Care of Prostate Cancer Patients During the COVID-19 Pandemic: Recommendations of the NCCN 

What is the NCCN

The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit alliance of 30 leading cancer centers devoted to patient care, research, and education. NCCN develops patient and treatment specific guidelines that many doctors and insurance companies follow in order to provide comprehensive state of the art treatment to patients.

 The NCCN has developed new guidelines for the treatment of many different cancers in light of the COVID-19 Coronavirus pandemic.  You can find these guidelines at https://www.nccn.org/covid-19/default.aspx.   

 The following are the prostate cancer COVID-19 Guidelines as well as Cancer ABCs glossary of some of the terms used in the guidelines:

  (Contributions from: Abramson Cancer Center at the University of Pennsylvania, City of Hope National Cancer Center, Dana-Farber/Brigham and Women’s Cancer Center, Duke Cancer Institute, Fox Chase Cancer Center, Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Huntsman Cancer Institute at the University of Utah, Massachusetts General Hospital Cancer Center, Moffitt Cancer Center, the Ohio State University Comprehensive Cancer Center – James Cancer Hospital and Solove Research Institute, Prostate Health Education Network (PHEN), Robert H. Lurie Comprehensive Cancer Center of Northwestern University, the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Stanford Cancer Institute, UCSF Helen Diller Family Comprehensive Cancer Center, University of Michigan Rogel Cancer Center, University of Wisconsin Carbone Cancer Center, and Vanderbilt-Ingram Cancer Center) 

Introduction: 

During the COVID-19 global pandemic, cancer patients and physicians must carefully weigh the potential benefit of routine cancer care versus the high morbidity and mortality of COVID-19, especially in patients of older age, patients with comorbidities, and those with cancer.(1) Staff and resources may also be redistributed to care for COVID-19 patients, and thus judicious use of resources is critical during this time. There are continuously evolving policies and guidelines on a global, national, state, institutional, and departmental level; thus, these guiding principles are intended to provide a framework to think about how to manage prostate cancer patients. 

For recommendations on prostate cancer early detection during the COVID-19 pandemic, please refer to: https://www.nccn.org/covid-19/pdf/Prostate_Early_Detection.pdf.

General Principles: 

1. The benefit of routine localized prostate cancer care should not be overestimated.(2, 3) In most instances, minimal harm is expected with delays in care or treatment of 3–6 months, especially when weighed against the risk of mortality of COVID-19. 

2. Remote visits: 

Telehealth (phone or video) visits should be used, with rare exceptions, in place of in- 

person visits. 

If necessary given reallocation of staff/providers, telehealth visits can usually be safely 

deferred for patients with localized disease. 

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Care of Prostate Cancer Patients During the COVID-19 Pandemic: Recommendations of the NCCN 

3. Avoid, defer, and shorten/reduce routine care, staging, and treatment when possible: a. Avoid: 

Patients with very low, low, and favorable intermediate risk (IR) disease should not undergo further staging, active surveillance, confirmatory testing/monitoring, and treatment until deemed safe. 

In general, prophylactic whole pelvic radiation therapy (WPRT) should be avoided during this time due to the increased risk of grade IV lymphopenia (Unpublished data, RTOG 9413). 

For patients with non-metastatic disease, avoid initiating androgen deprivation therapy (ADT) for patients with a prostate-specific antigen (PSA) doubling time of >9 months. Once ADT is initiated or intermittent ADT is started, consider remote telehealth visits and PSA/testosterone and other laboratory monitoring to avoid clinic exposures. 

b. Defer: 

Patients with asymptomatic unfavorable intermediate risk (UIR), high risk, 

and very high risk (HR) prostate cancer can defer further staging and radical 

treatment until deemed safe. 

Neoadjuvant ADT should be considered in asymptomatic UIR and HR 

patients planning to receive definitive radiation therapy (RT). This may safely 

be given for up to 4–6 months as necessary.(4-6) 

Data from Johns Hopkins suggest delaying surgical treatment for UIR and 

HR patients upwards of 6 months from biopsy diagnosis will not negatively 

impact their outcome.(7) 

Individuals who have received definitive treatment for their cancer with either 

radiation or surgery could defer initial post-treatment monitoring (PSA-based testing and digital rectal exam [DRE]) until deemed safe. Alternatively, telehealth visits with discussions of PSA and testosterone could be considered. 

c. Shorten/reduce: 

Consideration to use 3-, 4-, or 6-month formulations of ADT should be 

preferred over 1-month injections. 

If it is deemed safe for patients to receive RT, the shortest safe external beam 

RT (EBRT) regimen should be used. This can consist of 5 to 7 fractions, consistent with current NCCN Guidelines. 

2.  Care of Prostate Cancer Patients During the COVID-19 Pandemic: Recommendations of the NCCN 

iii. For symptomatic patients (eg, obstruction, bleeding), conservative measures should be prioritized (eg, medical therapy, ADT, clean intermittent catheterization). If necessary, surgical intervention or RT may be considered. 

4. Encourage and consider: 

Encourage communication with patients’ primary care providers to coordinate care, reduce overall health risks, and clarify advanced planning. 

Address and document goals of care and advanced directives early if frail, and/or limited life expectancy to avoid unwanted emergency department (ED) visits and hospitalizations. 

Discuss and document Durable Power of Attorney (DPOA) and emergency contact information. 

Encourage patients to have an adequate supply of oral cancer medications and supportive care medications on hand (and/or have delivered by mail). 

Consider deferring repeat imaging over time if PSA is declining and absence of symptoms until risk of COVID-19 has resolved. 

Educate patients receiving chronic steroids (eg, prednisone, methylprednisolone) and their caregivers that if they become sick, they may need stress-dose steroids. 

For patients with advanced disease: 

Consider non-myelosuppressive regimens when alternatives exist to 

minimize risk of immunosuppression and infectious complications. 

When cytotoxics are used consider growth factor support with administration 

of same-day growth factor injections or pegfilgrastim to minimize visits. 

Consider deferring sipuleucel-T until COVID-19 risk has resolved given risks 

of exposure in Red Cross centers and hospital infusion centers. 

Consider telehealth genetic counseling options if available, or deferring in-person visits 

until COVID-19 risk has passed to minimize exposure. 

Please consult your institutional, state, and federal policies. The following are useful resources: 

·  AMA: https://www.ama-assn.org/delivering-care/public-health/covid-19-2019-novel-coronavirus- resource-center-physicians 

·  ASCO: https://www.asco.org/asco-coronavirus-information 

·  ASTRO: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information 

·  AUA: https://www.auanet.org/covid-19-info-center 

3 . Care of Prostate Cancer Patients During the COVID-19 Pandemic: Recommendations of the NCCN 

·  CDC: https://www.cdc.gov/ 

·  CMS: https://www.ama-assn.org/delivering-care/public-health/cms-payment-policies-regulatory- 

flexibilities-during-covid-19 

·  WHO: https://www.who.int/health-topics/coronavirus#tab=tab_1 

·  *Prostate cancer radiotherapy guidelines: 

https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/COVID-Zaorsky-et- al(ADRO).pdf 

·  CMS Adult Elective Surgery and Procedures Recommendations: https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures- recommendations.pdf 

References: 

1. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020;21(3):335-337. 2. Wilt TJ, Vo TN, Langsetmo L, et al. Radical prostatectomy or observation for clinically localized prostate cancer: Extended follow-up of the Prostate Cancer Intervention Versus Observation Trial (PIVOT). Eur Urol 2020. 

3. Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in prostate cancer—29-year follow-up. N Engl J Med 2018;379(24):2319-29. 4. Pisansky TM, Hunt D, Gomella LG, et al. Duration of androgen suppression before radiotherapy for localized prostate cancer: radiation therapy oncology group randomized clinical trial 9910. J Clin Oncol 2015;33(4):332-339. 

5. Denham JW, Steigler A, Lamb DS, et al. Short-term neoadjuvant androgen deprivation and radiotherapy for locally advanced prostate cancer: 10-year data from the TROG 96.01 randomised trial. Lancet Oncol 2011;12(5):451-459. 6. Morris WJ, Tyldesley S, Rodda S, et al. Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): an analysis of survival endpoints for a randomized trial comparing a low-dose-rate brachytherapy boost to a dose- escalated external beam boost for high-and intermediate-risk prostate cancer. Int J Radiat Oncol Biol Phys 2017;98(2):275-285. 

7. Gupta N, Bivalacqua TJ, Han M, et al. Evaluating the impact of length of time from diagnosis to surgery in patients with unfavourable intermediate-risk to very-high-risk clinically localised prostate cancer. BJU Int 2019;124(2):268-274. 

  Definition of Terms – for Patients & Caregivers

·       ADT – Androgen Deprivation Therapy, also called Hormone Therapy.   These are usually injections like Lupron, Firmagon, Eligard, Trelstar, or Zoladex. ...

·      Asymptomatic - Having no signs or symptoms of a disease (NCCN).   In prostate cancer, the most common symptom is pain, but can also include urinary problems, and other less common symptoms.  .

·      Comorbidity - The condition of having two or more diseases at the same time. (NIH).   For example, heart disease would be a ‘comorbidity’ when considering a cancer treatment. .  

·      Cytotoxic – A substance that slows, stops, or kills cancer cells. (NIH)  In these NCCN Guidelines, chemotherapy is the most common cytotoxic they’re referring to..

·      Genetic Counseling – Having a certified genetic counselor help you and your family understand your inherited [germline] cancer risk. Inherited cancer risk may be passed from parent to child. A genetic counselor explains available genetic tests and what they mean. He or she can also offer information about cancer screening, prevention, and treatment options and provide support. (ASCO).

·      Grade IV (4) – A severe side effect that is life-threatening - urgent intervention is needed. (FDA) .

·       Growth Factor - A substance that helps new blood cells to be made. (NCCN)   In these NCCN Guidelines they are probably referring to treatments for low white blood cells – ask your oncologist. .  

·       Localized disease - those that are presumed to be confined within the prostate based on pre-treatment findings such as physical exam, imaging, and biopsy findings. (AUA) For example, A DRE, prostate MRI, CT Scan,  don’t show any cancer outside the prostate. .

·       Lymphopenia - A condition in which there is a lower-than-normal number of lymphocytes (a type of white blood cell) in the blood.  (NCI)>

·       Neoadjuvant - A treatment that is given before the main treatment to reduce the cancer. (NCCN)  In this case, neoadjuvant ADT before radiation is the example given..

·       Non-Myelosuppresive - Treatment that DOESN’T stop or slow the growth of blood-forming cells in the bone marrow, such as red blood cells, white blood cells, and platelets. (NIH)  In prostate cancer, the most common MYELOSUPPRESSIVE therapy is chemotherapy, but can also be radiation therapy in some situations.