EMUC 2020: The COVID-19 Pandemic: The Urologist's Experience

(UroToday.com) The European Multidisciplinary Congress on Urological Cancers (EMUC) 2020 virtual meeting featured a round table discussion on the impact of the COVID-19 epidemic on the management of Genitourinary (GU) cancers, including a presentation by Dr. Chris Wallis discussing the urologist’s perspective.

Dr. Wallis started by noting that on January 20^th, 2020 four countries were affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) COVID-19, followed by 28 countries on February 15^th, 66 on March 1^st, and nearly all countries affected (165) on March 20^th. Based on this data, there are three rationales for changes to care, including (i) protecting our patients, (ii) protecting ourselves as healthcare workers, and (iii) protecting the capacity of healthcare systems.

Early data from China was the first to suggest that patients with cancer may be susceptible to a more aggressive COVID-19 phenotype. However, subsequent data that emerged from the United States suggested that patients with a history of cancer did not have a higher mortality rate from COVID-19; also, recent surgery or chemotherapy did not predispose one to worse outcomes from COVID-19. However, data from the COVIDSurg collaborative demonstrated that predictors of 30-day mortality were very similar to many of the urologic oncology patients we treat, including¹:

• Men: OR 1.75 (95% CI 1.28-2.40)
• >=70 years: OR 2.30 (95% CI 1.65-3.22)
• ASA 3-5: OR 2.35 (95% CI 1.57-3.53)
• Emergent surgery: OR 1.67 (95% CI 1.06-2.63)
• Cancer surgery: OR 1.55 (95% CI 1.01-2.39)

Furthermore, among 1,591 patients admitted to the ICU in the Lombardy Region, Italy the median age was 63 years (IQR 56-70), 82% were male, 68% had ≥1 comorbidity, 88% required ventilator support, and the mortality rate was 26%, with a large proportion requiring ongoing ICU level care at the time of data cut-off.²

There have been several initiatives that have been used to guide treatment during these trying times,^3,4 but Dr. Wallis quotes the famous boxer, Mike Tyson, noting that “Everyone has a plan until they get punched in the mouth.” Dr. Wallis states that there are several general principles to adhere to:

• Adhere to existing guidelines where feasible
• Minimize patient and physician exposure to the greatest extent possible
• Carefully consider competing risks of morbidity and treatment toxicity
• Defer treatment and investigation where delays are unlikely to affect cancer outcomes

There are several avenues for which we can explore comorbidities in our patients, including the University of Michigan OncCOVID Resource: Intersection of Oncology and Coronavirus (COVID-19), integrated survival estimates from immediate versus delayed treatment. This allows a provider to input important data, such as comorbidities, cancer risk, and community COVID-19 risk, and subsequently generate predictors of both oncology and COVID-19 related outcomes.

In the initial assessment, individualized overall survival estimates were associated with patient age, number of comorbidities, treatment received, and specific local community estimates of COVID-19 risk [5].

Since the pandemic, there has certainly been global decreases in new patient visits and interventions. Work from Oderda et al. [6] shows that as the pandemic continues, there is an increasing backlog of genitourinary oncology cases that need to be performed. As a result, except in rare circumstances, these increases will not be able to be met and wait times are likely to increase:

A collaborative group led by Dr. Wallis worked to re-envision the future of genitourinary cancer care given the impact of the COVID-19 pandemic:

Particularly important is the delivery of surgical care. One important initiative is the idea of COVID-19 free surgical pathways during the pandemic, such that there is no overlap at all between patients undergoing surgery and those that are being treated for COVID-19. As such, it may be prudent and necessary to restructure our hospital systems in order to appropriately allocate these resources. Secondly, is the issue of patients that have had COVID-19 and required rescheduling of their oncology operation. As seen from data from the COVIDSurg Collaborative, among 122 patients with a previous positive SARS‐CoV‐2 swab, 22.1% (n = 27) were operated on within 2‐weeks of diagnosis, 49.2% (n = 60) between 2 and 4 weeks, and 28.7% (n = 35) after 4 weeks [8]. In a propensity score matched model, previous SARS‐CoV‐2 infection was associated with increased odds of pulmonary complications compared to no infection (10.7% versus 3.6%, adjusted OR 3.84, 95% CI 1.51‐9.74, p = 0.004). When split by time from swab to surgery, both pulmonary complications and mortality were lowest at least 4 weeks after notification of a positive swab test:

With regards to how we interact with our patients, there has been a rapid implementation of telehealth and non-contact measures for interacting patients in the clinical setting. But, Dr. Wallis cautions, we must be careful to ensure that telemedicine doesn’t exacerbate disparities already present in medicine, specifically among those who have poor technological access, the elderly, and minorities.

Dr. Wallis concluded with several important take home messages from the urologist’s perspective on COVID-19:

• COVID-19 has reshaped the fabric of our society and the of healthcare
• Some temporary changes enacted are likely to lead to long-term harm
• Others offer the potential for improvements if retained
• Moving forward, COVID-19 is likely to continue to influence how we deliver care for the foreseeable future

Presented by: Christopher J.D. Wallis, MD, Ph.D., Instructor in Urology, Vanderbilt University Medical Center, Nashville, Tennessee