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Kokorovic et al

h. In men with painful bone metastases or bone metas- monly practiced and may delay the time to initiation
tases at high risk of fracture (weight-bearing bone of chemotherapy. This may be advantageous in the
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such as vertebra/pelvis/femur), we recommend refer- setting of COVID-19. However, practitioners must be
ral to radiation oncology for a short course of pallia- aware that there is currently a global shortage in access
tive radiotherapy. to dexamethasone.
7. Many institutions have restricted visitor access. This
Special considerations challenge may be of particular concern to patients with
advanced prostate cancer, cognitive challenges, or lan-
1. The treatment of localized or locally advanced prostate guage barriers, whose caregivers are highly involved in
cancer within the COVID-19 context requires complex treatment decisions and information synthesis. Patients
decision-making, not only with respect to timing but should be encouraged to use technology (video, tele-
also choice of treatment modality. Surgery and brachy- phone) to enhance discussion and comprehension dur-
therapy carry the risk of serious complications, require ing the clinic visit.
use of hospital resources, and have increased risk of 8. Men with advanced prostate cancer are generally older,
SARS-CoV-2 exposure to patients and healthcare per- frail, and have multiple comorbidities in addition to an
sonnel. External beam RT mitigates some of these risks, advanced malignancy. This makes them a vulnerable
however, patients are subject to multiple, repeated out- population during the COVID-19 pandemic. Patients
patient hospital visits. Many RT groups have instituted and their families should be encouraged to discuss sub-
short-course interim policies leaning heavily on stereo- stitute decision-making and advanced directives. A use-
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tactic body RT techniques. The optimal choice and ful framework on this subject is discussed elsewhere. 37
timing of treatment ultimately requires shared decision- 9. One of the major repercussions of COVID-19 is the
making and multidisciplinary collaboration. potential for economic instability and occupational
2. For robotic-assisted laparoscopic prostatectomy or insecurity. Many younger patients may not have con-
laparoscopic RP, there may be an increased risk for tinuing access to drug coverage benefits as a result. Use
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aerosolization of the virus. Although this has not yet of compassionate drug access programs, if available, is
been directly linked to SARS-CoV-2, urologists perform- strongly encouraged for these cases.
ing minimally invasive surgery should take necessary
precautions to mitigate this possibility, including use of Conclusions
filter devices. 16,35 There are several filter devices avail-
able on the market, and they have been summarized The COVID-19 pandemic has resulted in extraordinary chal-
elsewhere. 16 lenges to healthcare systems, which raises several concerns
3. For patients on ADT, strong consideration should be for the treatment of prostate cancer patients. Herein, we
given to using longer-acting depots and implementing provide a framework for Canadian physicians managing this
home injection programs where available in order to complex malignancy during a global health crisis, as sum-
decrease patient and healthcare practitioner exposures. marized in Table 1. The proposed recommendations act as a
4. Special consideration should be given to patients on guide and must be considered in the context of a fluctuating
bone-targeted therapies, specifically denosumab. For and evolving environment. They do not address the impact
men with mCRPC receiving monthly dosing, self-injec- of potentially delayed care on the healthcare system once
tions should be encouraged when possible to limit expo- operations return to pre-COVID-19 levels. We recognize that
sure to healthcare personnel. The frequency of labora- this is a complex issue and that delayed care may result in
tory monitoring (calcium, specifically) and associated challenging triaging decisions in the future, however, these
exposure risk present an added challenge during the recommendations are meant to guide physicians during the
COVID-19 crisis. This must be balanced with the net acute crisis phase. We note that population-wide changes to
benefit of therapy. In patients who are unable to or prostate cancer care are not unprecedented, with one pop-
refusing laboratory testing during the pandemic, we rec- ulation-based study showing a decrease in PSA-detectable
ommend temporary discontinuation of denosumab or prostate cancer diagnoses and increased use of conservative
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consideration of longer treatment intervals (e.g., three management during the Great Recession. We believe that
instead of one month). the principles in this statement may remain applicable under
5. For patients receiving abiraterone, the home-monitor- future resource constraints.
ing program should be instituted to avoid unnecessary
hospital and clinic visits. Competing interests: Dr. So has been an advisory board member for Abbvie, Amgen, Astellas,
6. For patients receiving and progressing on abiraterone, Bayer, Janssen, Ferring, and TerSera; and has participated in clinical trials supported by Astellas,
the switch from prednisone to dexamethasone is com- Ferring, and Janssen. Dr. Hotte has received honoraria from Astellas Scientific and Medical Affairs

166 CUAJ • June 2020 • Volume 14, Issue 6