Introduction
Prostate cancer is the most common malignancy among men [1]. For many years the evaluation and diagnosis of this disease was based on PSA blood test [2] and digital rectal examination (DRE). In the last decade, new tests are available and may assist physicians distinguish between patients who harbor a high-risk significant prostate cancer and those with low-risk prostate cancer and thus rationally select patients who need prostate biopsies. One of the diagnostic options today is the 4K® score test which is a blood test sampling the level of three serological markers besides the PSA: free PSA, intact PSA and human kallikrein-related peptidase 2 (hK2) [3]. Different studies reported a greater efficiency in diagnosing aggressive prostate cancer by using the 4K® score test comparing the standard PSA level, allowing avoiding biopsies among patients assuming to have less aggressive disease [4,5].
Patients with 4K ® score of 7.5% or less are considered to have a low-risk for diagnosis of a prostate cancer of Gleason score of 7 or higher if a biopsy was performed. Also, these patients have less than a 1% risk of having metastasis within 20 years [6]. In contrast, patients with a 4K® score above 33% are 33% more likely to have a Gleason score ≥7 prostate cancer if a biopsy was performed [4, 7].
COVID-19 has a global effect with substantial mortality as well as indirect effect on evaluating other diseases [8], reducing human resources, reducing budgets, directing clinics to treat only COVID-19 patients, and reducing primary evaluating facilities with local or regional instructions to reduce visits in hospitals and outpatient clinics with other diseases. This reality may cause delayed diagnosis of other diseases, including malignancies. The diagnosis rates of different malignancies reduced significantly in USA comparing the pre-COVID 19 era, a finding which its implications may be noticeable for years to come [9]. A study using a mathematical model to evaluate the expected influence of a delayed diagnosis on the mortality rate, predicted an incline in preventable mortality rate the next years among patients with different malignancies [10].
In Israel, during the COVID era, few quarantine periods were declared in which people were instructed not to leave their homes unless for prespecified reasons such as essential medical treatment. In addition to that, the Israeli ministry of health instructed hospitals and clinics to reduce elective procedures.