Prostate and Pelvis on Pause Pending a Pandemic.

Taking into consideration your hospital policies and regional COVID-19 considerations, would you have done anything differently in March 2020?

One could consider a longer duration of androgen deprivation therapy (eg, for 3-6 months).

What is your recommended fractionation for unfavorable intermediate risk patients?

I would most likely recommend ultrahypofractionation (eg, 7.25 Gy × 5 fractions) or moderate hypofractionation (eg, 2.7 Gy × 26 fractions), depending on baseline symptoms and patient preference. This is supported by the statement from the United States and United Kingdom (Fig. 1 ) and a recent meta-analysis.

Fig. 1

Workflow of prostate cancer stereotactic body radiation therapy in the time of COVID-19.

How would you approach management of this patient after he represents with high-risk disease?

Are you irradiating elective lymph nodes for high-risk cases during this time? What if the patient has baseline lymphopenia? (Both pelvic lymph node radiation therapy and baseline lymphopenia are predictors of radiation-induced lymphopenia per Schad MD, Adv Radiat Oncol, 2019, and lymphopenia is a maker for poor prognosis in COVID-19 patients).

The coverage of pelvic lymph nodes in an elective volume is controversial. For many patients, I treat 70.2 Gy to the high-risk volume and 46.8 Gy to pelvic nodal volume, all in 26 fractions using a stereotactic integrated boost. Several factors may dissuade one from elective radiation therapy (eg, history of lower pelvic surgeries or adhesions, unmanaged diabetes, or lymphopenia in the setting of COVID-19 risk).

Would you test this patient for SARS-CoV-2 infection? When and how often?

I would follow hospital/facility policy. Our hospital routinely asks anyone entering about symptoms (eg, temperature, fever, and cough) and takes a temperature. If there is concern, formal testing is performed.

Has anything permanently changed about your management of unfavorable intermediate risk or high-risk cases as a result of the pandemic?

I delay more treatments with the use of androgen deprivation therapy and use moderate or extreme hypofractionation.

My team is working on several research projects to (1) evaluate which patients may delay their time until treatment initiation (eg, the OncCOVID work [http://onccovid.med.umich.edu/] with Daniel E. Spratt, MD) and (2) evaluate which patients may avoid follow-up visits because of high risk of infection from COVID-19 versus death from cancer.