Prostate cancer (PCa) is a heterogeneous diagnosis, usually with a significant latency between diagnosis and risk of cancer specific mortality. Those with clinically detectable lymph nodes on conventional imaging may be offered definitive therapy, including radical prostatectomy (RP) and pelvic lymph node dissection. More recently, a strategy of active surveillance and delays in definitive therapy has emerged as an effective treatment modality for the management of PCa (1). Several recent studies have assessed the impact of such delays in surgery for patients with both low-risk and high-risk PCa and demonstrated that delaying surgery is safe in selected patients, and thus RP should be considered as low priority compared to other emergent and cancer related surgeries (2–4).

The COVID-19 pandemic placed unprecedented stress on patients, providers, and our overall healthcare system. The need to balance the risk of COVID-19 exposure and resource allocation had resulted in a shift towards telemedicine (5) and delays in several non-emergent surgeries, including RP (6). The reduction in RP cases led to increased surgical wait times (SWT) for many patients with PCa patients (7). Even if safe, such delays in SWT can result in increased patient anxiety (8), and thus proper counseling surrounding the topic of surgical timing is critical for ensuring optimal patient outcomes, especially in the setting of potential metastatic or advancement of disease. Although existing studies have demonstrated that surgical delays do not negatively affect outcomes in those with localized PCa (2, 3, 9–11), the effects of such delays on patients with clinically node positive disease is less well described.

We aimed to assess whether increases in SWT result in an increased risk of pathologic node positive disease in the setting of clinically node positive PCa. Our study aims to expand upon existing literature by assessing the impact of delays in SWT on disease progression among node positive PCa patients using data derived from the Commission on Cancer’s National Cancer Data Base (NCDB) Participant User File, making it the largest assessment of node positive PCa outcomes to date. These results will be important in assisting physicians with providing proper patient counseling, managing expectations, and ensuring optimal patient outcomes when discussing treatment options for patients with node positive disease.

This study aimed to assess if increases in SWT resulted in an increased risk of pathologic node positive disease in the setting of RP for clinically node positive PCa. We were able to demonstrate that prolonged SWT was not associated with risk of node positive disease, and increases in SWT were not associated with reductions in overall patient survival. As expected, clinical characteristics such as increasing Gleason score, PSA >20, and increasing clinical stage portended node positive disease. These findings suggest that increasing SWT may not have direct effects on the risk of node positive PCa, and our findings provide a framework for patient counseling or preoperative risk stratification with surgical planning.

An understanding of the behavior of node positive PCa can assist in triaging patients as they await surgical treatments. This is especially relevant given the recent COVID-19 pandemic which has put a strain on global health care systems, resulting in delays in several non-emergent surgeries, including RP (2). Previous studies have described that patients who are subjected to delays in SWT may experience increased rates of depression and anxiety (13, 14), which can be magnified in the setting of a cancer diagnosis (15). Since the onset of the COVID-19 pandemic, the number of RP surgeries has fallen, resulting in significant treatment delay for many patients (7). Understanding the impact that these delays in treatment may impose on disease outcomes of node positive PCa can assist physicians with providing proper patient counseling, managing expectations, and ensuring optimal patient outcomes. It remains unclear the impact the pandemic has had on present and future surgical scheduling therefore, it is important for providers to reassure patients who may be concerned with their disease morbidity when facing delays in SWT. Our study population represents a timeframe prior to the COVD-19 pandemic, so the findings must be taken as hypothesis generating; however, these results can provide a framework for patient counseling and elective surgery triage. Although our findings largely support existing research describing the impact of delayed SWT on disease progression (3, 9, 10, 16, 17), we report several notable findings which warrant further consideration and our study is the first to highlight patients with clinically node positive disease.

We found that delayed SWT did not contribute to adverse nodal disease progression or diminished survival for patients with clinically node positive PCa. Our findings are in line with recent studies which have found that delayed RP did not adversely affect patients with low-risk (18), intermediate-risk (19), and high-risk PCa (3, 10, 19, 20). It has been well described that active surveillance is a safe alternative to immediate surgical treatment for PCa patients with low risk profiles (21, 22), however there is no consensus regarding the length of time that patients may delay definitive treatment, with higher risk disease (11). Our findings support that delaying surgery for up to 3 months is not associated with worse pathologic nodal outcomes; however, this must be carefully integrated with an understanding of the inherent selection bias of our analysis. In essence, surgeons may have unmeasured but individualized risk stratification that guides the timing of RP for clinically node positive patients, and our analysis suggests that surgeons can trust their judgement in this setting. Providers who may be considering delaying surgery for patients due to circumstance, as in the event of COVID-19, may be safely implemented for up to 3 months without worsening adverse events. These findings must be balanced with the provider’s own interpretation of metastatic potential and oncologic risk and patients’ comfort level with surgical and treatment timing.

A diagnosis of PCa may invoke fear and anxiety among patients (23), which may be exacerbated during periods of uncertainty such as in the context of an ongoing COVID-19 pandemic and the subsequent following era that may delay access to necessary treatments. As with any cancer diagnosis, PCa treatment plans should be prepared through a shared-decision making process between patients, their families, and their healthcare providers, taking into consideration several individualized patient factors. Our results are not meant to advocate for the intentional delay of treatment for patients diagnosed with PCa, however our findings support the conclusion that circumstantial or planned delays in SWT are not associated with overt adverse nodal disease progression or short-term morbidity. These findings may alleviate some of the stress and anxiety that patients may have and should be included in the body of evidence which is shared with patients and their families when discussing treatment strategies for PCa.

Our findings suggest that a delay in SWT does not result in impact on surgical or morbidity outcomes among patients diagnosed with pathological node positive PCa. The results described in this study will be important to share with patients and their families when discussing treatment options and can result in improved patient outcomes and satisfaction with treatment regimens.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

FD, GR, KM, and ZH contributed to conception and design of the study. ZH performed the statistical analysis. MZ, RH, FD, and GR wrote sections of the manuscript. All authors contributed to the article and approved the submitted version.