A 72-year-old man with a history of coronary artery disease requiring angioplasty and 2 stents in 2017 (no history of myocardial infarction and no ongoing cardiac issues) received a diagnosis of National Comprehensive Cancer Network unfavorable intermediate-risk (UIR) prostate adenocarcinoma (Gleason score 4 + 3 in 4 of 12 cores, cT2a, prostate-specific antigen 8.2 mg/L) in October 2019. He refused surgery and met with a radiation oncologist. After prolonged discussions about his prostate cancer risk and his cardiac history, he elected for stereotactic body radiation therapy (SBRT) without androgen deprivation therapy1 and was scheduled for computed tomography simulation in the beginning of March 2020.
With the increases in the numbers of SARS-CoV-2 cases, and after lengthy discussions regarding reasonable and safe delays for UIR patients,2 the patient elected to delay SBRT due to his concerns about viral exposure. He received a 1-month leuprolide depot injection in March 2020 as a bridge to SBRT but missed a 3-month shot in April because of fear of exposure. He was planned for a computed tomography simulation in May as clinics started reopening but was lost to follow-up for several additional months because of his fears of exposure.
During a COVID-19 second wave surge several months later, the patient has a repeat prostate biopsy that shows Gleason score 4 + 4 in all 6 out of 12 cores. He continues to refuse surgery and requests RT with androgen deprivation therapy.
Questions
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1.Taking into consideration your hospital policies and regional COVID-19 considerations, would you have done anything differently in March 2020?
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a.What is your recommended fractionation for UIR patients?
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a.
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2.How would you approach management of this patient after he re-presents with high-risk disease?
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a.Are you irradiating elective lymph nodes for high-risk cases during this time? What if the patient has baseline lymphopenia?
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b.Would you test this patient for SARS-CoV-2 infection? When and how often?
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a.
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3.
Has anything permanently changed about your management of UIR or high-risk cases as a result of the pandemic?
Footnotes
Note—CME is available for this feature as an ASTRO member benefit, to access visit https://academy.astro.org.
Disclosures: none.
See expert opinions on page 20.
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References
- 1.Widmark A., Gunnlaugsson A., Beckman L. Ultra-hypofractionated versus conventionally fractionated radiotherapy for prostate cancer: 5-year outcomes of the HYPO-RT-PC randomised, non-inferiority, phase 3 trial. Lancet. 2019;394:385–395. doi: 10.1016/S0140-6736(19)31131-6. [DOI] [PubMed] [Google Scholar]
- 2.Zaorsky NG, Yu JB, McBride SM, et al. Prostate cancer radiotherapy recommendations in response to COVID-19 [e-pub ahead of print]. Adv Radiat Oncol. https://doi.org/10.1016/j.adro.2020.03.010. Accessed June 28, 2020.