The Shifting Landscape of Genitourinary Oncology During the COVID-19 Pandemic and how Italian Oncologists Reacted: Results from a National Survey

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Research

Letter

The

Shifting

Landscape

of

Genitourinary

Oncology

During

the

COVID-19

Pandemic

and

how

Italian

Oncologists

Reacted:

Results

from

a

National

Survey

Laura

Marandino

*

,

Massimo

Di

Maio

,

Giuseppe

Procopio

,

Saverio

Cinieri

,

Giordano

Domenico

Beretta

,

Andrea

Necchi

Theoutbreakofthenovelcoronavirusdisease-19 (COVID-19) caused bysevere acute respiratory syndrome corona virus2(SARS-CoV-2)suddenlyrevolutionizedthewaywe take care of patients with cancer. This situation was dramatically feltin geographic regionswherethe spread of the infection, qualified as a pandemic by the World Health Organization on March 11, 2020, was causing an emergencyhealthcaresituation.Aftertheoriginaloutbreak inWuhanCity,HubeiProvince,China,theinfectionrapidly spreadthroughouttheworldin morethan199 countries (www.worldometers.info/coronavirus). At the time of writing,Italy,andtheLombardy regioninparticular,was ranked first in terms of COVID-19-associated deaths, making this region one of the most critical hotspots of theCOVID-19outbreak[1].InItaly,atotalof10779deaths had been reported by the health care authorities and 3906patientsrequiredintensivecareunit(ICU)admittance atthetimeofwriting.

Patients diagnosed with cancer have a higher risk of developingseriouscomplicationsanddyingfromCOVID-19

[2,3]. Besides this consideration, a number of critical dilemmas have emerged regarding indications for cancer therapiesandmanagementofassociatedsideeffects.General clinical recommendations for patients with genitourinary cancershavealreadybeenpublished,obviouslybiasedbythe lackofactualdataformostoftheguidelines[4].

Itisimportanttoanticipatetheshiftinglandscapethat will probably occurin themanagement of patients with cancertobetterpreparehealthcareprovidersandsystems forfutureneeds.InMarch2020wethereforecarriedouta nationwidesurveyamongItalianmedicaloncologiststhat focusedonthemanagementofpatientswithgenitourinary malignancies.

Thesurveywasendorsedbyandconductedthroughthe AssociazioneItalianadiOncologiaMedica(AIOM)network,

and took theform ofan online questionnaire sentto all AIOMmembers.

Atotalof72physiciansprovidedfeedback;theirgeneral characteristics are shown in Supplementary Table 1. The questions and corresponding results are shown in

Figure1.Ingeneral,therewasconsensusamongoncologists to pursuetreatment,possiblywithoutdelaysor interrup-tions, for patients with locally advanced or metastatic diseaseforwhichaninductionorfirst-linetherapyoptionis indicatedin guidelines,particularly for patients suffering from prognostically aggressive disease requiring timely treatment (Fig.1A–H). A higher proportion of physicians werewillingtoconsiderdelaysorinterruptionforclinical settings characterizedby moreindolent disease or treat-mentsassociated,onaverage,withclinicalbenefitoflower magnitude. Of note, despite the public health care emergency,Italian oncologistswerestillin favorofclose adherence toguidelinesregardingadministrationof peri-operativetherapies,suchasneoadjuvantchemotherapyin patientswithclinicalT3–4N0M0urothelialbladdercancer (Fig.1C,D)andadjuvanttherapyinhigh-risk,clinicalstageI germ-cell tumors (Fig. 1F,G). Overall, although the main factor taken intoaccount for treatmentdecisions wasits provensurvivalbenefit,thenumberofhospitalvisitsranked second,aheadofotherfactorsusuallyconsideredimportant inclinicaldecisions.

Lastly,twoimportantnotionsemergedfromthissurvey. First, Italian oncologists are still in favor of considering delivery of the best treatment option for genitourinary cancer patients through inclusionin clinical trials (61%), although mostofthem (54%)underlinedtheunavoidable morestringentselectionandtheneedtofaceseverelogistic difficulties,asindicatedinFigure1I.Second,althoughthe risksassociatedwithimmunecheckpointinhibitorsinthe presentpandemiccontextarenotwelldefined,mostofthe

EUROPEANUROLOGY78(2020)E27–E35

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j o u r n al h o m e p a g e : w w w . e u r o p e an u r o l o g y . c o m

Letter

to

the

Editor

https://doi.org/10.1016/j.eururo.2020.04.004

respondentswouldjustifyinterruptionoftherapyonlyafter case-by-case discussions with patients with a sustained response during treatment, or would consider skipping somedosestoreducethenumberofhospitalvisits(Fig. 1M). Implementation of telemedicine will be critical in managing follow-up visits and oral drug delivery, as is currentlydoneinseveralinstitutionsnationwide.

ThissurveyprovidesasnapshotoftheopinionofItalian oncologists regarding the management of patients with genitourinary malignancies. Similarconsiderations would probablyapplyto othersolidtumors. Inouropinion,the mainmessageisthatinspiteofhugesuddenchangesina geographicarearepresentinganepicenteroftheCOVID-19 pandemic, oncologists are still determined to achieving

Fig.1–Questionsandcorrespondinganswerscollectedduringthesurvey.

EUROPEANUROLOGY78(2020)E27–E35

treatmentdeliveryascloseaspossibletoclinicalguidelines orroutineclinicalpractice,atleastfortreatmentssupported byevidenceofaclinicallyrelevantgaininlifeexpectancy.In thesettingofadvanceddiseasewithoutcurativeintent,a non-negligiblenumber of oncologists woulddelay treat-mentinitiation(orconsiderinterruption)inthesecondor furtherlinesoftreatmentassociatedwithalowerclinical

benefit.Forpatientswhodeserveasystemictreatmentwith curativeintent,weshouldstillrelyonthemultidisciplinary approachamongseveralotherspecialists.Thiscontinuing collaborationwillrequireprofoundorganizationalchanges, primarilyrelatedtotheobviousdelaysinbiopsiesorradical surgical interventions that were promptly outlined by Italianurologists[5].

Fig.1.(Continued).

Fig.1.(Continued ).

EUROPEANUROLOGY78(2020)E27–E35

Fig.1.(Continued).

Fig.1.(Continued ).

EUROPEANUROLOGY78(2020)E27–E35

Fig.1.(Continued).

Conflicts of interest: Massimo Di Maio has received advisory board or consultant fees from Merck Sharp & Dohme,Bristol-MyersSquibb,Eisai,Janssen,Astellas, Astra-Zeneca,Pfizer,andTakedaandaninstitutionalresearchgrant

fromTesaro.GiuseppeProcopiohasreceivedadvisoryboard or consultantfees from AstraZeneca, Bayer, Bristol Myers Squibb,Janssen,Ipsen,MerckSharp&Dohme,Novartis,and Pfizer.Theremainingauthorshavenothingtodisclose. Fig.1.(Continued ).

EUROPEANUROLOGY78(2020)E27–E35

AppendixA. Supplementarydata

Supplementary material related to this article can be found,intheonlineversion,atdoi:https://doi.org/10.1016/j. eururo.2020.04.004.

References

[1] GrasselliG,PesentiA,CecconiM.CriticalCareUtilizationforthe

COVID-19OutbreakinLombardy,Italy:EarlyExperienceand

Fore-castDuringanEmergencyResponse.JAMA2020.http://dx.doi.org/

10.1001/jama.2020.4031,Mar13.[Epubaheadofprint].

[2] LiangW, GuanW,ChenR,etal.CancerpatientsinSARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020;21:335–7.

[3] ZhangL,ZhuF,XieL,etal.Clinicalcharacteristicsof

COVID-19-infectedcancerpatients:Aretrospectivecasestudyinthree

hospi-talswithinWuhan,China. AnnOncol2020.http://dx.doi.org/10.

1016/j.annonc.2020.03.296,Mar26. pii:S0923-7534(20)36383-3

[Epubaheadofprint].

[4] Gillessen S, Powles T. Advice Regarding Systemic Therapy in PatientswithUrologicalCancersDuringtheCOVID-19Pandemic. EurUrol2020;77:667–8.

[5]NasproR,DaPozzoLF.Urologyinthetimeofcorona.NatRevUrol

2020. http://dx.doi.org/10.1038/s41585-020-0312-1,Mar23.[Epub

aheadofprint].

a_{DepartmentofMedicalOncology,FondazioneIRCCSIstitutoNazionaledei}

Tumori,Milan,Italy

b_{DepartmentofOncology,UniversityofTurin,AziendaOspedalieraOrdine}

Mauriziano,Turin,Italy

c_{MedicalOncology&BreastUnit,AntonioPerrinoHospital,Brindisi,Italy} d_{MedicalOncologyDepartment,HumanitasGavazzeniClinic,Bergamo,Italy}

*Correspondingauthor.DepartmentofMedicalOncology,Fondazione IRCCSIstitutoNazionaledeiTumori,ViaG.Venezian1,20133Milan,Italy. Tel.:+390223902402;Fax:+390223903150. E-mailaddress:laura.marandino@istitutotumori.mi.it(L.Marandino). EUROPEANUROLOGY78(2020)E27–E35 35