Risks from Deferring Treatment for Genitourinary Cancers: A Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic

Christopher J D Wallis, Giacomo Novara, Laura Marandino, Axel Bex, Ashish M Kamat, R Jeffrey Karnes, Todd M Morgan, Nicolas Mottet, Silke Gillessen, Alberto Bossi, Morgan Roupret, Thomas Powles, Andrea Necchi, James W F Catto, Zachary Klaassen, Christopher J D Wallis, Giacomo Novara, Laura Marandino, Axel Bex, Ashish M Kamat, R Jeffrey Karnes, Todd M Morgan, Nicolas Mottet, Silke Gillessen, Alberto Bossi, Morgan Roupret, Thomas Powles, Andrea Necchi, James W F Catto, Zachary Klaassen

Abstract

Context: The coronavirus disease 2019 (COVID-19) pandemic is leading to delays in the treatment of many urologic cancers.

Objective: To provide a contemporary picture of the risks from delayed treatment for urologic cancers to assist with triage.

Evidence acquisition: A collaborative review using literature published as of April 2, 2020.

Evidence synthesis: Patients with low-grade non-muscle-invasive bladder cancer are unlikely to suffer from a 3-6-month delay. Patients with muscle-invasive bladder cancer are at risk of disease progression, with radical cystectomy delays beyond 12 wk from diagnosis or completion of neoadjuvant chemotherapy. Prioritization of these patients for surgery or management with radiochemotherapy is encouraged. Active surveillance should be used for low-risk prostate cancer (PCa). Treatment of most patients with intermediate- and high-risk PCa can be deferred 3-6 mo without change in outcomes. The same may be true for cancers with the highest risk of progression. With radiotherapy, neoadjuvant androgen deprivation therapy (ADT) is the standard of care. For surgery, although the added value of neoadjuvant ADT is questionable, it may be considered if a patient is interested in such an approach. Intervention may be safely deferred for T1/T2 renal masses, while locally advanced renal tumors (≥T3) should be treated expeditiously. Patients with metastatic renal cancer may consider vascular endothelial growth factor targeted therapy over immunotherapy. Risks for delay in the treatment of upper tract urothelial cancer depend on grade and stage. For patients with high-grade disease, delays of 12 wk in nephroureterectomy are not associated with adverse survival outcomes. Expert guidance recommends expedient local treatment of testis cancer. In penile cancer, adverse outcomes have been observed with delays of ≥3 mo before inguinal lymphadenectomy. Limitations include a paucity of data and methodologic variations for many cancers.

Conclusions: Patients and clinicians should consider the oncologic risk of delayed cancer intervention versus the risks of COVID-19 to the patient, treating health care professionals, and the health care system.

Patient summary: The coronavirus disease 2019 pandemic has led to delays in the treatment of patients with urologic malignancies. Based on a review of the literature, patients with high-grade urothelial carcinoma, advanced kidney cancer, testicular cancer, and penile cancer should be prioritized for treatment during these challenging times.

Keywords: Bladder cancer; Coronavirus; Coronavirus disease 2019; Delayed treatment; Kidney cancer; Penile cancer; Prostate cancer; Sstemic therapy; Surgery; Testicular cancer; Upper tract urothelial carcinoma.

Copyright © 2020. Published by Elsevier B.V.

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