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Table of Contents
Year : 2020  |  Volume : 3  |  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 Submission09-May-2020
Date of Decision11-May-2020
Date of Acceptance11-May-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Akhil Kapoor
Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_183_20

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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

How to cite this URL:
Kapoor A. Systemic therapy in patients with genitourinary cancers during the COVID-19 pandemic. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Sep 18];3:354-6. Available from: http://www.crstonline.com/text.asp?2020/3/2/354/287229

We congratulate the authors on bringing out the various aspects of managing patients with genitourinary cancers in this COVID era.[1] 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.[2] 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.[3] 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.[4],[5]

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.[6] 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.[7] 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).[8] 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).[8] 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.[9] 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).[10],[11] 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.[12]

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Majumdar S, Joshi A. Caring for patients with genitourinary cancer during the COVID pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:102-5.  Back to cited text no. 1
Thomas VM, Mathew A. Immunotherapy during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:149-50.  Back to cited text no. 2
FDA Approves Merck's KEYTRUDA® (pembrolizumab) for Use at an Additional Recommended Dose of 400 mg Every Six Weeks for All Approved Adult Indications; Published 28April, 2020. Available from: https://bit.ly/3aMyb6w. [Last accessed on 2020 May 08].  Back to cited text no. 3
Lala M, Li M, Sinha V, de Alwis D, Chartash E, Jain L. A six-weekly (Q6W) dosing schedule for pembrolizumab based on an exposure-response (E-R) evaluation using modeling and simulation. J Clin Oncol 2018;36 Suppl 3062.  Back to cited text no. 4
Patil VM, Noronha V, Joshi A, Abhyankar A, Menon N, Banavali S, et al. Low doses in immunotherapy: Are they effective? Cancer Res Stat Treat 2019;2:54-60.  Back to cited text no. 5
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Dabkara D, Ganguly S, Biswas B, Ghosh J. Metronomic therapy in metastatic castrate-resistant prostate cancer: Experience from a tertiary cancer care center. Indian J Cancer 2018;55:94-7.  Back to cited text no. 6
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Ramamurthy C, Handorf EA, Correa AF, Beck JR, Geynisman DM. Cost-effectiveness of abiraterone versus docetaxel in the treatment of metastatic hormone naïve prostate cancer. Urol Oncol 2019;37:688-95.  Back to cited text no. 7
Montopoli, M, Zumerle, S, Vettor, R, Rugge, M, Zorzi, M, Catapano CV, et al. Androgen-deprivation therapies for prostate cancer and risk of infection by SARS-CoV-2: A population-based study (n=4532). Ann Oncol 2020;S0923-7534(20)39797-0.  Back to cited text no. 8
Tarentino AL, Maley F. A comparison of the substrate specificities of endo-beta-N-acetylglucosaminidases from Streptomyces griseus and Diplococcus Pneumoniae. Biochem Biophys Res Commun 1975;67:455-62.  Back to cited text no. 9
Ravind R, Prabhash K, Joshi A, Patil V, Noronha V. Systemic treatment options in bladder cancer. Cancer Res Stat Treat 2018;1:98-109.  Back to cited text no. 10
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Culine S, Gravis G, Flechon A, Soulie M, Guy M, Laguerre B, et al. Randomized phase III trial of dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (dd-MVAC) or gemcitabine and cisplatin (GC) as perioperative chemotherapy for muscle invasive urothelial bladder cancer (MIUBC): Preliminary results of the GETUG/AFU V05 VESPER trial on toxicity and pathological responses. J Clin Oncol 2020;6 Suppl 36:437.  Back to cited text no. 11
Abdelhafez M, Williams M. Safety and efficacy gemcitabine-cisplatin split dose as a neoadjuvant chemotherapy for muscle invasive bladder cancer. Boston, MA: Presented at: 2017 American Urological Association Annual Meeting; 12-16 May, 2017.  Back to cited text no. 12


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