Table 4. Management of metastatic PCa during the COVID-19 era.

Tumor stage	Recommendations	Comments
Metastatic castration-sensitive prostate cancer	ADT 6-months formulations must be initiated.	ADT is the current standard of care ( 15 , 16 ).
	Avoid intermittent ADT.	Intermittent ADT requires a closer PSA and testosterone monitoring in addition to possible images.
	Consider combination castration therapy with the new hormonal treatments (abiraterone, apalutamide or enzalutamide).	These drugs have demonstrated benefits in terms of survival compared to ADT alone ( 24 - 26 ).
	Prefer apalutamide or enzalutamide to abiraterone.	Effect of corticosteroids in population infected with SARS-CoV-2 is not yet clear ( 5 , 28 ).
	Avoid CTx.	CTx is associated with hematological toxicity and implies multiple visits to the hospital ( 6 ).
Metastatic castration-resistant prostate cancer	ADT 6-months formulations must be maintained.	ADT maintenance is the current standard of care ( 15 , 16 ).
	Consider combination castration therapy with the new hormonal treatments (abiraterone, enzalutamide).	These drugs have demonstrated benefits in terms of survival compared to ADT alone ( 29 , 30 - 32 ).
	Prefer enzalutamide to abiraterone.	Effect of corticosteroids in population infected with SARS-CoV-2 is not yet clear ( 5 , 27 ).
	Avoid CTx.	CTx is associated with hematological toxicity and implies multiple visits to the hospital ( 6 ).
	Avoid Immunotherapy (Sipuleucel-T).	Sipuleucel-T might cause cytokine release while cytokines as IL-6 have been directly related to the most aggressive forms of COVID-19 (4, 34 ).
	Avoid Radium-223.	Radium-223 is associated with overall survival benefit by 3,6 (in the absence of visceral metastases) compared to ADT alone, but it is also associated to hematologic toxicity ( 35 ).
	Avoid starting denosumab or zoledronic acid.	Denosumab or zoledronic acid have no impact on overall survival but could generate osteonecrosis of the jaw or hypocalcaemia ( 36 , 37 ).
	In those patients under treatment, denosumab may be maintained while zoledronic acid should be delayed.	Denosumab can be administrated in its monthly subcutaneous formulation while zoledronic acid requires monthly hospital intravenous administration.