Taking a Tiered Approach to Prostate Cancer Surgery During the COVID-19 Pandemic

Quoc-Dien Trinh, MD

In light of the coronavirus disease 2019(COVID-19) pandemic,many have learned to adapt and develop new strategies to best care for patients with prostate cancer while preventing the spread of the virus, explained Quoc-Dien Trinh, MD, who added that several factors go into determining whether it is safe to perform radical prostatectomies, procedures should be delayed, or alternative treatments should be offered.

“COVID-19 has [caused many challenges] for all of us, including those of us who have been taking care of patients with prostate cancer. For those who are interested in surgery, we have to take a tiered approach depending on their risk category,” said Trinh, an associate professor of surgery at Harvard Medical School. “The contested category would probably be the high-risk group, where either we have to decide to take them to surgery despite the risk of COVID-19 or be creative in offering something like neoadjuvant ADT either on or off a clinical trial.”

Available guidance and recommendations have suggested that it may be possible to postpone surgery in patients with low- to intermediate-risk disease, according to Trinh; however, what should be done for patients with high-risk disease has been an area of debate. Because high-risk disease poses more complications, delays in treatment could potentially impact this population in a negative way, said Trinh.

For these patients, he noted that depending on the patient, his institution would either go through with the procedure as planned or consider alternative action, such as putting patients on androgen deprivation therapy (ADT) before proceeding with surgery. This tiered approach could be key to managing patients with prostate cancer while mitigating their risk of exposure to COVID-19, noted Trinh.

“This is a reminder that our patients are individuals, and they have their own priorities, preferences, and anxieties with regard to the disease that they're facing,” added Trinh. “We have to consider these factors in the decision-making process when recommending treatment and when we’re determining whether we can safely postpone their procedure throughout this pandemic.”

In an interview with OncLive during the 2020 Institutional Perspectives in Cancer webinar on Prostate Cancer, Trinh, who is also the co-director of the Dana-Farber/Brigham and Women's Prostate Cancer Center and director the of Ambulatory Clinical Operations in the Division of Urological Surgery at Brigham and Women’s Hospital, highlighted the impact of the pandemic on prostate cancer treatment and factors that are considered to inform treatment decisions.

OncLive: How has the COVID-19 pandemic impacted patients with prostate cancer?

Trinh: In March, we came to a consensus that elective procedures needed to be postponed. [However], the big questions are: What constitutes an elective surgery and, more importantly, what cancer surgery can be safely postponed? In the world of prostate cancer, there was some consensus that most prostate cancer cases could be postponed at least by a couple of weeks in a safe fashion. There's no controversy at all for low-risk patients with prostate cancer who would be safely put on active surveillance anyway. If for some reason we decided to operate on these individuals, a postponement of 1 month, 2 months, or 3 months, would not make much of a difference. For most intermediate-risk patients with prostate cancer, postponement is also not associated with worse outcomes based on some retrospective data from different sources that have been published throughout the years. The big question is focused on what we should do with high-risk patients with prostate cancer.

In some instances, people have advocated to go ahead with surgery despite the potential risk, the use of personal protective equipment, etc. In other instances, these cases were postponed. At Dana-Farber, there has been some consideration for putting these patients on neoadjuvant ADT for a number of months and then proceeding with surgery; that can be done either as part of a clinical trial, such as PROTEUS, or even off trial.

What is your methodology for determining whether to postpone surgery or switch to another treatment approach? Are you utilizing any specific guidelines to inform your decisions?

Many opinion pieces and some internal or external guidance that have been published. To my knowledge, however, no clear guidelines telling us what we should do with [one patient versus another]. The National Comprehensive Cancer Network did say that patients with low- or intermediate-risk [prostate cancers] could [have their surgeries] postponed, but high-risk patients should potentially receive treatment sooner. [However], I wouldn't consider [those recommendations to be] in the realm of clear guidance supported by level 1 evidence.

Internally, at the Brigham and Women’s Hospital and Dana-Farber, we did come up with some sort of guidance ob how we should manage these patients; [we wanted to achieve] some consistency among providers. Most of us could agree that most low-risk and intermediate-risk patients with prostate cancer can be safely postponed by 4 weeks, 8 weeks, or 12 weeks; that’s what we did in the majority of cases.

The trickier question is: What do we do with high-risk patients? In some instances, we proceeded to treatment immediately, as per usual, despite the risk of COVID-19; this would happen after we counseled our patients carefully about the pros and cons of proceeding with such treatment. We also proposed alternative plans, such as, for example, putting some of these patients on neoadjuvant ADT either as part of a clinical trial, such as PROTEUS, but even off trial to minimize the potential for spread of the disease while we're holding off on treatment because of the crisis.

What are some of the key challenges faced at your institution in light of the pandemic?

Back in March 2020, we told [some] patients that their surgeries could be safely postponed in light of the healthcare crisis. In general, most patients accepted that and understood why [we did that]. For patients who had a cancer that was indolent, it didn't make much sense to rush to treatment, risk getting COVID-19, or risk transmitting the virus to one of their loved ones; they accepted that pretty well. What was interesting is that in May 2020, when we decided that we could resume cancer procedures, especially high-priority procedures, and we started calling our patients to tell them to come back to the hospital, many of them [were still uncomfortable] about undergoing their procedure. They did not feel ready.

As an institution and as a division of providers treating [patients with] prostate cancer, we need to re-establish that trust and inform our patients of the measures we are taking to protect them so that we can continue their treatment.

That is definitely an interesting challenge and it obviously helps that there are now fewer cases in Massachusetts than there had been 1 or 2 months ago. There was something organic there, but there was also a whole process of re-establishing that trust with our patients that they can be safely operated upon, despite the pandemic.

Speaking to the re-establishing of trust and comfort with continuing treatment, how are some of the precautionary measures in place at many institutions, such as the no-visitor policy, affecting patients?

It's difficult. Prostate cancer is a very complex condition. The cancer can grow, spread, and [cause mortality]; at the same time, many quality of life concerns exist, as well. However, several alternative strategies are being examined. It’s a challenge to have our patients come in alone to go over [their treatment], to not have their loved ones on site to [help them] make decisions. To address that, some of our patients have been asking their loved ones to join on the phone or through Zoom. We've definitely had many of these multidisciplinary consultations [through telemedicine] and we’re trying to leverage technology so that their loved ones can be involved [in their care].

Telemedicine has played a huge role in the pandemic. We have been doing things that we never did before, such as new patient consults through Zoom, which allows multiple people to join. I remember having a Zoom call where I had a son and a daughter living in different cities, and the patient and his wife, all on the same call, which definitely helps from the perspective of gathering information and being proactive about decision making. The challenge that it poses to the surgeon is that now we don't get to examine our patients, which is an important aspect of making the decision to go to surgery.