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Kokorovic et al

4. Prioritization must be given to limiting exposures we recommend, at minimum, use of droplet precautions
of patients and healthcare workers to SARS-CoV-2. with mask, eye protection, gown, and gloves.
Implementation of telehealth visits significantly reduc-
es the risk of infection among frontline personnel and Treatment prioritization strategies
patients, but also preserves critically needed hospital
resources. For these reasons, telehealth visits are strongly Treatment recommendations depend on the predicted sever-
encouraged. In-person consultations should be limited ity of disease, which we have defined below using National
to men with new symptoms, those requiring a physical Comprehensive Cancer Network (NCCN) guidelines. 17
examination, and for the evaluation and management
of treatment-related serious adverse events. In men who 1. Localized low-risk prostate cancer (very low-, low- and
require an in-person assessment, consideration should favorable-intermediate-risk [FIR] groups).
be given to not repeating visits when two specialists are General principle: In men with asymptomatic, low-risk pros-
consulted, nor when preoperative assessment is needed. tate cancer, deferral of further investigations and treatments
The healthcare provider should coordinate their needs is recommended until return to routine clinical activities.
to minimize patient’s visits. a. In patients currently on or choosing active surveil-
lance, short-term suspension of active surveillance
Screening and detection protocols is recommended where appropriate,
including in-person clinic visits, DRE, PSA testing,
1. The CUA endorses prostate cancer screening and detec- imaging (including MRI), and repeat biopsy.
14
tion in appropriately selected men. However, the b. In men choosing surgical treatment for low or FIR
public health benefit from these recommendations is disease, delays of up to several months to one year
derived from long-term implementation and has no role from diagnosis to radical prostatectomy (RP) do not
in an acute setting. Therefore, we recommend cessation appear to worsen biochemical recurrence rates. 18-20
of routine prostate-specific antigen (PSA) screening in The length of delay until adverse outcomes occur is
asymptomatic men until resolution of this pandemic. unknown, however, 6–12 months is likely appropri-
2. In men with a suspicion of asymptomatic localized pros- ate based on these retrospective series. Therefore, in
tate cancer (based on PSA testing or clinical exam) we men with newly diagnosed low-risk prostate cancer
recommend delay of further investigations. This includes (including FIR), consider delay of RP until return to
digital rectal examination (DRE), cross-sectional or pros- routine elective procedures. Neoadjuvant androgen-
tate imaging, and transrectal ultrasound (TRUS)-guided or deprivation therapy (NADT) to bridge the COVID-
perineal biopsies. These procedures increase patient and 19-related delay to RP should not be used in this
occupational exposure to SARS-CoV-2, use healthcare patient population.
resources, and are unlikely to improve patient outcomes c. In men electing to proceed with radiation therapy
in the short-term. Magnetic resonance imaging (MRI) (RT), a delay in treatment is also recommended. There
has become a preferred imaging modality for diagnosis is no role for NADT in men with low-risk prostate
and staging of prostate cancer, however, access is cur- cancer, and it is not routinely used for FIR disease.
rently restricted and, therefore, its use should be limited Consultation with and referral to radiation oncology
for staging of high-risk cases when clinically indicated is advised where appropriate.
(see below). The risk of TRUS biopsy-related sepsis is d. In patients on ongoing surveillance following defini-
of particular concern given the potential severity of this tive therapy for low-risk and FIR disease, consider
complication, which can lead to hospitalization and fur- decreasing frequency of PSA testing and deferring
ther risk of exposure to the virus. A secondary concern in-office clinic appointments, particularly for patients
is that of possible fecal SARS-CoV-2 transmission aris- greater than one year since surgery or RT.
15
ing from the gastrointestinal tract. In rare cases where 2. Localized high-risk prostate cancer (unfavorable-inter-
a diagnosis of prostate cancer may change immediate mediate-risk [UIR], high-risk [HR], and very high-risk
management, we recommend that TRUS biopsies are [VHR] groups)
performed using adequate personal protective equipment a. For new consults, we recommend proceeding with
(PPE) and strict adherence to appropriate antimicrobial diagnostic interventions and staging investigations in
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prophylaxis. The risk of fecal transmission during a DRE these patients pending resource availability, since a
is unknown and, to our knowledge, international societ- finding of metastatic disease would significantly alter
ies have not addressed use of PPE during the examina- management.
tion. We recommend adherence to institutional Infection b. Patients with UIR, HR, and VHR prostate cancer
Prevention and Control (IPAC) guidelines. If unavailable, who choose RT should begin NADT, as per current

164 CUAJ • June 2020 • Volume 14, Issue 6