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Effect of COVID-19 pandemic on vaccination and treatment pattern of prostate cancer: a comprehensive literature review, phase 2

Soo Young Hwang1, Simona Ippoliti2, Petre Cristian Ilie3, Pinar Soysal4, Ai Koyanagi5,6, Hyunho Han7, Jae Il Shin8,*https://orcid.org/0000-0003-2326-1820, Lee Smith9
Author Information & Copyright
1Department of Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
2Urology Department, Hull University Teaching Hospitals, Hull, UK
3Research and Innovation Department, The Queen Elizabeth Hospital Foundation Trust, King’s Lynn, UK
4Department of Geriatric Medicine, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
5Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, ISCIII, Universitat de Barcelona, Fundacio Sant Joan de Deu, Sant Boi de Llobregat, Barcelona, Spain
6ICREA, Pg. Lluis Companys 23, Barcelona, Spain
7Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
8Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
9Centre for Health Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK
*Correspondence: Jae Il Shin, E-mail: shinji@yuhs.ac

© Copyright 2023 Life Cycle. This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: Nov 02, 2022; Revised: Dec 22, 2022; Accepted: Dec 29, 2022

Published Online: Jan 02, 2023

Abstract

During the COVID-19 pandemic, overall screening, diagnostics, and treatment have faced a downtrend, especially during the first wave and lockdown. Statistics showed improvements starting from the late era of the pandemic and the end of 2020. To improvise, the risk of delayed curative treatment was measured and treatment plans were amended accordingly in order to lower the number of hospital visits needed while the results were still contradictory. The protective role of androgen deprivation therapy on COVID-19 triggered many debates, but the majority of clinical studies found no significant association. Concerns about a reduced immune response to vaccination in patients with prostate cancer occurred, but additional research is needed. The pandemic added additional burdens to patients with prostate cancer and different aspects of the quality of life of patients were assessed. While we anticipate that we are reaching the end of the pandemic, it is essential to re-examine how the pandemic has changed the overall care of patients with prostate cancer and how to proceed even further.

Keywords: COVID-19; SARS-CoV-2; prostate cancer; urology

1. Introduction

During the COVID-19 pandemic, overall screening, diagnostics, and treatment have faced a downtrend, especially during the first wave and lockdown, with the statistics slowly improving by the late era of the pandemic or by the end of 2020. To improvise, the risk of delayed curative treatment was measured and treatment plans were amended to lower hospital visits while the results are still contradictory. In this review, we comprehensively reviewed additional burdens to patients with prostate cancer and different aspects of the quality of life that the COVID-19 pandemic brought.

2. The effect of delayed treatment

Compared to the 2019, there was an average 23% reduction in surgical volume between March and December 2020 in 8 European tertiary referral centers.[1] No association was observed between surgical delay and oncologic outcomes for a large European cohort of 926 men with a median 3 months delay.[2] According to a National Cancer Database study of 128,062 men with intermediate and high-risk prostate cancer, there was no significant difference in the pathology, node-positive disease, or post-radical prostatectomy secondary treatments between those who received immediate radical prostatectomy and those who experienced any level of delay up to 12 months.[3] There was no significant association between the length of time to radical prostatectomy and risk of developing metastases.[3] However, Zattoni et al, 2021 suggested that patients who were treated during the pandemic had a higher risk of extra-prostatic disease and lymph node invasion due to a delay in the administration of curative-intent therapies in patients with localized prostate cancer.[1]

A meta-analysis of four randomized controlled trials found that overall survival and cancer-specific survival significantly worsened among intermediate-risk patients but not in the case of low- and high-risk patients whose treatment was delayed. It was suggested that a 3-month course of neoadjuvant hormone therapy could improve pathological outcomes but not oncological outcomes.[4]

Other than radical prostatectomy, to reduce the frequency of hospital visits, switching from gonadotropin-releasing hormone antagonists to luteinizing hormone-releasing hormone agonists was also a comparable option that does not diminish efficacy or worsen adverse events.[5]

Table 1. Summary of trend in diagnosis of prostate cancer since the COVID-19 pandemic
Author, year Baseline Result Measure Period of interest (1) Result Period of interest (2) Result
Ip, 2021[17] 2018 to 2019 121,096,335 Physician attendances (including telehealth) 2019-2020 114,089,347 (6% reduction) 2020-2021 99,330,510 (18% reduction)
692,021 PSA tests 657,468 2020-2021 706,088
135,775 Free-to-total PSA tests 140,024 156,321
31,750 Multi-parametric MRI 35,672 35,942
19,923 Prostate biopsy 21,453 21,574
Ferrari, 2021[18], median (IQR) 2016 to 2019 283 (271 to 288) Vit D Lockdown (Mar to May, 2020) 66 (48 to 126)
146 (129 to 147) Total PSA 62% (median decrease)
2016 to 2019 256 (228 to 280) Vit D Post-lockdown 295 (267 to 322)
135 (116 to 151) Total PSA 181 (165 to 201)
Fallara, 2021[19] 2017 to 2019 2,285 Total cases 2020 1,458 (36% fewer)
Stroman 2021[20], number of centers Prostate MRI During the pandemic 14 (13%) centers stopped 39 (37%) centers offered with same indications 48 (46%) centers offered to selected high-risk patient group only
Before the pandemic 68 LATP During the pandemic 56
85 GATP 32
83 LATRUS 34
Surasi 2021[21], mean (SD) per week Before the pandemic 26.0 (26.0) Prostate MRI Lockdown period 11.6 (8.2) After lockdown 21.3 (25.3)
7.9 (11.7) Prostate biopsy 2.3 (3.3) 9.6 (8.0)
Pepe 2021[22] 2019 to 2020 2,000 Clinical office evaluation 2020 to 2021 1,015
351 Multi-parametric MRI 85
485 Prostate biopsy 201
187 (38.5%) Cancer diagnosis from biopsy 96 (47.7%)
Kaufman 2021[23], average monthly number Prepandemic 465,187 PSA tests Early Pandemic 295,786 (36.4% decrease) Late Pandemic 483,374 (3.9% increase)
659 PSA results ≥ 50 ng/mL 506 (23.2% decrease) 674 (2.3% increase)
1,453 Prostate biopsy results 903 (37.9% decrease) 1,190 (18.1% decrease)
182 Gleason score ≥ 8 130 (28.6% decrease) 161 (11.5% decrease)
Nossiter 2022[24] 2019 9,918/25,936 (38.2%) Transperineal/prostate biopsy 2020 10,592/16,551 (64.0%)
2019 32,409 Diagnoses 2020 22,419 (30.8% reduction)
Deukeren 2022[25] 2019 21,542 Diagnoses 2020 18,444 End of 2020 Restored to approximately 95% of expectation
13,621 (63.2%) N (%) of malignant pathology 12,756 (69.2%)

Abbreviations; IQR, interquartile range; PSA, prostate-specific antigen.

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3. Quality of life of patients with prostate cancer

COVID-19 did not add or induce significant anxiety in men being treated for prostate cancer,[6] but those whose operations were postponed had higher state anxiety levels than trait anxiety levels, with the younger population having been more affected by the pandemic.[7] The mean Beck Depression Inventory score was 4.3 (range, 0 to 13), signifying mild depression. This is comparable to a pre-pandemic study that identified that PSA level, patient age, and a number of comorbidities are not related to anxiety and depression in patients with prostate cancer.[8]

Additional challenges existed with patients with prostate cancer receiving ADT during the pandemic. A Portuguese prostate cancer study evaluating the Montreal Cognitive Assessment demonstrated that cognitive decline was more frequent in the ADT group, and declined even more after the onset of the COVID-19 pandemic.[9] According to a meta-analysis of three RCTs in male patients with prostate cancer on or previously treated with androgen suppression therapy, body fat is likely to be increased during COVID-19 restriction, possibly affecting metabolic health.[10]

Table 2. Summary of trend in treatment of prostate cancer since the COVID-19 pandemic
Author, year Baseline Result Measure Period of interest (1) Result Period of interest (2) Result
Sciarra 2020[26] 2019 Radical prostatectomy 2020 63.6% reduction
Radiotherapy 84.6% reduction
Fallara 2021[19] 2017 to 2019 1,622 Radical prostatectomy 2020 1,574 (3% reduction)
1,176 Radical radiotherapy 1,547 (32% increase)
946 ADT 709 (25% reduction)
Ip 2021[17] 2018 to 2019 6,259 Radical prostatectomy 2019 to 2020 7,107 2020 to 2021 6,477
2,419 Prostate fiducial markers 2,807 2,962
Pepe 2021[22] 2019 to 2020 54 Radical prostatectomy 2020 to 2021 39
47 External radiotherapy 52
pT3b: 11.2% nodal (+): 14.8 % metastatic: 5.9% % of advanced, metastatic prostate cancer after prostatectomy pT3b: 25.6% nodal (+): 46.1% metastatic: 9.3%
Nossiter 2022[24] 2019 5,331 Radical prostatectomy 2020 3,896 (26.9% reduction)
11,309 Radical radiotherapy 9,719 (14.1% reduction)
785 Brachytherapy 470 (40.1% reduction)
Deukeren 2022[25], odds ratio (95% CI) Low-risk localized. intermediate-risk, localized, high-risk, or localized/locally advanced Radical prostatectomy 2020 versus 2018 to 2019 1.32 (1.01 to 1.72)
1.25 (1.07 to 1.47)
1.16 (1.02 to 1.31)
Deukeren 2022[25], odds ratio (95% CI) Low-risk localized. intermediate-risk, localized, high-risk, or localized/locally advanced External beam radiotherapy and brachytherapy 2020 versus 2018 to 2019 1.09 (0.71 to 1.67)
1.26 (1.05 to 1.51)
0.99 (0.83 to 1.17)
Brachytherapy 1.17 (0.80 to 1.72)
0.63 (0.49 to 0.82)
0.99 (0.83 to 1.17)
Metastatic ADT & radiotherapy 2.27 (1.77 to 2.91)

Abbreviations; ADT, androgen deprivation therapy; CI, confidence interval.

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Through a computational linguistic ethnography analysis of posts online, a more collective tone (we, affiliation, friends) was present, with increased concern about health and death in 2020.[11] Significant concerns on the impact of COVID-19 on delayed the care or the effect of prostate cancer on COVID-19, and the risks of COVID-19 itself were discussed.[11]

4. Vaccination and prostate cancer

Vaccination against COVID-19 also poses many new challenges, one of them being the presence of vaccination-associated lymphadenopathy. A non-specific increase in ipsilateral axillary lymph nodes after vaccination was commonly reported through PET/CT scans.[12] Notohamiprodjo et al., 2022 observed vaccination-associated lymphadenopathy on 18F-rhPSMA-7.3 PET with a prevalence of 45% in patients with prostate cancer, with the standardized uptake value ratio dropping significantly after 8 weeks.[13]

There were concerns about the impaired immune response to vaccination in prostate cancer: in a study of patients with hormone-refractory metastatic prostate cancer, the CD4+ T cells of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) of unexposed patients had decreased CD4+ T cell immune responses to antigens from SARS-CoV-2 spike glycoprotein but not from the spiked glycoprotein of the ‘common cold’-associated human coronavirus 229E (HCoV-229E) as compared with healthy controls who responded comparably to both antigens.[14] However, a study analyzing the median titers of neutralizing antibodies against SARS-CoV-2 of twenty-five patients with prostate cancer under treatment with androgen receptor-targeted agents such as abiraterone or enzalutamide, found it to be similar to healthy volunteers.[15]

A different study suggested that a beneficial impact of COVID-19 vaccination on patients with prostate cancer as the SARS-CoV-2 spike protein reduced the survival of prostate cancer cells through inhibition of proliferation and promotion of apoptosis; downregulation of pro-proliferative molecule CDK4 and upregulation of pro-apoptotic molecule Fas ligand.[16]

5. Conclusions

During the COVID-19 pandemic, overall screening, diagnostics, and treatment have faced a downtrend, especially during the first wave and lockdown, with the statistics showing slow improving during the late era of the pandemic or by the end of 2020. To improvise, the risk of delayed curative treatment was measured, and treatment plans were amended accordingly in order to lessen hospital visits while the results are still contradictory. The protective role of androgen deprivation therapy on COVID-19 triggered many debate while the majority of clinical studies found no significant association. Concerns about a reduced immune response to vaccination in patients with prostate cancer occurred, but additional research in the future essential. The pandemic added additional burdens to patients with prostate cancer and different aspects of the quality of life of patients were assessed. While we anticipate that the end of the pandemic this coming, it is essential to re-examine how the pandemic has changed the overall care of patients with prostate cancer and how to proceed further in the future.

Capsule Summary
During the COVID-19 pandemic, overall screening, diagnostics, and treatment have faced a downtrend, especially during the first wave and lockdown, with the statistics showing slow improving during the late era of the pandemic or by the end of 2020.

Acknowledgements

All authors state that they have no actual or potential conflict of interest including any financial, personal, or other relationships with other people or organizations.

Author Contribution

All authors made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

Funding

None provided financial support for the conduct of the research and/or preparation of the article.

Conflicts of Interest

The authors have no conflicts of interest to declare for this study.

Provenance and peer review

Not commissioned; externally peer reviewed.

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