cancer surgery during COVID-19

New proposed approach to managing bladder cancer during the COVID-19 pandemic.

Over the past three months, healthcare systems the world over have understandably focused their resources almost entirely on the challenges of dealing with the COVID-19 pandemic. However, other diseases haven’t gone away. As many countries begin to get to grips with coronavirus, attention is beginning to return to the treatment of other conditions. Amongst the most time-sensitive of these is cancer treatment. Delays in diagnosis and cancer treatment can have a devastating impact on the disease prognosis. As a result, it is vital to find a balance between minimising the risk of SARS-CoV-2 transmission whilst also reducing the risk of harmful delays to cancer care.

A new study published in the Bladder Cancer journal examines how patients with non-metastatic bladder cancer should be managed during the pandemic (1). Bladder cancer is of particular importance as its management can be resource-heavy and certain types, such as non-muscle invasive bladder cancer (NMIBC) can require frequent procedures and monitoring that can only be conducted in a hospital setting.

By examining and pooling the available published evidence, the study team have developed a user-friendly algorithm to aid decision-making. The primary consideration is whether the cancer is muscle-invasive or not (NMIBC or MIBC).

NMIBC is the more frequently encountered type, with up to 80% of newly diagnosed bladder cancer cases falling into this category. Within this group, the researchers use a classification system based on factors such as tumour grade, tumour size, histology and other characteristics to categorise NMIBC as low, intermediate or high risk. The key recommendation is that all patients in the low risk category and the patients in the intermediate risk category who have low-grade tumours should be managed with active surveillance unless they are symptomatic.

Patients in either of these categories who are experiencing symptoms should be brought in to undergo transurethral resection of bladder tumour (TURBT) procedures. This approach minimises the number of bladder cancer patients who need to present to hospitals for procedures, without leaving patients who are experiencing debilitating symptoms untreated. Furthermore, the study supports this recommendation with evidence demonstrating that low and intermediate risk patients can be safely and efficiently managed with active surveillance.

Intermediate risk patients with high grade tumours and all high risk patients should be managed using TURBT combined with an immunotherapy procedure using intravesical BCG. For these patients, active surveillance poses too great a risk in terms of disease progression and intervention is required, despite the risks associated with COVID-19.

The less common form of bladder cancer, muscle invasive bladder cancer (MIBC), is the more lethal form of the disease. Therefore in all cases, MIBC will require intervention. For patients who are healthy enough to undergo the procedure, radical cystectomy (RC) is recommended if the resources are available. This is despite the fact that RC is associated with a significant post-op hospital inpatient stay (between 5-11 days) and requires the use of resources such as ventilators. The risks of delaying treatment in these patients outweigh any potential risks associated with COVID-19.

Finally, for patients with MIBC who are unsuitable for RC or where it is unavailable, the decision becomes less clear. Rather than making a formal recommendation for these patients, this study outlines three options to treatment. The first option is to use neo-adjuvant chemotherapy (NAC) to treat the tumour until radical cystectomy can be carried out. In cases where there is a chance and a desire to retain the natural bladder, a trimodal approach can be adopted where as much of the tumour as possible is removed using TURBT whilst the remains are then treated using both chemotherapy and radiation therapy. Finally, the authors encourage the consideration of clinical trial drugs in certain MIBC patients, particularly if the trial drugs allow patients to be treated remotely.

The swiftness with which COVID-19 has shut down non-coronavirus services in many hospitals has left healthcare providers somewhat in the dark about how best to manage their patients. This study provides  a template for how to consider the management of patients in light of COVID-19. It emphasises the risks to patient outcomes if treatments are deferred or delayed. It then prioritises the treatment of patients at greatest risk, whilst minimising both the use of healthcare resources and the risk of disease transmission.

Written by Michael McCarthy

1. Carvalho FLF, Galloway LAS, Saoud R, Agarwal PK, Stamatakis L. Considerations about Non-Metastatic Bladder Cancer Management During the COVID-19 Pandemic. Bladder Cancer. 2020;Preprint:1-8.

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