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How Has the COVID-19 Pandemic Affected Prostate Cancer Care?

#CancelEverything

On March 11, 2020, the World Health Organization (WHO) declared the coronavirus 2019 disease (COVID-19) a global pandemic. Its impact left the world uncertain about health, politics and the economy. The first wave caused a major disruption to health services, exacerbating concerns of patient and physician safety and resource availability. On trend with the “cancel everything” hashtag, regions ramped down or suspended “elective” or non-emergent surgeries in efforts to reduce transmission, and preserve personal protective equipment, hospital bed capacity and key equipment. Operating at a reduced capacity, the American College of Surgeons released a guide to patient triage for surgery relative to factors like severity of illness and time sensitivity. These safeguards, however, could not account for the physical and emotional stresses of delayed surgeries, diagnoses or treatments.1 

Missed Diagnoses

For patients, risk of infection often trumped existing health concerns like preventative health. Unsurprisingly, doctors and hospitals saw fewer patients for unrelated COVID-19 conditions. Consistent with pandemic shutdowns and initial fear, several studies show a similar decreasing trend in cancer diagnosis, with prostate cancer dropping the most.2 During the first wave, patient visits dropped and then dropped even lower before starting to recover to pre-pandemic volume. Although the magnitude of the decline and recovery in health care visits vary by prostate cancer risk category, low-risk prostate cancer seems to have had the steepest drop.3 One study, performed in Massachusetts, reported the number of men tested for PSA per month fell 50%, with the biggest monthly drop of 83%.4 Both UK and US studies show 33% and 31% drop in Stage I/ low-risk diagnoses, respectively. For urologists and prostate cancer patients, early detection and treatment are critical to successful outcomes. Approximately 80%- 85% of all prostate cancers are detected in stages I, II or III. Many diagnosed at this stage will likely be disease free after 5 years, with an average 15 year survival rate of 95%.8 A missed diagnosis could be early stage cancer that may not be identified until later, potentially affecting chances of survival.2, 3

Surgical Backlog

As hospitals and clinics are gradually permitted to perform more non-emergent surgeries, cancer diagnosis numbers are beginning to return to pre-pandemic levels. Unfortunately though, the ramping down directive will continue to affect health services and patients long after it is lifted. Within the first 3 months of the pandemic, the CovidSurg Collaborative estimated that ~28.4 million surgeries would be cancelled or postponed across 190 countries, with 37.7% of those being cancer related. It would take 45 weeks, operating at 20% higher volumes to clear the backlog from just 12 weeks. For Ontario, Canada, the estimated backlog clearance time is 84 weeks. In the UK, 60 weeks and US anywhere from 28- 64 weeks.5 Regardless of the exact number of cases or weeks at an increased volume, the bottom line is the same: diagnosis backlogs, lengthening wait times for treatment and high levels of anxiety for patients.2

Fast Track Diagnoses with Targeted Fusion Biopsies

When caught early, prostate cancer is very treatable. The current standard of care relies on a systematic biopsy to detect cancer. The caveat is that this approach blindly samples the prostate without knowing where the cancer is, if any. As such, systematic biopsies are often associated with missed cancer diagnoses and substantial grade misclassification. The result? Overtreatment of low-risk prostate cancer, or worse, undertreatment of high-risk missed cancer.6 Unsurprisingly, it’s not uncommon for men to undergo multiple systematic biopsies before cancer is detected. Under normal conditions, repeat biopsies are unfavourable, but given the current state of backlogs, not all patients have the luxury of waiting. With more than 90% accuracy, the MRI pathway is an alternative solution that can fast track patient diagnosis and treatment.6,7 MRI-targeted biopsies performed using a system like the Fusion Bx help to detect more clinically significant cancer and detect less insignificant cancers, resulting in fewer unnecessary treatments. Unlike ultrasound alone, MRI combined with ultrasound, allows physicians to determine the location and severity of the tumor, which directs the best course of action for treatment. Whereas a negative MRI means no biopsy at all.6 By “narrowing the search” to a pinpoint accuracy, MRI-targeted biopsies mean faster diagnosis, better treatment and ultimately peace of mind for patients.

1 Meredith, J. W., High, K. P., & Freischlag, J. A. (2020). Preserving elective surgeries in the COVID-19 pandemic and the future. JAMA, 324(17), 1725–1726. https://doi.org/10.1001/jama.2020.19594 

2 Limb, M. (2021). Covid-19: Early stage cancer diagnoses fell by third in first lockdown. BMJ, 373. https://doi.org/10.1136/bmj.n1179

3 Persaud, N. (2021, June 8). Prostate Cancer Care Declined During the Covid-19 Pandemic. Renal & Urology News. Retrieved from https://www.renalandurologynews.com/home/news/urology/prostate-cancer/united-states-prostate-cancer-health-care-visits-declined-sars-cov-2-pandemic-2020/.

4 Epstein, M. M., Sundaresan, D., Fair, M., Garber, L., Charpentier, M., Gurwitz, J. H., & Field, T. S. (2020). Abstract S11-03: Impact of covid-19 on breast and prostate cancer screening and early detection in a large health care provider group. American Association for Cancer Research , 26(18). https://doi.org/10.1158/1557-3265.covid-19-s11-03

5 Wang, J., Vahid, S., Eberg, M., Milroy, S., Milkovich, J., Wright, F. C., Hunter, A., Kalladeen, R., Zanchetta, C., Wijeysundera, H. C., & Irish, J. (2020). Clearing the surgical backlog caused by COVID-19 in Ontario: A time series modelling study. Canadian Medical Association Journal, 192(44). https://doi.org/10.1503/cmaj.201521

6 Wallace, J. (2021, August 4). Dr. Jinxing Yu comments on new evidence supporting MRI-targeted biopsies for prostate cancer. Massey Cancer Center. Retrieved from https://www.masseycancercenter.org/news/Dr-Jinxing-Yu-comments-on-new-evidence-supporting-MRI-targeted-biopsies-for-prostate-cancer.

7 Ahdoot, M., Wilbur, A. R., Reese, S. E., Lebastchi, A. H., Mehralivand, S., Gomella, P. T., Bloom, J., Gurram, S., Siddiqui, M., Pinsky, P., Parnes, H., Linehan, W. M., Merino, M., Choyke, P. L., Shih, J. H., Turkbey, B., Wood, B. J., & Pinto, P. A. (2020). MRI-targeted, systematic, and combined biopsy for prostate cancer diagnosis. New England Journal of Medicine, 382(10), 917–928. https://doi.org/10.1056/nejmoa1910038

8 “Prostate Cancer Prognosis.” Johns Hopkins Medicine, https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/prostate-cancer-prognosis.