|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 354-356
Systemic therapy in patients with genitourinary cancers during the COVID-19 pandemic
Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||09-May-2020|
|Date of Decision||11-May-2020|
|Date of Acceptance||11-May-2020|
|Date of Web Publication||19-Jun-2020|
Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kapoor A. Systemic therapy in patients with genitourinary cancers during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3:354-6
We congratulate the authors on bringing out the various aspects of managing patients with genitourinary cancers in this COVID era. The authors have discussed in detail about the present strategies being employed for all the major cancers in the uro-medical oncology outpatient department (OPD). We would like to highlight a few more points in this regard.
Regimens with a longer interval (4-weekly nivolumab or 6-weekly pembrolizumab) are being used wherever feasible. Nivolumab was already approved by the Food and Drug Administration (FDA) for a 4-weekly dose; the FDA has granted an accelerated approval to 6-weekly pembrolizumab at 400 mg across all indications in adult patients. This latest approval has made life easier, for both the medical oncologists and the patients, by reducing the number of hospital visits and eliminating the need for transport and the resultant risk of exposure to the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). It should be noted that this approval was not based on the present scenario of the coronavirus disease 2019 (COVID-19), but on the previous scientific studies on the exposure–response evaluation of the 6-weekly pembrolizumab.,
Another important strategic shift has been the increased use of oral metronomic chemotherapies, wherever they are feasible, and there are some data of their efficacy. The most commonly used regimen in the urooncology OPD is the combination of oral cyclophosphamide and low-dose dexamethasone in metastatic castration-resistant prostate cancer (mCRPC). In an Indian study, the prostate-specific antigen response rate was 44% in patients with mCRPC who failed or were not fit for docetaxel and/or abiraterone. We tend to use this regimen in patients who have previously received docetaxel and abiraterone and are not fit to receive third-line injectable chemotherapy and/or have financial constraints for other possible treatments.
In an attempt to reduce the number of hospital visits, there is a possibility of preferring abiraterone over docetaxel in the metastatic hormone-sensitive prostate cancer setting. This appears to be a more suitable option in the present scenario, when we additionally wish to avoid myelosuppression. It should be noted that both are approved in this setting, and there is no head-to-head comparison between the two. Along the same lines, we are preferring 3-monthly or 6-monthly preparations over the monthly preparations of androgen deprivation therapy (ADT). An interesting study has been recently published online in the Annals of Oncology, in which Montopoli et al. reported that patients with prostate cancer from the region of Veneto in Italy receiving ADT appeared to be partially protected from SARS-CoV-2 infections (3.75-fold increased risk if not on ADT). A greater difference was observed on comparing patients with prostate cancer receiving ADT to those with any other type of cancer (odds ratio, 5.17; 95% confidence interval, 2.02–13.40). However, it should be noted that the results were not adjusted for potential confounding factors, such as age, body mass index, and comorbidities, that are strong risk factors for SARS-CoV-2; men on ADT may have been more likely to self-isolate and therefore be at a reduced risk of getting the infection.
There are also recommendations to use immune checkpoint inhibitors rather than chemotherapy in PD-L1-positive frontline metastatic urothelial cancer. However, this might not be feasible in our setting in view of the financial constraints, and we prefer to use gemcitabine with carboplatin in such a scenario. If the patient is completely asymptomatic, which is usually not the case, the chemotherapy can be deferred after explaining the pros and cons.
Coming to the patients who are candidates for neoadjuvant chemotherapy for muscle-invasive urothelial cancer, dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin has shown a higher (42%) pathologic complete response (pCR) rate than gemcitabine with cisplatin (36%) (P = 0.02)., The survival data are not mature and are expected by next year. It should be noted that this improvement in pCR came at the expense of significantly higher toxicities, including anemia (22% vs. 8%; P < 0.001), febrile neutropenia (7% vs. 2%; P = 0.05), nausea/vomiting (10% vs. 3%; P = 0.03), and asthenia (14% vs. 4%; P < 0.001). Thus, we continue to use gemcitabine with cisplatin in this setting; we also tend to split the dose of cisplatin over 2 days, based on the premise that a split dose allows for reducing the toxicities, and therefore, more patients can complete the planned systemic therapy.
It is important to note that these modifications in the practice of medical oncology may be the “new normal” as we do not expect the situation to change over the next few months. Furthermore, the utilization of these practices is likely to be more cost-effective and will reduce the burden on our health-care system, even after this pandemic is over.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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