Since the COVID-19 pandemic began in December 2019, over 252 million confirmed cases and 6.5 million deaths were reported worldwide due to the pandemic by October 2022.¹ Over the last 2½ years, the landscape of COVID-19 has tested our approach to patient care. In the beginning of the pandemic, in-person contact was limited and providers were forced to stratify treatment into essential vs nonessential care in order to promote patient, occupational, and community safety.

Many cancer screening programs were disrupted, along with routine cancer surveillance and intervention. The treatment of localized, even high-risk, prostate cancer can be safely delayed up to 1 year without adverse impact on adverse pathology or need for secondary treatments.² As such, there were significant efforts to postpone screening until the initial wave had passed, with societal and institutional guidelines recommending delaying prostate biopsies and routine prostate cancer screening.³ These recommendations were rapidly accepted and mirrored in cohort studies. At Massachusetts General Brigham, Bakouny et al reported a significant finding of greater than 50% significant decrease in PSA screening during the initial pandemic period.⁴ Similarly, within the Pennsylvania Urologic Regional Collaborative (PURC), a multi-center quality improvement consortium of over 120 urologists in Pennsylvania and New Jersey, prostate biopsies declined by 55% during the first 2 months of the pandemic.⁵ Detection of cancer, however, was mixed between the 2 studies. Within the Massachusetts General Brigham cohort, the proportion of patients with cancer increased, resulting in a less than expected decline in cancer detection. This trend, however, was not replicated within the PURC study, with no difference in the cancer detection rate during and prior to the pandemic.

Despite clear recommendations to defer care, there were no universal directives or mandates resulting in large variations in care delivery. Within PURC, the change in prostatectomy volume ranged from a 13% increase to complete shutdown of surgical services depending on the hospital. Most striking, however, was the marked change in the racial distribution of patients with prostate cancer receiving prostatectomy. Prior to the pandemic, approximately 18% of Black and White men with prostate cancer underwent surgery; however, relative to White men with prostate cancer, Black patients experienced a 97% reduced likelihood of surgery during the lockdown.⁶ Further, clinical sites that cared for a higher proportion of Black patients were those most impacted by the lockdown with all sites experiencing a reduction in the volume of surgery for Black patients.

Lee et al recently published on the Veterans Administration’s experience with prostate cancer during the COVID-19 pandemic.⁷ In this retrospective analysis from January 2019 to August 2021, the authors reviewed the impact of COVID-19 on PSA screening and the incidence of prostate cancer among White and Black veterans. Overall, they found a sharp decline in screening and biopsies during the initial pandemic period for all patients; however, the magnitude of decline was larger among Black veterans. Not unexpectedly, the decrease in screening and biopsies translated into a decreased incidence of new prostate cancer during the early pandemic. As the pandemic continued, the incidence of overall prostate cancer diagnoses recovered to baseline levels. However, the incidence of metastatic prostate cancer among Black veterans significantly increased, providing a worrisome example of stage migration secondary to more pronounced screening declines among Black veterans.

Disparities in prostate cancer care for Black men have been well documented within the literature. In the years preceding the pandemic, the gap in prostate cancer mortality had been closing and increased screening efforts have been highlighted as a key factor. Basourakos et al recently published on increased benefit of PSA screening in Black men relative to other races, reporting decreased relative harm from overtreatment and a lower number needed to treat.⁸ The pandemic has disproportionately negatively impacted minority populations both directly via the virus itself and indirectly through adverse social and economic effects, such as increased barriers to health care, job loss, housing insecurity, and reduced childcare. During the pandemic, Black cancer patients were more likely to experience modifications in treatment including prolonged delays.⁹ These delays, however, were nearly always at the behest of the health care team and rarely (2%) due to patient request. As we continue to move through the COVID-19 pandemic, increased attention, research, and advocacy are needed to re-engage patients with or at risk for prostate cancer, with particular focus on minority communities.