Global health policy continues to stridently educate us upon the importance of physical distancing, limiting travel, and frequent handwashing. In addition, expert scientific guidance for both newer safeguards (e.g. facemasks and antibody testing) combined with pathways leading toward relaxation of these policies—based on regional variances of infection rates, hospitalizations, critical supplies, and mortality rates—will help inform us. As urologists, we are a part of the essential workforce whereby we cannot always stay home—we evaluate both urgent and emergent care as well as patients either with high-risk cancer diagnoses or those who need a differential diagnosis answered; these evaluations and care cannot always be comfortably or safely delayed during a potentially prolonged quarantine.
Clinic volume, diagnostic procedures, and surgeries have been dramatically diminished for many urologists. Unfortunately, the biology of cancer initiation, evolution, and progression is not abated by a novel and deleterious virus. To ensure that the patient population you serve is receiving the best possible care during the evolving social distancing protocols, we’ve outlined some tactics and considerations for your practice.
Early Detection of Prostate Cancer
The National Comprehensive Cancer Network (NCCN) recently released guidelines to align the urology community on the early detection of prostate cancer amidst the COVID-19 pandemic. The guidance included principles that address patient safety, occupational safety, maintenance of physical distancing, and resource utilization—all measures which have been universally agreed upon. The guidance does not address the potential for the utilization of biomarkers for prioritizing both cancer diagnoses and the need for immediate vs. delayed treatment.
Risk stratification has always been a challenging component of medical/urologic care. Now, in addition to balancing patient anxiety and fear for cancer diagnosis and the concerns for over or under diagnosis and over or under treatment, we must also factor in the new COVID-19 concerns. There exists the potential for precision medicine to augment our evaluation and management from a passive reactive approach to a proactive and preventative strategy. There are biomarkers that are specifically designed to help detect prostate cancer and further inform clinical significance. Specifically, having an enhanced understanding of the aggressiveness of a patient’s prostate cancer is an integral aspect of informed patient-physician shared decision making.
Precision medicine tools, or biomarkers, can help throughout the prostate cancer journey, from detection to treatment management. These tools are philosophically in abidance with the Center for Disease Control (CDC) guidelines, which encourage medical care professionals to safeguard patient care with regard to COVID-19 risk without compromising cancer care evaluation.
As a summary review, we created this chart of biomarker tests—acknowledging that there are many other commercially available tests and many in development—which explain when each biomarker test can be used, if an office visit is required or whether the test is lab-based for collection.
In an effort to further educate and promote patient advocacy, elevate prostate cancer awareness and to reassure the prostate cancer patient community that urologists are taking precautions to maximize patient safety during COVID-19, we worked with the Prostate Conditions Education Council (PCEC) to launch a resource hub that shares the best practices for improving risk stratification and clinical decision-making during the COVID-19 pandemic. This resource puts a strong emphasis on the adoption of biomarker tests and other innovative tactics. To learn more, visit the PCEC website for further resources.
Elective Surgeries and Non-Essential Services
Some prostate cancer patients and those with risk factors of immunocompromise are at an increased risk of both severity of illness as well as death if they contract the novel coronavirus. This makes minimizing their contact with the healthcare system a priority for at-risk patients when appropriate. Thus, the Surgeon General and the American College of Surgeons has recommended postponing any elective surgeries during times of strict shelter-in-place health policy.
Some studies suggest that delaying treatment between one and three months, depending on the stage of the disease, outweighs the risk of COVID-19 exposure and its potential lethality. During these times, we delay treatment in order to:
- Minimize unnecessary patient-public contact, especially important for immunocompromised patients
- Lessen the burden on a healthcare ecosystem, especially when resources are diminished
- Provide resources, such as personal protection equipment (PPE) and medical staff time/expertise where most optimally needed
While these decision-making points are both complex and controversial and may be both off-putting and anxiety-provoking for our patients, we are aware of the heterogeneity of prostate cancer and thus its potential for unique and individualized disease management. We also acknowledge the fact that upwards of 40% of newly diagnosed localized prostate cancer patients may benefit from active surveillance1 as their best treatment option. Active surveillance strategies may sometimes not require an in-office visit. Furthermore, selecting an interventional therapy (e.g. surgery or radiation) and their attendant follow-up appointments may further allow for consideration for flexibility. However, patient anxiety for fear of missed cancer or cancer recurrence/progression may be very challenging. Here are some considerations in combatting this:
- Leverage innovations, such as prostate cancer biomarker tests, to identify patients most at risk for prostate cancer. For example, ConfirmMDx uses residual tissue from an initial biopsy to detect clinically significant prostate cancer that may have been missed. This test can be ordered without an office visit, and the results can be reviewed via telehealth.
- Consider individual patient factors, such as age, comorbidities, concomitant medications, and general health to optimize care.
Currently, we are all aligned to “flatten the COVID-19 curve” without compromising prostate cancer patient health care. It is essential that we keep patients and their caregivers as well as our health care teams regularly informed of new and emerging data for both prostate cancer and COVID care strategies. Consider the following:
Use Telehealth Services
Telehealth was historically difficult to implement due to technology, privacy, and reimbursement barriers. Practices implementing telehealth strategies due to CARES legislation, liberalizing telehealth access, have discovered that it can be an integral practice component. Telemedicine can be effectively used for reviewing biomarker tests as well as monitoring prostate cancer patients of active surveillance and used for post-interventional treatments. Undoubtedly, telehealth may not be a practical option for some elderly patients or patients having difficulty accessing or navigating these services. Because cross-state licensing has been temporarily removed, telemedicine visits are an acceptable solution when desired. Although the telemedicine regulations have been relaxed, there are still concerns over privacy and safety for healthcare delivery. To make sure you are using telemedicine properly, we recommend reviewing LUGPA’s summary in response to COVID-19.
Keep Staff Updated
As you determine which patients require face-to-face appointments, it is essential to keep your staff updated on the latest guidelines from the American College of Surgeons (ACS), the Centers for Disease Control and Prevention (CDC), the National Comprehensive Cancer Network (NCCN) and the Centers for Medicare and Medicaid Services (CMS) to ensure that your practice progressively evolves given the rapidly changing information. Patients will experience heightened anxiety, oftentimes, brandished upon the non-physician healthcare team. Therefore, having clear communication will avoid message confusion amongst the health care team and fortify your innovative strategies.
Share Resources Within Your Network
The “house of urology” must continue to stay fully connected and united as we deal with a pandemic enveloped in so much uncertainty. Already, we’re acclimating to virtual care when possible and embracing newer technology, such as biomarker tests, to continue delivering care to our patients. Here are some additional, useful resources during this time:
- LUGPA’s list with regularly updated information on the COVID-19 pandemic
- NCCN’s recommendations for management of prostate cancer
- The Advisory Board’s checklist of strategies outlining ways to balance patient demand and resource shortages
- PCEC’s resource hub on coronavirus and prostate cancer
- AUA’s information center for COVID-19
Michael S. Cookson, MD, MMHC, Professor and Chairman, Department of Urology, Donald D. Albers Endowed Chair in Urology, Stephenson Cancer Center, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Reference:
- Hayes, Julia H., Daniel A. Ollendorf, Steven D. Pearson, Michael J. Barry, Philip W. Kantoff, Susan T. Stewart, Vibha Bhatnagar, Christopher J. Sweeney, James E. Stahl, and Pamela M. McMahon. "Active surveillance compared with initial treatment for men with low-risk prostate cancer: a decision analysis." Jama 304, no. 21 (2010): 2373-2380.