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ESMO management and treatment adapted recommendations in the COVID-19 era: Prostate cancer

The tiered approach of ESMO in delivering a guidance for cancer patients during the COVID-19 pandemic is designed across three levels of priorities, namely: tier 1 (high priority intervention), 2 (medium priority) and 3 (low priority) – defined according to the criteria of the Cancer Care Ontario, Huntsman Cancer Institute and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS), incorporating the information on the value-based prioritisation and clinical cogency of the interventions

  • High priority: Patient's condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g. significant overall survival [OS] gain and/or substantial improvement in quality of life [QoL]);
  • Medium priority: Patient's situation is non-critical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority;
  • Low priority: Patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is non-priority based on the magnitude of benefit (e.g. no survival gain with no change nor reduced QoL).

 

Priorities for prostate cancer patients

Outpatient visit priorities

High Priority

  • First visits of symptomatic patients or patients with high-burden/high-volume metastatic disease who are likely to have rapid progression resulting in symptoms and/or complications (spinal cord compression, bleeding, acute urine retention, hydronephrosis)
  • New patients with metastatic aggressive variant and small-cell prostate cancer
  • Patients with severe side effects of ongoing systemic treatment or symptoms that cannot be managed via telephone consulting

Medium Priority

  • Initiation of systemic treatment in asymptomatic patients with low-volume metastatic disease
  • Asymptomatic patients with suspicious or proven local/systemic relapse on imaging

 Low Priority

  • Patients under ADT and other AR-targeted agents with a long stable course of disease (refer to telemedicine/telephone visit) or patients under active surveillance

Priorities for imaging

High Priority

  • Any acute symptoms (neurological, bleeding, fracture, thrombosis, pulmonary emboli), that need urgent imaging (MRI, CT, ultrasound)

Medium Priority

  • Any imaging that serves to make necessary treatment changes or decisions and has an impact on disease management and outcome

 Low Priority

  • Imaging for monitoring in clinically stable patients

Priorities for surgical oncology 

See guidelines of the European Association of Urology (EAU) on Considerations in the triage of urologic surgeries during the Covid-19 pandemic

 

Priorities for radiation oncology

High Priority

  • Hypofractionated or extreme hypofractionated RT for symptomatic lesions (e.g. bone metastasis)

Medium Priority

-

 Low Priority

  • Generally, extend neoadjuvant ADT as required until RT can be given
    • Intermediate risk or high risk
    • Hypofractionated RT
    • Pelvic lymphatic drainage RT: only if nodal involvement
    • Salvage setting

Priorities for medical oncology – advanced disease (systemic treatment: chemotherapy and AR-targeted agents) 

High Priority

  • Initiation of ADT in progressive, symptomatic locally advanced or metastatic HSPC
  • First-line treatment for symptomatic metastatic CRPC in addition to ADT, where postponing treatment initiation is most likely to have an impact on overall survival and outcome
  • Chemotherapy (docetaxel or cabazitaxel) in rapid progressing/symptomatic patients not sensitive to AR-targeted agents, likely to respond and to have symptoms controlled. Prophylactic G-CSF support is recommended with chemotherapy

Medium Priority

  • Adding an AR-targeted agent to ADT in metastatic HSPC (can be postponed to latest possible timepoint as defined in pivotal trials)
  • Slowly progressing first-line castration-resistant metastatic/recurrent disease
  • AR-targeted agents in non-metastatic CRPC

 Low Priority

  • Treatment change or initiation of systemic treatment in later lines of metastatic disease in low-burden, asymptomatic patients with rising PSA or minimal progression on imaging

 

General comment:

  • ADT has a low frequency of application and is therefore much easier to apply than chemotherapy with less relevant potential side effects concerning the COVID-19 disease, so there is rarely a situation where it cannot be given
  • Prefer AR-targeted agents over chemotherapy in metastatic HSPC and metastatic CRPC whenever possible, consider home delivery if feasible
  • Minimising the number of chemotherapy cycles or prolonging cycle length may be justified
  • Reduce steroids as concomitant treatment if possible

 

List of abbreviations: ADT, androgen deprivation therapy; AR, androgen receptor; COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; CRPC, castration-resistant prostate cancer; CT, computed tomography; G-CSF, granulocyte colony-stimulating factor; HSPC, hormone-sensitive prostate cancer; MRI, magnetic resonance imaging; PSA, prostate-specific antigen; RT, radiotherapy.

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