Prostate cancer in a Covid world

By Alan Doherty, consultant urologist, the Birmingham Prostate Clinic

As Covid-19 changes our lives in every conceivable way, inevitably, in the field of prostate cancer, we are working through significant change.

We are becoming a little more adept with the technicalities of zoom and accustomed to consulting without being able to physically see and examine patients.

We have new protocols focused on how we manage the relatives risks of prostate cancer and Covid-19, against benefits. If a patient’s PSA reading is below 20, we are advised to avoid further diagnostics and repeat the test in three months’ time. If PSA is above 20, the guidance states the patient should go onto hormone treatment to halt disease progression.

This is, of course, a difficult trade-off between different risks of Covid-19 and prostate cancer. The judgement is that within three months, by having hormone treatment or active surveillance, there will be no real impact on the patient in terms of overall survival or quality of life. But it is not easy; many men do not want to go onto hormone treatment as a first line approach and for those assessed as being low or intermediate risk, being told to go home and return for another test in three months’ time does not always sit well.

In some of the private hospitals where we operate, providing they are Covid-free, we are able to carry out diagnostics and urgent treatment.

We are advised to avoid TRUS (trans-rectal ultrasound biopsies) due to the risk they carry of sepsis. At BPC, the TRUS has not been part of our diagnostic pathway for many years, due to infection risks and imprecision. The MRI scan – always a key part of our pathway – is likely to become even more important in assessing whether a biopsy is required. If we are clear that a biopsy is required, we use a template-guided approach.

We have consistently emphasised the value of a high-quality MRI scan in the prostate cancer assessment process. Now more than ever, the need to be precise about who needs a biopsy and who does not is critical.

What will the future look like in the prostate cancer field? Even as we move out of full lockdown restrictions, some changes are likely to be lasting.

Events at sports clubs where charities have offered free PSA testing are unlikely to return soon and may, in fact, never return in the same way. We often see patients who come to us and are diagnosed with prostate cancer after one of these events; they would otherwise not have had any indication anything was wrong. This may have an impact if these opportunities to identify prostate cancer via screening at an early stage are lost.

At the same time, men of all ages have become increasingly comfortable with video communications as a result of Covid. This may increase the way patients connect with specialists such as urologists, going directly to consultants for advice and opinion.

We have been offering telephone advice and guidance at the Birmingham Prostate Clinic for several years; we have always supported patients seeking a second opinion and those considering accessing our service from distant locations. It is likely that a long-term consequence of this experience will be more movement in this direction: people feeling increasingly confident to consider different treatment options and to access services that closely reflect their priorities, rather than choosing on the basis of a service which happens to be within your locality.