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Consensus: Managing prostate cancer during COVID-19

best practice recommendations. Four to six months these men depending on clinical scenario. Full stag-
of NADT is appropriate for patients with UIR. (Note ing evaluation, including laboratory testing and imag-
that RTOG 9910 showed that nine months of ADT ing, is also recommended.
did not improve local control, biochemical disease- b. In men with high-risk features post-RP, early salvage
free survival, cancer-specific mortality, metastasis- RT is recommended over upfront adjuvant RT. 26,27 Men
free survival, or overall survival. ) Hypofractionated with BCR and no evidence of metastases should have
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RT protocols should be considered to minimize ongoing PSA and imaging assessments as indicated,
patient visits. and the frequency should be dictated by disease risk
c. UIR, HR, and VHR patients electing to proceed with and PSA doubling time. Hypofractionated RT protocols
RP require special consideration. Within the current should be considered to minimize patient visits.
COVID-19 climate, many centers are deferring non- c. Men with newly diagnosed node-positive prostate
emergent surgical cases, therefore, a delay in time cancer without evidence of further metastases should
to RP from diagnosis may be expected. In a retro- receive ADT and consideration for external beam
spective analysis of UIR, HR, and VHR patients, a RT as per current best practice. Hypofractionated RT
treatment delay for up to six months did not affect protocols should be considered. Abiraterone has also
biochemical recurrence (BCR) or recurrence-free sur- shown benefit in these patients, however, this must
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vival, whereas a study of HR and VHR cases only be balanced with requirement for laboratory monitor-
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suggested no adverse oncological outcomes from a ing and physical examination. Therefore, we would
three-month delay. Hence, a delay of three months recommend a delay of abiraterone therapy for of up
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may be considered in places where surgical resource to six months from time of diagnosis.
capacity is limited. d. In men with newly diagnosed metastatic hormone-
d. NADT prior to RP for localized prostate cancer is sensitive prostate cancer (HSPC), we recommend
not recommended outside of a clinical trial because treatment with an ARAT over docetaxel chemotherapy
current best available evidence suggests no overall in addition to ADT. While outcomes of prostate cancer
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survival benefit. However, there is a significant patients infected with SARS-CoV-2 are unknown, can-
improvement in multiple pathological variables, cer patients with a history of receiving chemotherapy
including nodal metastases and positive margins within one month are at higher risk for severe illness. 2
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with an acceptable safety profile. In a randomized Chemotherapy administration is also associated with
study comparing three- and eight-month durations more intense resource use and risk exposure.
of NADT prior to RP, patients in the eight-month e. Men with oligometastatic HSPC require ADT and
group had ongoing pathological and biochemical may benefit from external beam RT to the prostate
regression of localized prostate cancer, suggesting (with or without an ARAT). 29,30 We recommend
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safety of this approach. Therefore, this option may withholding or delaying RT in this setting during the
be considered in patients with UIR, HR, and VHR pandemic. If RT is administered, a hypofractionated
disease during the COVID-19 crisis if prolonged sur- course should be considered.
gical delays are expected. Patients should be aware f. In men with a new diagnosis of high-risk (PSA dou-
that this is not standard practice, and the risk-benefit bling time <10 months), non-metastatic castrate-
discussion should be documented. Use of androgen resistant prostate cancer (nmCRPC), we recom-
receptor axis-targeted therapies (ARAT) in this context mend consideration of apalutamide, enzalutamide,
remains experimental and is not recommended. or darolutamide per current standard of care. 31-33 In
e. For patients on surveillance following definitive nmCRPC patients with a prolonged PSA doubling
therapy for high-risk prostate cancer, we recom- time, we recommend considering a decrease in the
mend ongoing PSA testing and imaging, if needed, frequency of imaging.
to assess for recurrent disease. Consideration may be g. In men with a new diagnosis of metastatic castrate-
given to decreased frequency of testing in men who resistant prostate cancer (mCRPC) who have not pre-
have been disease-free for two years or greater, and viously been treated with an ARAT, we recommend
to transition them to telehealth visits. this therapy over chemotherapy for the reasons dis-
3. Advanced prostate cancer (clinical nodal involvement, cussed above. Another option may be radium-223 in
BCR post-primary treatment, metastatic disease) men with bony metastases, however, the benefit must
a. Patients with newly diagnosed advanced prostate be weighed against the risk of pancytopenia. Men
cancer are complex and require comprehensive and should be referred to medical oncology for discus-
preferably multidisciplinary assessment. We recom- sion of risks and benefits of systemic therapy within
mend considering in-person clinic consultations for the COVID-19 setting.

CUAJ • June 2020 • Volume 14, Issue 6 165