April 15, 2020

Navigating the Care of Patients With Advanced Prostate Cancer Amid the COVID-19 Pandemic

By Emily A. Lemke, DNP, AGPCNP-BC, AOCNP^®, Medical College of Wisconsin, Milwaukee, Wisconsin

With daily updates regarding coronavirus 2019 (COVID-19) statistics, changing practice recommendations, and updated surge predictions, caring for patients with cancer has become increasingly challenging. Health-care providers, including advanced practitioners and physicians alike, are having to continually reevaluate the risk-benefit ratio of treating patients with cancer amid this pandemic while also rethinking day-to-day clinical practices.

Prostate Cancer Population
What little peer-reviewed literature exists on COVID-19 suggests that older (age > 65) males are at the highest risk for serious illness and mortality (Bhatraju et al., 2020). Prostate cancer most commonly affects this same demographic, making navigating caring for these patients especially challenging in the current environment.

Multiple treatment options are available for advanced prostate cancer. In the curative intent setting, this involves either radical prostatectomy or definitive radiation therapy with or without androgen deprivation therapy (ADT). For patients with more advanced or metastatic disease, treatment involves ADT in addition to oral antiandrogens or chemotherapy (National Comprehensive Cancer Network, 2020).

Deciding on a Course of Action
For patients with newly diagnosed prostate cancer or recurrent prostate cancer, there are many tools available for clinicians to stratify the aggressiveness of the patient’s disease; some of these include PSA doubling time calculator and a nomogram predicting prostate cancer specific-mortality for men with biochemical recurrences after radical prostatectomy (Brockman, et al., 2015; Pound, et al., 1999). These can help guide provider decisions regarding who warrants immediate treatment and who can safely delay starting treatment. For the most part, the majority of patients with localized prostate cancer can safely delay initiating treatment for 3 to 6 months with minimal risk (National Comprehensive Cancer Network, 2020).

The decision to delay care, however, becomes less clear in patients with progressive or metastatic disease, especially when the patient is > 65 year of age and/or has significant comorbidities. Specifically, preexisting lung disease, diabetes mellitus, and hypertension seem to carry a higher COVID-19 specific mortality (Bhatraju et al., 2020). For this population, clinicians must consider the current state of their institution among this pandemic. The number of COVID-19 patients being seen, number of available ICU beds, number of OR suites, availability of satellite centers, patient-to-patient proximity in chemotherapy infusion centers, and estimated date of peak COVID-19 infections in respective geographic region are all important factors. For prostate patients > 65 years of age being seen in institutions with strained resources and high rates of COVID-19 infections, the risk-benefit ratio leans heavily towards delaying treatment 3 to 6 months in clinically stable prostate cancer.

Considerations for Patients on Active Chemotherapy
For patients who are on active chemotherapy, clinicians are faced with challenging decisions regarding whether or not to continue treatment, and how to ensure the safest delivery of care. When possible, considering non-myelosuppressive regimens (such as oral anti-androgens) as an alternative or in place of chemotherapy may be reasonable. If cytotoxic chemotherapy is deemed necessary, consider growth factor support with same-day administration or use of on-body injectors where available to decrease visits (National Comprehensive Cancer Network, 2020).

Lastly, it is increasingly important to be mindful of how many health-care providers interact with the patient; minimizing duplicate efforts and the number of personnel interacting with patients is key to protect the health-care team, the patient, and to conserve PPE. Advanced practitioners and physicians should be well-equipped to complete many functions of a clinic visit historically completed by nursing and other support staff in an effort to minimize patient exposure.

Telehealth Resources
Amid these conditions, maximizing telehealth resources is the best way to minimize patient and provider risk, while also providing continuity of care. Effective January 27, 2020, the U.S. Department of Health and Human Services (HHS) secretary Azar declared a public health emergency, allowing the Centers for Medicare and Medicaid Services (CMS) to allow flexibility of coverage for telehealth services for Medicare beneficiaries. This allows clinicians the option to change existing in-person follow-up appointments to virtual telephone or video visits per their discretion. For a vast majority of patients with prostate cancer, this is an ideal avenue to provide uninterrupted care.

Furthermore, many pharmacies are shipping cancer-related medications to patients, minimizing patient risk by decreasing trips to the pharmacy, while avoiding lapses in medication adherence. For patients who need to have laboratory testing completed, utilizing regional care centers with lower patient volumes or using home-health services to complete laboratory draws when available can help patients avoid busier laboratory locations.

ADT Dosing
The vast majority of patients with prostate cancer are treated with ADT, most commonly delivered through LHRH agonist injections which are dosed in 1 month, 3 month, 4 month, and 6 month preparations. Strong consideration should be made to avoid 1-month formulations (National Comprehensive Cancer Network, 2020).

For most patients, especially those > 65 years, ADT injections can be safely delayed, as the risk of COVID-19 mortality is likely much higher than the risk of prostate cancer mortality in the short-term environment (National Comprehensive Cancer Network, 2020). It can often take up to 9 months for testosterone to fully recover to pretreatment levels, and longer for patients > 65 years of age; therefore, delaying ADT for 3 to 6 months should not affect patients’ care in most circumstances (Nascimento et al., 2019). This, of course, warrants a discussion between patient and provider, to ensure the patient is comfortable and understands the rationale behind delaying such treatments.

Useful Guidelines
The majority of major medical societies have issued COVID-19–related guidelines to help clinicians navigate these challenging times. The NCCN has developed prostate cancer–specific recommendations which some might find helpful (National Comprehensive Cancer Network, 2020).

Other useful resources are available from the Oncology Nursing Society (ONS), American Society of Clinical Oncology (ASCO), American Society for Radiation Oncology (ASTRO), American Urologic Association (AUA), Centers for Disease Control and Prevention (CDC), and World Health Organization (WHO).

These are challenging times which necessitate flexibility of both health-care providers and patients alike. On the other side of this pandemic, we will have learned lessons highlighting the value of telehealth, the resiliency of our health-care teams, and importance of pandemic preparedness in the oncologic setting.

References

Bhatraju, P., Ghassemieh, B., Nichols, M., Kim, R., Jerone, K., Nalla, A.,…Mikacenic, C. (2020). Covid-19 in critically ill patients in the seattle region - case series. New England Journal of Medicine, 1–11. https://doi.org/10.1056/NEJMoa2004500

Brockman, J., Alanee, S., Vickers, A., Scardino, P., Wood, D., Kibel, A.,…Stephenson, A. (2015). Nomogram predicting prostate cancer-specific mortality for men with biochemical recurrence after radical prostatectomy. European Urology, 67(6), 1160–1167. https://doi.org/10.1016/j.eururo.2014.09.019

Nascimento, B., Miranda, E., Jenkins, L., Benfante, N., Schofield, E., & Mulhall, J. (2019). Testosterone recovery profiles after cessation of androgen deprivation therapy for prostate cancer. Journal of Sex Medicine, 16(6), 872–879. https://doi.org/10.1016/j.jsxm.2019.03.273

National Comprehensive Cancer Network. (2020). Management of prostate cancer during the COVID-19 pandemic. Retrieved from https://www.nccn.org/covid-19/pdf/NCCN_PCa_COVID_guidelines.pdf

Pound, C. R., Partin, A. W., Eisenberger, M. A., Chan, D. W., Pearson, J. D., & Walsh, P. C. (1999). Natural history of progression after PSA elevation following radical prostatectomy. Journal of the American Medical Association, 281(17), 1591–1597. https://doi.org/10.1001/jama.281.17.1591

Read more from the APSHO Advance: Special COVID-19 Series