No one can argue with the fact that the earlier prostate cancer (PCa) is diagnosed, the more treatment options there are, and chances for complete cancer control are improved. With this in mind, men are encouraged to get their PSA checked annually. If the test results in a suspiciously high or rising number, a doctor will recommend a needle biopsy of the prostate. (NOTE: today’s newer standard of care is a multiparametric MRI or mpMRI of the gland to determine if a biopsy is truly warranted.)

The March 2020 start of the COVID pandemic had a dramatic impact on the delivery of healthcare services. One study points to a major shift due to “large reductions in services, particularly in places hit hard by the pandemic… Many people have missed out on much needed care, such as vaccination or life extending interventions for cancer.”^[i] Research has already shown that routine screenings for several cancers, including breast, colon and prostate, had decreased considerably due to the pandemic,^[ii] leading to a drop in diagnosis of several types of cancer.

COVID and PCa biopsies

Now, a multi-institutional team has explored the effect of the pandemic on prostate cancer (PCa) biopsy rates. To a certain extent, it may seem obvious that in reaction to the risk of COVID infection—which appears to hit older patients harder—older men who are at increased risk for PCa would have avoided normal check-ups and PSA testing. However, what does real-world data show?

To answer this, Klaassen et al. (2022) turned to case records in the Veterans Affairs Health Care System (VAHCS).^[iii] They statistically analyzed “all prostate biopsies performed on patients in the VAHCS without a preexisting PC diagnosis between January 2018 and March 2021. The base population included all living male patients who had at least 1 visit to the VAHCS during the 3 years prior to each month of the study.” In all, they had access to 51,606 records of patients who had at least 1 biopsy during the entire study period, a substantial number that adds to the strength of their research.

Based on running monthly biopsy totals from the 3 years prior, starting with January 2018, the team projected the number of biopsies that would have occurred had COVID not struck. This allowed them to calculate the probable number of missed biopsies once the pandemic began. They also performed an additional analysis of Black and White patients to determine if COVID was linked with prostate biopsy and PC diagnosis rates by race (in comparison with the prepandemic period).

Findings

Over the total 6-year period (prepandemic and pandemic), monthly biopsy numbers ranged between 1230-1695. The monthly percentage of biopsies that were positive for PCa ranged from 56%-60%. The authors found that, “During the pandemic peak from March through May 2020, there was a sharp decrease in the number of biopsies performed and a higher proportion of positive biopsy results.”

They then calculated that from March 2020 (start of pandemic) through March 2021, the number of missed PCa diagnoses ranged from an estimated 97 – 573 cases as the pandemic progressed. In general, from January 2018 onward, there was a general trend in Black men receiving more biopsies than White men; the pandemic had no apparent effect that altered this trend, even though biopsies decreased across the board. The authors note that “this is the first study, to our knowledge, showing this association, evaluating by race, in the VAHCS population.”

It will likely be several years before the longer-term implications of delayed screening and biopsies become clear. We expect that over time, a rise in the diagnosis of PCa at later stages will become evident. In addition, we can hypothesize broader social outcomes in the aftermath of the COVID pandemic based on 700 years of history with other pandemics, including the Black Death in 1347, smallpox in the New World (1520s), and the Spanish Flu in 1918. If you are interested in a comprehensive backward look at these diseases and the effect they had—and how measures to curb COVID should be informed by their aftermath—I refer you to an excellent public health article titled “Societal Impacts of Pandemics: Comparing COVID-19 With History to Focus Our Response.”

In the meantime, we at the Sperling Prostate Center, encourage men to continue annual PSA screening in accordance with American Cancer Society recommendations—and to follow the COVID safety guidelines of your healthcare facility where you receive your annual wellness checkup. One last very important note: if a PSA test shows an unusually high or rising PSA, be sure to have a multiparametric MRI done on a 3T magnet at an expert facility. It could make the difference between whether or not you need a biopsy. If so, an in-bore MRI guided targeted biopsy is the least invasive yet more accurate biopsy procedure. In the best interests of your health as a man, don’t settle for less.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Moynihan R, Sanders S, Michaleff ZA, et al. Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review. BMJ Open 2021;11:e045343.
[ii] Bakouny Z, Paciotti M, Schmidt AL, Lipsitz SR, Choueiri TK, Trinh QD. Cancer screening tests and cancer diagnoses during the COVID-19 pandemic. JAMA Oncol. 2021;7(3):458-460.
[iii] Klaassen Z, Stock S, Waller J, De Hoedt A, Freedland SJ. Association of the COVID-19 Pandemic With Rates of Prostate Cancer Biopsies and Diagnoses in Black vs White US Veterans. JAMA Oncol. 2022 Jun 1;8(6):914-918. doi: 10.1001/jamaoncol.2022.0467.