|Year : 2020 | Volume
| Issue : 5 | Page : 102-105
Caring for patients with genitourinary cancer during the COVID pandemic
Swaratika Majumdar, Amit Joshi
Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||04-Apr-2020|
|Date of Decision||05-Apr-2020|
|Date of Acceptance||08-Apr-2020|
|Date of Web Publication||25-Apr-2020|
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Majumdar S, Joshi A. Caring for patients with genitourinary cancer during the COVID pandemic. Cancer Res Stat Treat 2020;3, Suppl S1:102-5
Coronavirus has finally found its way into our country. In addition to the current economic and emotional pandemonium the nation is facing, the medical fraternity has important decisions to make. Optimizing cancer care delivery with pre-existing poor nutrition, other comorbidities, and restricted resources is a challenge; doing so during the coronavirus pandemic is an entirely different ballgame. Delaying therapy, especially in the curative setting or in symptomatic cancer patients, is a difficult call to take. However subjecting vulnerable patients to severe COVID-19 infection is not desirable either. Our task, as oncologists for taking the correct decisions in the absence of strong evidence, is a daunting one. The conundrum we face is between prescribing therapy or delaying therapy in this situation; each of these approaches has its pros and cons.
Giving systemic therapy to patients at risk of COVID-19 poses a few unique challenges. One, is cancer care an urgency? Are we justified in subjecting these patients to the risk of immunosuppression? Two, are we equipped to handle patients developing severe COVID-19 in our set up? Do we have the workforce and resources to allocate to patients, especially those with stage IV cancers, who develop COVID-19? Three, emotionally, are we as a fraternity strong enough to accept the suboptimal care of a few for the greater benefit of community?
In a nationwide analysis in China, patients with cancer had a higher risk of developing severe COVID-19 infection. Patients with active malignancy or undergoing treatment for cancer had more frequent severe events (requiring invasive ventilation or death) than those without cancer (39% vs. 8%). However, only 1% of patients diagnosed with COVID-19 had cancer comorbidity (n = 18), and only four of the 1572 patients diagnosed were receiving cancer-directed therapy. As such, this is considered insufficient evidence to compromise care in all cancer patients. However obeying the directions of the Government of India (GOI) to contain the pandemic, we find ourselves in a situation where the influence of common sense and logistics of care prevail over scientific reasons. As the threat of severe coronaviral infections looms large, I will attempt to enumerate the strategies we have adopted in dealing with patients with genitourinary (GU) malignancy presenting to Tata Memorial Hospital in Mumbai, India.
In the GU outpatient department (OPD), we deal with advanced prostate cancer, kidney cancer, bladder cancer, and germ cell tumors (GCTs). GU malignancy is unique in that most of our patients are over 65 years and have multiple comorbidities placing them at a higher risk of severe COVID-19 infections compared with other cancer patients. In addition, most of our patients travel across the country for cancer care at our center, placing them at a higher risk of COVID-19 exposure. GOI started imposing travel advisory warnings weeks before the final mandatory 21-day lockdown effective from midnight March 24, 2020. Anticipating the lockdown, we took several steps in accordance with the American Society of Clinical Oncology and the Centers for Disease Control and Prevention recommendations to mitigate the spread of COVID-19.
Social distancing and personal protective measures were adopted by healthcare staff. Patients on follow up are being telephonically advised against travel. We have effectively postponed all appointments of patients who are not on active therapy. As the number of patients visiting the OPD dwindled, we re-allocated healthcare staff so that the effective workforce exposed to COVID-19 reduced. This applied to ancillary staff like the cleaning and clerical personnel. Many of the patients' ailments are being addressed telephonically, and references for follow up with local oncologists are given. More complex medical concerns are addressed via email, so there is appropriate documentation of the therapy plan. Nonessential consults like dietician or physiotherapy are being avoided to prevent crowding and prolonged waiting times at the hospital. New patients of all cancers and in all stages are continuing to register with us. All endeavors are being taken to complete the patients' fitness for therapy work-up and start the required systemic therapy in a single visit. We find that our threshold to advise against palliative chemotherapy, especially in patients with poor performance status or those progressing on standardfirst-line systemic therapy is significantly lowered. Patients who require longer than one day of chemotherapy are being admitted, when possible, to prevent repeated visits to the hospital daycare. Patients on intensive chemotherapy were being called for clinical assessments weekly, in the pre-pandemic time. Currently, patients are either kept admitted for a longer duration to cross the neutropenic nadir or are advised to telephonically report toxicity, if any. Such practices have significantly reduced hospital visits and crowding. Further, it saves the patients the trouble of arranging transportation for hospital visits among the shutdown of public transport. Our medical social worker department and various nongovernmental organizations have been untiring in their efforts at providing accommodation and transport to patients stranded in Mumbai after the lockdown. In general, efforts are being taken to reduce patients waiting in the hospital.
Cancer-specific management has also changed in our OPD, and we will attempt to describe the various GU tumor types in the following paragraphs:
| Prostate Cancer|| |
The most common cancer we deal with remains prostate cancer. Patients with de novo hormone-sensitive prostate cancer are being advised to start medical androgen deprivation therapy (ADT) alone. Since there is a benefit of adding docetaxel or abiraterone even after delayed initiation, we have advised patients to review back with us after they have completed 2 months of ADT. Patients already on hormonal therapy are being advised to postpone prostate-specific antigen (PSA) testing and OPD visits if they are asymptomatic. We are delaying the initiation of chemotherapy in patients with castrate-resistant prostate cancer (CRPC) and preferentially recommending oral hormonal therapy instead. Patients who are on docetaxel for CRPC, have completed a few cycles with good disease control and are asymptomatic with PSA value below 10 ng/dl have been advised to hold further chemotherapy. Dental evaluation, which we routinely sought prior to zolendronate initiation, is now being deferred, and hospital visits for scheduled bisphosphonate injections are being delayed.
| Renal Cancer|| |
Adjuvant sunitinib for patients with kidney cancer is currently avoided, and patients have been advised to review back after 4 weeks. In patients with de novo metastatic disease, tyrosine kinase inhibitors (TKIs) are preferred over combination therapy currently. Although evidence that immunotherapy worsens COVID-19 infection is lacking, initiating therapy that requires repeated hospital visits or places the patient at a risk of lung injury is best avoided. Patients already on TKIs are advised to delay response assessment scans unless symptomatic for progressive disease. Toxicity assessments for patients on therapy that has been recently started or changed is being assessed through telemedicine or emails. Given the patterns and frequency of TKI intolerance in our population, we anticipate difficulties in the coming months.
| Bladder and Urothelial Cancer|| |
Bladder and urothelial cancers are often possible to treat with curative intent. While adjuvant therapy is certainly being delayed for 3 weeks at most, we are initiating neoadjuvant chemotherapy. We are encountering a unique situation in patients who have completed neoadjuvant chemotherapy, but in whom surgery is being deferred until the stabilization of coronavirus pandemic. In our hospital, the number of working operation theaters have been reduced to half capacity due to limited availability of blood donors and ancillary staff being in short supply. In these patients who have completed neoadjuvant chemotherapy and are awaiting surgery, the benefit of administering additional cycles of chemotherapy is weighed against observation, and the risk of progression. Patients who are on therapy are continuing scheduled chemotherapy as planned. In fact, one of our patients on definitive chemoradiation for bladder cancer has received the past 2 weeks of therapy as an inpatient given the difficulties of arranging transport. As the outcomes of patients with metastatic bladder cancer are poor, palliative chemotherapy or immunotherapy is being delayed. Patients who progress after two lines of therapy are counseled for best supportive care alone. Whether this translates into suboptimal cancer care is to be seen.
| Immunotherapy|| |
A special note needs to be made regarding immunotherapy. It is not certain that immunotherapy negatively impacts COVID-19; however, the logistics of administration may expose the patient to the virus.
Patients who have received at least eight cycles of immunotherapy for metastatic renal cell carcinoma and metastatic bladder cancer and have achieved a complete remission or partial remission and are asymptomatic, have been advised to hold further cycles of immunotherapy if they are not able to get the drugs at the local place as delaying therapy in responding patients may not affect the overall outcome. As such, in patients who are receiving once-in-4-weeks regimens, the duration between immunotherapy administration may be extended to once-in-6-weeks and those on once-in-2-weeks or once-in-3-weeks regimens, the period between cycles may be increased to 4 weeks.
| Germ Cell Tumors|| |
GCTs are a heterogeneous group of malignancies. Given the younger age group at presentation, excellent prognosis, and chemosensitivity of the tumors, we have taken a case-by-case decision on systemic therapy. In patients with early GCTs in whom active surveillance is an acceptable therapeutic option to adjuvant chemotherapy (i.e., single-agent carboplatin AUC 7) or radiotherapy, we prefer the former at present. In our regular setup, we prefer giving chemotherapy to surveillance, as we anticipate significant attrition and loss to follow-up due to myriad logistic difficulties. Perhaps, the current pandemic situation is an opportunity to truly assess follow-up in our patients, and this may guide our counseling in future. In patients with advanced GCTs who are platinum-naïve, we are initiating therapy. We frequently encounter patients with advanced disease and large volume retroperitoneal disease; compromising the treatment in such patients at the risk of COVID-19 currently seems unacceptable. We are admitting these patients for 5 days of platinum-based chemotherapy. Although this strategy increases the cost of therapy, we believe it minimizes OPD visits and exposure to COVID-19. Choice of chemotherapy either etoposide/ifosfamide/platinum (VIP) or bleomycin/etoposide/platinum is as per standard practice. Although we are not omitting bleomycin per se, we prefer VIP as it obviates the need for a weekly visit for bleomycin injection and the need for pulmonary function testing. In patients with platinum-refractory disease or who experience progression on standard lines of therapy, we are not starting new lines of salvage therapy unless patients are symptomatic.
Patients presenting with toxicity or symptomatic disease requiring repeated evaluation are preferably admitted to the hospital to ease the OPD workload and eliminate the need for repeated hospital visits.
Hydroxychloroquine (HCQ) is a recommended prophylaxis against coronavirus in asymptomatic contacts of laboratory-confirmed cases in addition to self-quarantine of 14 days. We will advise HCQ prophylaxis only if our patient is known to be in contact with a laboratory-confirmed case of coronavirus. As self-quarantine is mandatory, no intravenous chemotherapy can be administered in this period. As there are no known interaction of HCQ and abiraterone, we will advise those on HCQ to continue abiraterone. However, with TKIs such as sunitinib, pazopanib, and drugs like everolimus, HCQ poses a significant risk of QTc prolongation and the threat to life., The above drugs will be advised to be discontinued till review with a physician/oncologist and monitoring of ECG and serum electrolytes.
For a patient, dealing with cancer is a difficult task. The fear of the coronavirus pandemic and the consequent disruption of “normal” life, both for the patient and caregivers, have caused additional anxiety. The issues we have primarily noted in our patients are related to logistics. Most have traveled from various parts of the country and find themselves “stuck.” Finding adequate lodging and meals is the chief concern, facing the challenges of cancer therapy is secondary. Struggles of patients include difficulty in transportation to OPD, procurement of medicines due to lack of availability, and dealing with delay in therapy whether systemic or local treatment. Every patient is at high risk of contracting infection, and it is a risk they brave to reach our OPD. We find communication to be key in allaying patient and caregiver distress. Most patients accept delay and interruptions of systemic therapy if it is conveyed that the therapeutic decision is taken in their best interest.
We anticipate new issues in the coming months, including the shortage of drugs and the reduced workforce of health care personnel. We often feel perturbed at the thought of leaving our patients in the lurch. After all, the onset of a pandemic does not make the existing diseases disappear. However, given the current scenario, we consider it best to delay therapy if feasible for most patients. None of us want to be faced with the situation of a hospital working with minimal health-care staff in wards filled with patients of advanced cancers and severe COVID-19 infection. Practical decision making, although difficult, is key to optimal usage of health-care resources in the coming times. We take comfort in knowing that, like everything else in life, this too shall pass.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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