Optimizing Cancer Surgery Management in Healthcare Systems During the COVID-19 Pandemic

New Proposed Approach to Managing Bladder Cancer During the COVID-19 Pandemic

Introduction

In recent months, healthcare systems worldwide have prioritized resources to tackle the COVID-19 pandemic. Despite this focus, other medical conditions, particularly cancer, remain pressing issues. As countries begin to regain control over the coronavirus, the treatment of non-COVID conditions is being reconsidered. Cancer treatment, in particular, is time-sensitive, and delays in diagnosis can severely affect patient outcomes. Therefore, it is crucial to balance minimizing the risk of SARS-CoV-2 transmission with ensuring timely cancer care.

Study Overview

A new study published in the *Bladder Cancer* journal explores the management of patients with non-metastatic bladder cancer during the pandemic. Bladder cancer is noteworthy due to its resource-intensive management requirements, especially for non-muscle invasive bladder cancer (NMIBC), which necessitates frequent hospital procedures and monitoring.

Decision-Making Algorithm

The study’s research team has developed an accessible algorithm to assist in clinical decision-making by evaluating published evidence. The algorithm’s primary focus is on distinguishing between muscle-invasive bladder cancer (MIBC) and NMIBC. NMIBC accounts for up to 80% of newly diagnosed bladder cancer cases. The researchers categorize NMIBC based on tumor characteristics, including grade, size, and histology, into low, intermediate, or high-risk classifications.

Recommendations for Low and Intermediate Risk Patients

For patients classified as low-risk and those in the intermediate-risk category with low-grade tumors, the recommendation is to implement active surveillance unless symptoms arise. Patients experiencing symptoms should be scheduled for transurethral resection of bladder tumor (TURBT) procedures. This strategy reduces hospital visits while ensuring symptomatic patients receive necessary treatment. The study provides evidence indicating that low and intermediate-risk patients can be effectively managed through active surveillance.

Management of Intermediate and High-Risk Patients

Intermediate-risk patients with high-grade tumors, along with all high-risk patients, should undergo TURBT combined with intravesical BCG immunotherapy. For these individuals, active surveillance is deemed too risky due to potential disease progression, necessitating intervention despite the COVID-19 related risks.

Approach for Muscle-Invasive Bladder Cancer

MIBC, being the more aggressive form of bladder cancer, requires intervention in all cases. When feasible, radical cystectomy (RC) is recommended for patients who are healthy enough to undergo the procedure. Although RC involves a significant post-operative hospital stay and resource utilization, the risks associated with delaying treatment in these patients surpass any COVID-19 related concerns.

Treatment Options for Unsuitable Candidates

For MIBC patients who are not candidates for RC or where resources are limited, the treatment approach is less definitive. The study outlines three potential options. First, neo-adjuvant chemotherapy (NAC) may be utilized to shrink the tumor until RC can be performed. Alternatively, a trimodal approach can be considered, where a combination of TURBT, chemotherapy, and radiation therapy is employed to preserve the bladder. Lastly, the authors suggest exploring clinical trial medications for specific MIBC patients, particularly if these options permit remote treatment.

Conclusion

The rapid shift in healthcare priorities due to COVID-19 has created challenges in managing non-coronavirus related conditions. This study offers a framework for the management of bladder cancer patients during the pandemic, highlighting the importance of timely treatment to improve patient outcomes. By prioritizing high-risk patients and optimizing healthcare resource use, the study aims to mitigate the impact of COVID-19 on cancer care.

Reference

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.