A Call to Test Men With Prostate Cancer for COVID-19

Higher Death Rate in NYC Cohort

Nick Mulcahy

August 07, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Men with prostate cancer should be routinely tested for COVID-19, say a team of urologists from New York City in a review paper that focuses on the two diseases. The article was published July 8 in Nature Communications Biology.

"The particular vulnerability of older men to COVID-19 compels us to advocate for routine screening of SARS-CoV-2 infections in prostate cancer patients," write Dimple Chakravarty, MD, and colleagues from the Tisch Cancer Institute at Mount Sinai in New York City.

However, the call is not in sync with major cancer groups such as the American Cancer Society and the American Society of Clinical Oncology, who do not advise COVID-19 testing on the singular basis of a person having a cancer.

In their new article, the Mount Sinai team also reveals previously unpublished data from their health system on prostate cancer and COVID-19 mortality.

From March 1 to April 26, the system had 9,648 COVID-19-positive patients, of which 5238 (54.3%) were male, including 114 (2.2%) with a previous diagnosis of prostate cancer.

In this COVID cohort, the mortality rate among patients with prostate cancer (n = 27) was nearly double of that among all male patients with a malignancy (n = 43) other than prostate cancer (23.7% vs. 12.7%; P < .01).

However, these are "preliminary" data and "caution is warranted since confounding is likely massive," warns Alexander Kutikov, MD, of Fox Chase Cancer Center in Philadelphia, Pennsylvania, who was approached for commented.

Kutikov also told Medscape Medical News that he does not agree with the authors' proposal that all patients with prostate cancer should be tested for COVID-19.

"It is difficult to advocate for routine screening of otherwise asymptomatic men when early detection of viral infection is unlikely to be actionable. Indeed, as of early August 2020, robust protocols for early intervention and prevention of severe COVID-19 are not yet available," he explained.

Despite their bold call to action, the Mount Sinai authors also strike a conservative note in their article: "The true susceptibility of prostate cancer patients to COVID-19 remains unclear at this point, despite early evidence of overlapping biology and common comorbidities."

The authors review that "overlapping" biology and epidemiology in what Kutikov calls an "extremely thought-provoking thesis" — namely, that there may be a shared molecular pathogenesis between prostate cancer and COVID-19.

In an ICU and Prostate Cancer Clinic: Same Type of Men

There are sex disparities with regard to COVID-19, with men at higher risk of infection and mortality than women, observe the Mount Sinai team, citing reports from multiple countries.

Furthermore, incidence of comorbidities among COVID-19-positive patients has been found to be higher in males than females.

Both the authors and Kutikov point out that male gender and age are two main risk factors for a lethal COVID-19 infection and for prostate cancer.  

The authors also state that "older age and comorbidities (hypertension, diabetes, obesity, and smoking) that adversely affect COVID-19 are also lethal for prostate cancer."

There appears to be a "perfect storm" of COVID-19 risk, consisting of age, race [among black men], sex, comorbidities, and cancer among many patients with prostate cancer, explained senior author Ashutosh Tewari, MD, also of Mount Sinai, in an interview with Medscape Medical News.

Being a large hospital in New York City, Mount Sinai was "the epicenter of the epicenter" in the early weeks of the pandemic, he said.

"There was a convergence between [the type of man] who showed up in the ICU and who showed up in my prostate cancer clinic," observed Tewari, who, like many staff at Mount Sinai, eventually provided care to COVID-19 patients.

"I also saw first-hand that men were more likely to get infected, be hospitalized, be in an ICU, and to die," he continued.

Tewari eventually was infected himself and spent 2 weeks in the ICU before being released; his wife and daughter also contracted the virus.

During his interview with Medscape Medical News, Tewari slightly moderated the call for testing among patients with prostate cancer. "Have a low threshold for testing is what I am suggesting," he said. "[Men with prostate cancer should] get tested if they have even slight fear that they have been exposed."

A Shared Biology?

As noted above, the New York team posits that there may be biological mediators of the sex differences seen with COVID-19. In their review of these, they note research suggesting that in men with prostate cancer, the use of  androgen deprivation therapy (ADT) may be protective against COVID-19, as reported by Medscape Medical News.

Clinical trials to further explore the link between COVID-19 and prostate cancer and ADT are underway. For example, a trial on the use of bicalutamide, an antiandrogen, among patients with COVID-19 is being conducted in Baltimore. And the US Department of Veterans Affairs launched a phase II trial for the use of the hormone suppresser degarelix (a GnRH analog that blocks luteinizing hormone and thereby reduces androgens) for COVID-19-infected male patients.

Tewari said men with prostate cancer need to be "super cautious" in following CDC guidelines to avoid COVID-19 and doctors need to reach out to them via telehealth for ongoing monitoring.

He advises physicians to encourage behavior change for the sake of improved health and comorbidities. "Men usually don't focus on these things, so pay attention to changeable behaviors. Stop smoking. Control your blood pressure. Control your diabetes. Lose weight."

"We men think we are invulnerable, but this is one battle you can win by being afraid, not by being brave," Tewari concluded.

The review authors and Kutikov have disclosed no relevant financial relationships.

Commun Biol.  Published online July 8, 2020. Full text

Nick Mulcahy is an award-winning senior journalist for Medscape. He previously freelanced for HealthDay, MedPageToday and has had bylines featured on WashingtonPost.com, MSNBC, and Yahoo. Email: nmulcahy@medscape.net and on Twitter: @MulcahyNick

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