Effects of Delayed Radical Prostatectomy and Active Surveillance on Localised Prostate Cancer-A Systematic Review and Meta-Analysis

Impact of the COVID-19 Prioritization Recommendations on Pathological Stages of Urologic Malignancies: A Real-World Analysis at a High-Volume Referral Institution

Background: In response to the COVID-19 pandemic, the European Association of Urology (EAU) Guidelines defined priority groups to guide the prioritization of surgery for urological malignancies. The objective of this study was to evaluate the impact of the COVID-19 prioritization recommendations on tumor pathological characteristics in a real-world setting at our academic referral institution. Methods: We compared baseline and pathological tumor features of all patients with urological malignancies treated during the pandemic period (2020-2021) versus in the post-pandemic period (2022-2023). Our institution adhered to the international recommendations and prioritized those cases defined as "high-risk". Results: Data from 9196 patients treated for urological malignancies were reviewed and grouped according to period of surgery (4401 in the pandemic period vs. 4785 in the post-pandemic period). The overall number of surgical procedures was comparable for all diseases except for the number of radical prostatectomies (1117 vs. 1405; p = 0.03) and partial nephrectomies (609 vs. 759; p = 0.02), which were significantly lower in the pandemic period. Regarding tumor pathological features, none of the recorded variables were found to differ according to period of surgery, including disease stage, tumor grading, presence of necrosis, lymphovascular invasion, and histological variants. Conclusions: A correct policy of prioritization of oncological pathologies during emergency periods and a centralization of oncological cases in reference centers reduce the possible risk of worsening cancer disease features related to the reorganization of healthcare resources.

Predicting prostate cancer grade reclassification on active surveillance using a deep learning-based grading algorithm

Deep learning (DL)-based algorithms to determine prostate cancer (PCa) Grade Group (GG) on biopsy slides have not been validated by comparison to clinical outcomes. We used a DL-based algorithm, AIRAProstate, to regrade initial prostate biopsies in 2 independent PCa active surveillance (AS) cohorts. In a cohort initially diagnosed with GG1 PCa using only systematic biopsies (n = 138), upgrading of the initial biopsy to ≥GG2 by AIRAProstate was associated with rapid or extreme grade reclassification on AS (odds ratio = 3.3, P = .04), whereas upgrading of the initial biopsy by contemporary uropathologist reviews was not associated with this outcome. In a contemporary validation cohort that underwent prostate magnetic resonance imaging before initial biopsy (n = 169), upgrading of the initial biopsy (all contemporary GG1 by uropathologist grading) by AIRAProstate was associated with grade reclassification on AS (hazard ratio = 1.7, P = .03). These results demonstrate the utility of a DL-based grading algorithm in PCa risk stratification for AS.

Treatment delays for cancer patients in Sub-Saharan Africa: South Africa as a microcosm

Purpose

Delays in initiating cancer treatment time to treatment initiation (TTI) can negatively impact patient outcomes. This study aimed to quantify the association between TTI and survival in breast, cervical and prostate cancer patients at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa, as a microcosm of Sub-Saharan Africa (SSA).

Methods

We analyzed electronic medical records of patients diagnosed with breast, cervical or prostate cancer at IALCH between 2010 and 2020. Median TTI was calculated for different treatment modalities. To assess the link between treatment delay and mortality, we employed a Cox proportional hazards model to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), treating breast cancer and patients over 40 as competing events. Additionally, Kruskal-Wallis one-way analysis and linear regression were used to compare TTI across racial groups.

Results

The study included patients with breast (44%), cervical (44%) and prostate cancer (12%). Mean age at diagnosis was 62.6, 56.6 and 73.0 years, respectively. Breast cancer patients experienced the longest delays for mastectomy (median 18.4 weeks), followed by prostate cancer patients waiting for radiotherapy (median 16.6 weeks). Significantly longer TTI for radiotherapy was observed in patients younger than 40 with cervical (HR = 2.30, 95% CI: 2.16-2.44, p < 0.001) or prostate cancer (HR = 1.42, 95% CI: 1.03-1.95, p = 0.033) compared to older breast cancer patients. Similar trends were seen for younger patients with cervical cancer receiving chemotherapy. Notably, all racial groups exhibited substantial delays in initiating treatment for all three cancers (breast p < 0.001, prostate p = 0.004 and cervical cancer p < 0.001).

Conclusion

This study identified significant delays in treatment initiation (TTI) for breast, prostate and cervical cancer patients at Inkosi Albert Luthuli Central Hospital (IALCH) in South Africa. These delays were concerning, particularly for younger patients and individuals across all racial backgrounds. Delays in treatment initiation have been linked to increased mortality risk in other studies, highlighting the urgency of addressing this issue. Furthermore, this study serves as a valuable model for future research throughout SSA to collectively address the challenges of treatment delays and improve cancer care for the region.

A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond

Purpose

The COVID-19 pandemic has led to competing strains on hospital resources and healthcare personnel. Patients with newly diagnosed invasive urothelial carcinomas of bladder (UCB) upper tract (UTUC) may experience delays to definitive radical cystectomy (RC) or radical nephro-ureterectomy (RNU) respectively. We evaluate the impact of delaying definitive surgery on survival outcomes for invasive UCB and UTUC.

Methods

We searched for all studies investigating delayed urologic cancer surgery in Medline and Embase up to June 2020. A systematic review and meta-analysis was performed.

Results

We identified a total of 30 studies with 32,591 patients. Across 13 studies (n = 12,201), a delay from diagnosis of bladder cancer/TURBT to RC was associated with poorer overall survival (HR 1.25, 95% CI: 1.09–1.45, p = 0.002). For patients who underwent neoadjuvant chemotherapy before RC, across the 5 studies (n = 4,316 patients), a delay between neoadjuvant chemotherapy and radical cystectomy was not found to be significantly associated with overall survival (pooled HR 1.37, 95% CI: 0.96–1.94, p = 0.08). For UTUC, 6 studies (n = 4,629) found that delay between diagnosis of UTUC to RNU was associated with poorer overall survival (pooled HR 1.55, 95% CI: 1.19–2.02, p = 0.001) and cancer-specific survival (pooled HR of 2.56, 95% CI: 1.50–4.37, p = 0.001). Limitations included between-study heterogeneity, particularly in the definitions of delay cut-off periods between diagnosis to surgery.

Conclusions

A delay from diagnosis of UCB or UTUC to definitive RC or RNU was associated with poorer survival outcomes. This was not the case for patients who received neoadjuvant chemotherapy.

Severe acute respiratory syndrome coronavirus 2 pandemic and surgical diseases: Correspondence

This letter to editor discussing on the publication on severe acute respiratory syndrome coronavirus 2 pandemic and surgical diseases. Concerns on procedures are raised and discussed.

Implications and effects of COVID-19 on diagnosis and management of prostate cancer

PURPOSE OF REVIEW

The Coronavirus disease 2019 (COVID-19) pandemic has led to uncertainty on the optimal management for prostate cancer (PCa). This narrative review aims to shed light on the optimal diagnosis and management of patients with or suspected to have PCa.

RECENT FINDINGS

Faecal-oral or aerosol transmission is possible during prostate procedures; caution must be in place when performing digital rectal examinations, transrectal ultrasound-guided prostate biopsies and prostate surgeries requiring general anaesthesia. Patients must also be triaged using preoperative polymerase chain reaction tests for COVID-19. COVID-19 has accelerated the adoption of multiparametric Magnetic Resonance Imaging (MRI), reducing the need for prostate biopsy unless when absolutely indicated, and the risk of COVID-19 spread can be reduced. Combined with prostate-specific antigen (PSA) density, amongst other factors, multiparametric MRI could reduce unnecessary biopsies in patients with little chance of clinically significant PCa. Treatment of PCa should be stratified by the risk level and preferences of the patient. COVID-19 has accelerated the development of telemedicine and clinicians should utilise safe and effective teleconsultations to protect themselves and their patients.

SUMMARY

COVID-19 transmission during prostate procedures is possible. Patients with a Prostate Imaging-Reporting and Data System (PI-RADS) of <3 and PSA density <0.15 ng/ml/ml are deemed low-risk and are safe to undergo surveillance without MRI-targeted biopsy. Intermediate- or high-risk patients should be offered definitive treatment within four months or 30days of diagnosis to avoid compromising treatment outcomes; three-month courses of neoadjuvant androgen deprivation therapy can be considered when a delay of surgery is anticipated.

Impact of the COVID-19 Pandemic on Urologic Oncology Surgery: Implications for Moving Forward

The COVID-19 pandemic has caused the destruction of routine hospital services globally, leading to an increase in the backlog of elective surgery cases. The aim of the study was to retrospectively investigate the pandemic's impact on the urologic oncology surgical activity of a high-volume center located in Milan, Italy. The number and type of procedures performed in 2020 during the COVID-19 pandemic was evaluated using 2019 data as control. Waiting times for each surgical procedure were compared, on a bimonthly basis, between the two different years. Overall, a 26.7% reduction in the number of urologic oncology surgeries between 2019 and 2020 was observed (2019: 720, 2020: 528). Both the main indication for surgery and the type of procedure performed significantly differed between 2019 and 2020 (all p < 0.0001), with a decrease in the number of radical prostatectomies and an increase in the number of radical cystectomies and radical nephrectomies/nephroureterectomies performed in 2020. Waiting time decreased by 20% between 2019 and 2020, with the most significant reduction seen after the first wave of the COVID-19 pandemic (July-October 2020), in particular for partial nephrectomy and radical prostatectomy, possibly due to the underdiagnosis of cases. In conclusion, in accordance with recommendations by international urological societies on prioritization strategies for oncological procedures, a higher proportion of surgeries for high-risk tumors was performed in 2020 at our center at the expense of procedures for lower risk diseases; however, future implications for patients' prognosis still need to be determined.