Commentary: COVID-19 and Prostate Cancer—A Perspective on Risks and Responses

Ashutosh Tewari, MD
Chairman, Milton and Carroll Petrie Department of Urology
Icahn School of Medicine at Mount Sinai
New York, New York

As the COVID-19 pandemic evolves, it’s time to think about tigers.
Let me explain. As a prostate cancer surgeon, I often show patients who have been diagnosed with the disease a series of 3 images to help them understand the level of risk associated with their particular cancer. The first image is a group of newborn tiger cubs. Like human babies, they’re born toothless, and the cubs appear relatively harmless. In the Gleason grading system, which is used to estimate a cancer’s aggressiveness, these cubs represent a Gleason 6. The tumor cells appear close to normal and are less likely to spread. The second photo is of a tiger several months old with its mouth open and its white baby teeth gleaming. This one represents a Gleason 7; it may pose great danger, or it may not. The final image is the “man eater,” the adult tiger, jaws open wide, revealing long, sharp incisors—representing a Gleason 8, 9, or 10—a lethal threat. We need to understand the level of risk to mount the right response.

There is another image we are all seeing quite a lot these days, the by now familiar spike protein of the SARS-CoV-2 virus that drives the virus into the body’s cells, causing the infection known as COVID-19. Although COVID-19 affects both men and women, people of all ages, and people of all ethnicities, the risk for severe disease and death is much higher in older men, the same group of patients at risk for prostate cancer, and higher still for those with underlying conditions, such as cancer. For men who are at risk for, diagnosed with, or survivors of prostate cancer, COVID-19 may have a greater likelihood of becoming a lethal threat.

For the 12 million men worldwide who are on their prostate cancer “journey,” the COVID-19 pandemic will very likely present 1 of 2 scenarios. Those not infected with SARS-CoV-2 may need to undergo evaluation for prostate cancer, plan for a biopsy, wait for surgery, or undergo treatment (radiation, hormone therapy, chemotherapy) while living with the threat of COVID-19. Others with a prostate cancer diagnosis may also have received a diagnosis of COVID-19 infection. Both situations are, of course, frightening for patients and their families, and concerning to their medical teams. And both situations highlight the need to understand as much as possible about the level of risk to mount the right response.

By definition, risk implies uncertainty, and there is indeed a great deal we do not yet know about COVID-19, or about COVID-19 as it may interact with prostate cancer. Nonetheless, scientists are learning about the biology of the virus, deciphering its genome and investigating the protein interactions that give rise to infection. We have come to understand a great deal about the epidemiology of the disease, determining comorbidities and other factors that contribute to the severity of disease or to higher risk for death—heart disease, hypertension, diabetes, cancer, older age, smoking, obesity. Importantly, we know that prostate cancer patients are much more vulnerable to COVID-19 complications because of their compromised immune status. Finally, what we can be fairly certain of is that as the pandemic evolves and if or when, as predicted, there is a new surge, COVID-19 will have an impact on how decisions related to diagnosis, treatment, and even survivorship are made. Assessing risk in a time of restricted or delayed services, or as new treatments emerge, will be more critical than ever.

Where does that leave prostate cancer patients and the medical teams that care for them? My advice here is not all that different from the guidance I have given to the more than 10,000 patients I have treated over the course of my career: Know which tiger you are. 

Patients should seek the advice of clinicians who are relying on scientific guidance. They should be encouraged to try to make the lifestyle changes that we have long known to be important for prostate cancer patients—smoking cessation, a healthy diet, exercise, and stress reduction (in my practice, we encourage mindfulness and meditation), and manage their other health conditions with particular care. Patients should not put off evaluations needed to monitor the progression of their cancers (as physicians, we can work with patients to determine how, where, and when these tests can proceed). Patients also should be reminded to follow the guidelines and regulations designed to keep them safe: Wear protective gear (face covering, gloves), stay at home as much as possible, practice physical distancing, and avoid crowds. At least 50 large health systems around the country, including my own institution, have digital telemedicine systems in place. Patients may be able to schedule remote appointments and even have contactless follow-up after on-site treatments. Patients also can ask their physicians to advocate for screening for prostate cancer patients, given their particular vulnerabilities. Finally, understand that a patient dealing with a “man eater” of a tiger will need to weigh the risks quite differently than a patient whose cancer is at a less aggressive or advanced stage.

These are extraordinary times. COVID-19 is a global health emergency the likes of which none of us has seen before. For me, as for millions of people around the world, the crisis has been quite personal. First, as a prostate cancer surgeon who also conducts research in basic science and immunology, I became interested in the virus in the earliest days of the pandemic, working with colleagues on COVID-19 clinical trials, conducting studies of the gender disparity in the disease (from the perspective of prostate cancer), and, of course, working on the front lines in the hospital with my patients. Then, I contracted the infection myself, became ill, and was hospitalized. I must admit I was afraid for myself and for my family (my wife and daughter both contracted COVID-19 but, fortunately, had milder cases). The experience has made me all the more convinced that we must come together—patients, scientists, and clinicians—in our fight against COVID-19 and cancer.