Impact of COVID-19 on Urologic Oncology

The crisis of COVID-19 (coronavirus disease 2019), an illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has brought drastic changes to the patient care pathway across all medical disciplines. Currently, its long-term impact on urologic oncology care in the United States remains unknown. Issues in oncologic care that remain to be fully elucidated include determining which diseases can be safely managed with monitoring versus which require early intervention despite pandemic limitations; changes in patterns of oncologic referrals; and the impact of the pandemic on education of trainees (residents and fellows). For patients with a new diagnosis, the pandemic has added greater uncertainty to an already stressful process of learning to cope with the requirements of managing their malignancy. These issues must be considered with extra care in the case of older patients, whose predilection for COVID-19 is disproportionately likely to result in mortality.

Resource Limitations and Guideline Recommendations

Urologic malignancies are managed with surgical options ranging from partial nephrectomy for small renal masses to more urgent therapies, such as radical orchiectomy for testicular cancer or partial or total penectomy for suspected penile cancer. Because of the additional burden placed by COVID-19 on limited hospital resources, many hospitals have been forced to prioritize which oncologic surgical cases must be performed, leaving urologists tasked with deciding which malignancies warrant high priority for immediate surgery and which can be delayed.

In a systematic review of existing literature, Katims et al¹ found that although the majority of urologic malignancies were managed with surgery as initial treatment, some diagnoses, such as intermediate- or high-risk prostate cancer, can be safely deferred for up to six months. The authors explained that many clinicians included in their review designated large renal masses (>T3), penile cancer, and upper tract urothelial carcinoma as requiring expedited therapy during the pandemic. However, they also used chemotherapy as an initial therapeutic option for patients with muscle-invasive bladder cancer (MIBC) or even patients with testicular cancer, with surgery to follow a short time later.

Several urology-focused professional societies have released their own recommendations for changes in managing urologic oncology. The Canadian Urologic Oncology Group and the Canadian Urological Association² describe a process of generalized principles for the approach to treating patients with prostate cancer. This includes consideration of regional resource capacity and candid discussions with individual patients to achieve shared decision-making based on the recognition that infection with SARS-CoV-2 is more likely than prostate cancer to cause morbidity in the short term.

The guidelines also advocate for use of telehealth protocols to alleviate the burden and risk for both patients and healthcare workers. In following these management recommendations, which are stratified by extent of disease, patients with localized low-risk, or even favorable intermediate-risk prostate cancer were found not to experience adverse biochemical recurrence rates as a result of delays in scheduling surgical therapy. Similarly, patients who had chosen to undergo primary radiation therapy were given the recommendation to delay this therapy. In their discussion of advanced prostate cancer, however, the authors did recommend obtaining staging workups for new patients. Additionally, they recommend that patients with newly diagnosed metastatic disease to undergo therapy, including chemotherapy and androgen-deprivation therapy, regardless of the status of the pandemic.

Such recommendations provide a framework that surgeons can use to triage and guide patients through the oncologic diagnosis and treatment process. However, considerable variability exists in the available guidance. For example, recommendations for management of T1 renal masses vary between guidelines,^1,2 with Desouky et al³ reporting the British Association of Urological Surgeons (BAUS) recommendation to delay surgery for all clinical T1 lesions, and Kutikov et al⁴ reporting US consensus-based recommendations for no delay when lesions are at stage T1b or higher.

A comparison of these recommendations also reveals the limitations of the guidance, since no recommendations for testicular cancer are given.⁴ Despite this heterogeneity, however, there is general agreement that, owing to concerns for potentially worse clinical outcomes, radical cystectomy for MIBC, large renal cell carcinomas (>T3), or radical orchiectomy for suspected testicular cancer should not be deferred.

An Expanded Role for Telehealth

Some patients refer themselves to urologists, but most physicians receive referrals from primary care or medical oncology colleagues. However, whether the cause is limited access to urologic care or delays in referral times due to labor shortages, the impact of such interruptions remains to be fully understood. Maganty et al⁵ studied this issue by performing a retrospective review of patients referred to their institution for urologic oncology. They reported a 38% decline in new referrals in the three months following the onset of the pandemic compared with the three months prior. When they stratified the data by disease type, the authors also reported notable differences. For example, they found no discernible changes in referrals for patients with kidney and bladder cancer, whereas patients with prostate cancer experienced a 43% decline in screening visits. The authors remarked that access to telemedicine visits likely facilitated patient access to screening for malignancy and they emphasized the importance of continuing reimbursement for telemedicine services.

The psychosocial impact of the COVID-19 pandemic on society is hard to overstate. Vulnerable populations, including immunocompromised individuals, the elderly, and those requiring complex oncologic medical care, remain especially affected by the barriers required to help prevent viral transmission. Such patients endure higher risks when undergoing oncologic care, including potential infection and risk of death from SARS-CoV-2. Tsamakis et al,⁶ in a review documenting the hazards undertaken by such patients, described psychosocial impacts ranging from increased anxiety to loneliness that may precipitate poor mental health outcomes. The authors also remarked that isolation has been documented to result in higher mortality rates in oncology patients. Like Maganty et al, they emphasized the importance of telemedicine in increasing accessibility to care for patients, as well as enhancing the process of interaction between them and their healthcare providers. Other virtual venues, such as online patient support groups and mental healthcare, remain important complementary modalities for care of oncology patients.

Impact on Medical Education

Along with its impact on patient care, the pandemic has significantly altered the medical education process on both the graduate (medical school) and postgraduate (residency/ fellowship) levels. Several factors have contributed to the decline in availability of tangible educational ventures. In many hospitals, residents, including those in the urology field, have been reassigned from their primary care designations to assist in caring for patients with COVID-19.⁷ This diversion, in combination with state mandates to cease elective surgeries or operation of outpatient clinics, has undoubtedly limited the learning opportunities available to trainees in surgical and clinical disciplines.

Westerman et al⁷ documented the impact on urologic oncology trainees by remarking that many program directors reported declines in surgical volumes of up to 83% during the peak of the pandemic. They noted that, compared to other urologic subspecialties, oncology itself was likely the least affected; however, many hospitals required that procedures be performed by the most experienced urologists to limit complications and resource utilization. Because of these imposed restrictions, the authors theorized that the high complexity of urologic oncology cases, combined with the steep learning curve, has limited the opportunities for trainees to learn the intricacies of these procedures.

In response, many virtual and online learning formats have adapted to include virtual demonstrations of surgical procedures, such as live surgery, as well as online lectures given by professors who are experts in their fields. Examples include the UC San Francisco Urology Collaborative Online Video Didactics series (COViD)  and the New York Section of the American Urological Association’s Educational Multi-institutional Program for Instructing Residents (EMPIRE).

Conclusion

The SARS-CoV-2/COVID-19 pandemic has created significant hurdles for physicians and patients. For physicians-in-training, the restrictions and diversions brought on by the pandemic have limited in-person learning experiences and required educational institutions to respond with augmented online learning processes. For physicians in practice, the role of telemedicine has grown and guidelines for the management of urologic oncology have been in flux, with the ultimate outcomes resulting from delays still to be discovered. For patients, the psychological impacts of treatment delays have highlighted the value of virtual support groups and bolstered the importance of telemedicine in routine medical care.

Akhil Abraham Saji, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include urology education and machine learning applications in urologic care. He is a founding and current member of the EMPIRE Urology New York AUA section team.

References

1. Katims AB, Razdan S, Eilender BM, et al. Urologic oncology practice during COVID-19 pandemic: a systematic review on what can be deferrable vs. nondeferrable. Urol Oncol. 2020;38(10):783-792. doi:10.1016/j.urolonc.2020.06.028
2. Kokorovic A, So AI, Hotte SJ, et al. A Canadian framework for managing prostate cancer during the COVID-19 pandemic: recommendations from the Canadian Urologic Oncology Group and the Canadian Urological Association. Can Urol Assoc J. 2020;14(6):163-168. doi:10.5489/cuaj.6667
3. Desouky E. Urology in the era of COVID-19: mass casualty triage. Urology Pract. 2020;7(4): 266-271. doi:10.1097/UPJ.0000000000000152
4. Kutikov A, Weinberg DS, Edelman MJ, Horwitz EM, Uzzo RG, Fisher RI. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. 2020;172(11):756-758. doi:10.7326/M20-1133
5. Maganty A, Yu M, Anyaeche VI, et al. Referral pattern for urologic malignancies before and during the COVID-19 pandemic. Urol Oncol. 2021;39(5):268-276. doi:10.1016/j.urolonc.2020.11.027
6. Tsamakis K, Gavriatopoulou M, Schizas D, et al. Oncology during the COVID-19 pandemic: challenges, dilemmas and the psychosocial impact on cancer patients. Oncol Lett. 2020;20(1):441-447. doi:10.3892/ol.2020.11599
7. Westerman ME, Tabakin AL, Sexton WJ, Chapin BF, Singer EA. Impact of CoVID-19 on resident and fellow education: current guidance and future opportunities for urologic oncology training programs. Urol Oncol. 2021;39(6):357-364. doi:10.1016/j.urolonc.2020.09.028