize that the majority of men with prostate cancer are older. The median age of diagnosis with prostate cancer is 66, so that means that many of the men diagnosed with prostate cancer are going to be over 65, which is really the cutoff that we've seen for patients who have more hospitalizations, more ICU admissions, and potentially more fatalities associated with COVID-19. So, we've tried to alter our clinics to care for these patients without having them come into the healthcare setting. That's the biggest change from my standpoint. What have you seen from your standpoint as a urologist, who does a lot of his care, certainly in person, or even in the operating room?

Edward Schaeffer: Yeah, I think those are really great points for the listeners to think about. The overall mortality risks for this particular viral infection, this Coronavirus infection, are generally low and are thought to be around 1%. If you're young under the age of 45, the mortality rate for those individuals is well under 1%, more like half a percent or less. But as you highlighted, if you're over the age of 60 to 65, your risk of death from this particular virus if you get it, can be upwards of 15 to 20%.

I agree with you 100%. We really have to balance the 30-, 60-, and 90-day risk of deaths from prostate cancer with potentially the COVID-19 infection. So, that's been a fundamental guiding principle in my practice. Like you, most of my patients are older, and these individuals also can have some comorbidity, and so we have to balance that out.

In general, one of the guiding principles that I think about is, "Well, what is their short term risk from a cancer perspective?" and balance that with, "What's their short term risk if they were to get a COVID-19 infection?" We have a tremendous emphasis on remote telehealth visits. They can be over the phone or over the video. I think that those are helpful for the patients, helpful for the providers, and as a healthcare community, it enables us to give direction to our patients while conserving really vital resources at this unprecedented time.

Now in general, we have adopted an approach where we break things down in terms of our treatment plans into general bins. Those bins would be things that we could avoid, those are things that we could potentially defer, and then those are the things that we could shorten or reduce. So, what things should we avoid? Well, face-to-face visits for men who have a diagnosis of very low-risk, low-risk or favorable intermediate-risk prostate cancer do not need to happen at this particular time. Those visits can be done remotely. In general, we can try to pare down those exposures for our patients and for our providers. That will enable us to have reduced risk of infection, and potentially to minimize the use of personal protective equipment, and so forth.

I think within that category, you can also think about deferring or shifting the timing of some of our testing. So, PSA testing, and potentially imaging, like prostate MRIs, and CAT scans, and bone scans. Those things for those people with very low risk, localized cancers can probably be deferred for three to six months. There will be no harm for that patient, and that will provide no change at all in the patient's cancer outcome. So, those are the things that we spend a lot of time messaging to our patients. I'm really trying to get them to get across to them because they don't need to come out into the community to do that.

Alicia Morgans: I completely agree. I think that conveying the balance between protecting the person in all of those ways that we do, which includes caring for the cancer, as well as preventing exposure, is going to be really, really important as we continue to move forward. 

I wonder if you could answer a few questions that patients have posed specifically around treatment for localized disease and thoughts that they have, is that something you'd be able to do?

Edward Schaeffer: Sure.

Alicia Morgans: Great. Most of these questions except a couple that I've added myself from things that I've heard in clinic have actually come from patient advocates who have reached out and have had specific questions around things that are really on their minds. So one of the ones that has been most discussed has really been around treatment for newly diagnosed prostate cancer, localized disease, and whether patients who are maybe on the borderline of treatment for active surveillance, meaning that they have maybe unfavorable intermediate risk with a Gleason 3+4 or a 4+3, maybe should be considering active surveillance or certainly patients who have a lower grade 3+4 or 3+3 if they should be considering active surveillance.

I know that that's something that you actually routinely recommend for patients with very low and low-risk prostate cancer. But they're just wondering, is this something that should be expanded to patients with higher risk?

Edward Schaeffer: Yeah, it's a good thought. I think about this in two ways. One, what the risk group or the aggressiveness of the cancer that the patient has is really not negotiable. That is independent of whether or not we have a COVID-19 or COVID-20 or COVID-21 infection going around the world. So your risk groups are general categories, very low, low, and favorable intermediate. That's kind of the good group. And then unfavorable intermediate, high, and very high. Those are the more aggressive groups. I kind of break out and dichotomize those groups into different bins. That, your actual diagnosis and your risk group, how aggressive your cancer is, no change.

Now, the next question would be, well, should the treatments that you consider for those different risk groups change? In my opinion, the treatments should not change. So if you're deemed to be somebody who has a 10 plus your life expectancy and you have unfavorable intermediate-risk prostate cancer, that's Gleason 4+3 prostate cancer, no, we should not second guess what is an appropriate treatment for you. But we can critically review what would be an appropriate timing for you for that treatment. So again, as you mentioned, people with low and very low-risk prostate cancer, those are ideal candidates for active surveillance. We strongly encourage that most active surveillance programs can be put on hold for three to six months with no negative effect to the patient whatsoever. So that's what we're encouraging. If you have favorable intermediate-risk prostate cancer and you want to do surveillance, yes, you can still put some of the confirmatory testings like MRIs and so forth on hold for three to six months and there should be no change.

If you have favorable intermediate-risk prostate cancer and you want to seek active treatment, then I think you do have time to wait for the pandemic to die down to seek treatment. For people who have riskier prostate cancers that are still localized, that would be unfavorable intermediate and then the high-risk groups, those individuals should seek treatment. If those folks are going to have and have decided to have a radiation-based approach, they need to have hormonal blockade androgen deprivation therapy before they receive the radiation. They should get that androgen deprivation shot and they can safely that shot alone to prepare for radiation for up to two years. So from a perspective of controlling the cancer and prepping the patient for future radiation, yes, we say, "Well, you should do six months of androgen deprivation or you should do two months before you start your treatment." But you can actually extend that and you do not have any increased harm in terms of your cancer treatment. So that's good news for those patients.

For patients who have these riskier cancers and they're choosing or thinking about surgical management, that's when you really have to focus in and communicate directly with your provider to understand the local landscape of the disease, of the coronavirus and the outbreak, and understand when they think it may be safe to have the procedure in the hospital. Now I should walk that back a second and say, it's generally incredibly safe to have surgical procedures in hospitals even during crises like this, but what we really think about from a broader perspective is, is there capacity in the hospital to actually accommodate patients that are coming in for their cancer treatment? At each hospital, the answer to that is different. So it does require just directly asking.

Now, there's a really, really nice study done out of Johns Hopkins. The study looked at men who had unfavorable intermediate-risk prostate cancer, high-risk prostate cancer, and very high-risk prostate cancer. They looked at men who got diagnosed with a biopsy and treatment within three months and those that had a biopsy and had treatment between three months and six months after their actual biopsy. They looked to say, "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 good news for patients at this particular time was that there was no difference. That is if you were diagnosed with aggressive prostate cancer, and it just happened that it was one month before the coronavirus outbreak, well, you could safely wait if you need to, if resources are critical in your local environment, you could wait up to six months and not compromise your overall cancer outcome.

That's really great news for our patients because everyone is anxious and worried about their cancer progressing. I always tell my patients, we want to take care of you when it's the right time for you and when our system can appropriately accommodate you. Does that help, Alicia?

Alicia Morgans: Yeah, absolutely. I think it really emphasizes, again, this balance between keeping the person safe while also trying to be aggressive against the cancer. So that's absolutely helpful. I think, along the same lines, there are questions about PSA screening and whether we should be thinking about that given all that's going on in terms of COVID-19. There are people who think about, my family history is such that I should think about this or my PCP visit is coming up and I'm now of age to consider PSA screening. What would you advise for those folks?

Edward Schaeffer: Yeah, in general, I think the recommendations are that if it's a healthy annual physical checkup, in most situations those can be deferred for sure from a face-to-face perspective and can be safely deferred for three to six months. If you look at the European screening data, that data showed that PSA-based screening proves cancer-specific survival. So it was a very good beneficial thing for men to have PSA screening. Those trials, they use screening that was every other year. So in general in the US, we use annual screening as our baseline and we do that because most people go see their doctor once a year. So I like once a year screening, but if your once a year screening wasn't in 12 months after your last one, but if it was 15 or 16 months later, I think that that's okay. I do think we need to minimize the burden on our healthcare providers and our phlebotomists and so forth, our blood drop folks, at this particular time. We do want to adhere to good social distancing. So I don't think you need to go on for your screening PSA blood tests right now, at least not in Chicago. I think that those things can be safely deferred until this pandemic dies down in your local region.

Alicia Morgans: I completely agree. Just because the hotspots right now are New York and Chicago and a couple of other places does not mean that these will not continue to migrate across the country and the different regions are going to be hit over the weeks and months to come. So please consider that it is important to be safe and that screening is something that, like Dr. Schaeffer said, doesn't necessarily need to happen at exactly 12 months, could happen at 15, might even happen at 18 months. It's important that we stay on some sort of schedule and are aware of it, but you should never compromise your health today for something that you're trying to screen for and look for in the future.

Edward Schaeffer: I think the other thing to emphasize too, Alicia, is that we're talking about elective interventions, meaning, we are doing the right thing for our patients, we proactively screen them. They have cancer and they need to or want to enter into surveillance or they need to or want to active treatment. This still falls under the umbrella of elective procedures. So we have time to be strategic and plan out the right time. Now, our hospital, and every hospital that I'm aware of in the US, is still open for business for emergencies. It's sad to say, but it is true, that prostate cancers do cause emergencies that require emergent procedures, bleeding, obstruction of the urinary tract, sometimes infection, sometimes pain. So yes, I want all the listeners out there to understand that our hospital and all the hospitals in the country are still open for business for these emergencies. So if you think that you're having some kind of urgent problem, bleeding, obstruction, pain, you definitely should go to your emergency room, contact your care team and they'll tell you the next steps. But the hospitals are open to help take care of you in those situations.

Alicia Morgans: Agreed. The only other thing I would add is that cord compression too, so weakness in the legs associated with severe back pain, numbness and tingling in the feet, the toes, or even the hands and the arms. These are things that can be caused by prostate cancer and other cancers and there are certainly reasons for you to go to the emergency room regardless of COVID-19 and be evaluated. But for those patients who are diagnosed, Ted, and maybe patients who have just gone through a prostatectomy... one of the patients asked, "How necessary is the first PSA check after my radical prostatectomy? Is this something that I need to get?" It's a blood test of course. "Is it something I need to get now? Is it something I can delay? What should I do in terms of thinking of the postop management after one of these surgeries?"

Edward Schaeffer: That's a great question. We use the PSA blood test to check to see if the cancer is at bay. So we like to do PSA testing after treatment with surgery or with radiation. We always tell patients, "Well, yes, we want your first PSA at three months," or some say two months. Everyone has a specific regiment. But my advice to the general listener out there is to really say, hey, reach out to your provider through their physician portal and ask them, "Is it okay if I delay my treatment? I might delay my blood test by a month or by two months." The reason that there's not a right answer for every single patient is because everybody has different degrees of aggressiveness of their cancer. So for some individuals, actually getting their blood tests is worth that "risk of going to a lab to get the draw." There are others that have very favorable pathology reports or had this favorable cancer after their radiation treatment and they probably could delay their blood work by six months and have no problem.

So I do think that it's a good question. There are many answers in terms of how you handle it and it's primarily going to be based on how aggressive was your cancer before your treatment? What did the pathology report show at the time of your surgical removal? Those factors are going to play a role in the exact timing for your blood tests. But in general, again, they've probably can be pushed back slightly.