Prostate cancer management challenges due to COVID-19 in countries with low-to-middle-income economies: A radiation oncology perspective

Abstract

Description: The COVID-19 pandemic poses an unprecedented challenge for urologic oncology and radiotherapy. Radiation oncology departments and international collaboration groups are sharing their management adaptations made in response to the pandemic. The present narrative review summarizes the current recommendations.
 Relevance: There is a need to define which patients are candidates for safe treatment delay until the pandemic is over or controlled, to reduce exposure to the virus in the healthcare personnel and patients. 
 Conclusions: Telemedicine is recommended for follow-up visits. Active surveillance is the preferred treatment for patients with favorable intermediate risk. In greater risk disease, hormone therapy safely postpones radiotherapy up to 7 months. Radiosurgery is suggested in centers that have the necessary technology and previous experience. A moderately hypofractionated regimen is recommended if radiosurgery/ultra-hypofractionation is not available. Hypofractionation should be implemented if image-guided radiation therapy is already in place. Countries with low and middle-income economies face challenges in adopting the recommendations for prostate cancer management during the pandemic. Postponing treatment may result in the overwhelming of radiation oncology center capacity, after the pandemic.

Management Recommendations for Prostate Cancer during the COVID-19 pandemic: A Systematic Review

“…Six papers (all of them being either narrative reviews or consensus-based recommendations) addressed the role of active surveillance (AS) in PCa patients and concluded that in very low risk (VLR), low risk (LR), and favorable intermediate risk (FIR) PCa patients, AS is an adequate management strategy [20,24,27,29,30]. For LR and FIR patients, Rodriguez-Sanchez et al and Caicedo-Martinez et al suggest implementation of AS while delaying RP and RT until the pandemic is controlled [27,30], and Kokorovic et al suggest either AS or delaying RP up to 12 months [20]. Detti et al recommend multi-parametric MRI (mpMRI) of the prostate instead of re-biopsy in patients on AS [28].…”

“…For low-and intermediate-risk PCa patients, all publications agree on active surveillance and delay of any modality of treatment [18,[20][21][22][23][24][25][26][27][28][29][30]34,39,40]. For highrisk patients and locally advanced disease, 3 systematic reviews [18,34,42] conclude that if primary curative RT is planned, delay between 1 and 3 months is feasible.…”

“…Three expert consensusbased recommendations suggest the use of RT with ADT in HR localized and locally advanced disease for patients not eligible for RP, with immediate initiation of long deposit ADT [20,21]. A delay of up to 3 months is considered safe and feasible [16]; however, most expert consensus documents recommend delays of up to 6 months, with initiation of ADT while waiting for RT [25][26][27][28]30,41]. For postprostatectomy RT, adjuvant RT should not be initiated; instead, salvage RT is recommended [18,20,22,28,29,34,39,42,43].…”

“…Metastatic disease requiring palliative RT management should be undertaken as soon as possible on the basis of symptomatic disease or risk of fracture and medullary compression [20,21,28]. Regardless of PCa risk and stage, brachytherapy is not recommended, and the ideal EBRT treatment should be either hypofractionated or ultra-hy pofractionated [18,[20][21][22][25][26][27][28][29][30]34,39,41,44]. Follow-up with PSA testing after RT may be at 6-month intervals to reduce hospital exposure [27,30].…”

“…Regardless of PCa risk and stage, brachytherapy is not recommended, and the ideal EBRT treatment should be either hypofractionated or ultra-hy pofractionated [18,[20][21][22][25][26][27][28][29][30]34,39,41,44]. Follow-up with PSA testing after RT may be at 6-month intervals to reduce hospital exposure [27,30]. A summary of recommendations is provided in Table 5.…”