Bernstein A, Talwar, R, Handorf B et al: Impact of COVID-19 on initial management and evaluation of prostate cancer. Urol Pract 2021; 8: 668.

The COVID-19 pandemic has impacted every aspect of health care delivery. During the first wave, non-essential care was postponed to promote resource stewardship and prioritize patient and occupational safety. These recommendations extended to oncology, with guidelines to defer non-emergent care during the spring of 2020.¹ Specifically, for prostate cancer (PCa), prior research has shown treatment can be safely deferred by 6 to 12 months, even for those with high-risk disease.^2,3 Furthermore, initial reports from China suggested that surgical and oncology patients were at increased risk for poor COVID-19-related outcomes, leading to widespread recommendations for delayed PCa care. However, there were no governmental directives regarding the delivery of non-emergent oncologic care, allowing for individual appraisal of the appropriateness of PCa treatment during the spring of 2020.

Although several single institutional studies describing PCa practice patterns during the pandemic have been published, comprehensive regional appraisal of PCa care delivery has been limited. The Pennsylvania Urologic Regional Collaborative (PURC) is a multicenter quality improvement consortium of more than 120 urologists in Pennsylvania and New Jersey.⁴ The collaborative spans urban, rural, academic and private practices capturing granular disease and treatment details. Data abstraction has been ongoing throughout the pandemic, and as such this data source provided a unique opportunity to assess the impact of COVID-19 on PCa care.

To that end, we queried PURC to determine the impact of the COVID-19 pandemic on PCa care, evaluating trends in procedure volumes and difference in patient characteristics prior to and during the initial wave of the pandemic.⁵ Overall, we appreciated a substantial decrease in the prostatectomy and prostate biopsy rates—39% and 55%, respectively—during the initial wave of the pandemic (see figure). These trends were contextualized by concurrent drops in population mobility from home (abstracted from aggregated data of users’ cell phone movements) and rising COVID-19 cases. As expected, as COVID cases began to decrease, people’s mobility increased, with a concurrent increase in PCa care. Mobility strongly correlated with both prostatectomy (r=0.87, p=0.002) and prostate biopsy volume (r=0.85, p=0.004).

Figure. Regional temporal trends in prostatectomy and prostate biopsy relative to COVID-19 diagnoses and relative mobility in Pennsylvania. March 16, 2020 marked beginning of lockdown within Pennsylvania. Trends in weekly procedure volumes (prostate biopsy in green and radical prostatectomy in yellow) were plotted before and after beginning of lockdown. Weekly new COVID-19 diagnoses are represented by shaded red area and percent change in aggregate population level mobility is depicted by grey line. Figure used by permission of the American Urological Association.

Given the lack of unified directives, it was not unsurprising that we discovered large variation in procedure volume at the practice level. This likely represents the complex interplay of physician attitudes toward the pandemic, local incidence of COVID-19 cases and associated shifts in hospital resource allocation. Prior to the pandemic, biopsies were performed broadly across multiple sites; however, during the lockdown period the volume became concentrated to specific sites. Similarly, changes in prostatectomy volume varied from a 13% increase to complete shutdown of surgical services.

Most striking, we found that there was a marked change in the racial distribution of patients receiving prostatectomy. Prior to the pandemic, Black patients made up 19.5% of prostatectomy patients; this dropped to 2.9% during the initial pandemic period (p=0.001). Historically, it has been well-established that Black Americans experience increased cancer-specific mortality compared to White patients. Specifically in PCa, it has been demonstrated that this gap resolves when access to care is equitable, suggesting that the complex interplay of social determinants and systemic inequities are driving these differences rather than cancer biology.⁶

Within PURC, this reduction was further explored, comparing prostatectomy rates in men with nonmetastatic prostate cancer during and prior to the initial lockdown. Relative to White men with PCa, Black patients experienced a 97% reduced likelihood of surgery during the lockdown, when no differences existed prior to the pandemic.⁷ Furthermore, there was no difference in age, COVID-19 risk factors (diabetes, cardiovascular disease etc) or PCa characteristics between Black and White patients in our cohort. Institutions that cared for a greater proportion of Black patients experienced the greatest decline in operative volume. These findings provide insight into the fragility of our health care system to weather events equitably.⁸ Similarly, an early report from New York City articulated the disparate changes in breast cancer care within the New York City hospital system.⁹ And, more recently, a study found that recovery of overall urological care was slower for Black patients when compared to other racial groups.¹⁰

Race is a social construct. Last year the American Medical Association published research guidelines to promote reporting and understanding of racism as a determinant of health. Specifically, the American Medical Association noted that “accepting race as a biological construct—known as racial essentialism—exacerbates health disparities and results in detrimental health outcomes for marginalized and minoritized communities.”¹¹ Per the World Health Organization, social determinants of health, or the conditions in which we are born and live, are “mostly responsible for health inequities—the unfair and avoidable differences in health status.”¹² As we continue to navigate the ongoing COVID-19 pandemic, medical and surgical management of nonCOVID-19-related conditions will continue to be influenced by geographical and temporal trends in cases. With the continued presence of COVID-19 and its variants, we need to not just identify gaps in care, but work to understand the unseen societal levers that continue to shift the harshest outcomes toward minority communities and work to change these institutions to provide equitable care regardless of the climate.