Underpinning quality improvement with public reporting of outcomes

Matt Parry, NPCA Clinical Fellow and Urology Registrar

Our Quality Improvement workshop, held in December 2019, was a great opportunity to share results from the National Prostate Cancer Audit’s 6th Annual Report. It was good to get reactions from the clinicians to our findings which became the basis for some of the discussion during the QI workshop.

With the publication of the latest NICE guidelines, in May 2019, it was important for the NPCA to report on the newly highlighted provision for multiparametric MRI as part of the diagnostic pathway and docetaxel in metastatic disease. Encouragingly, we found that multiparametric MRIs are available onsite at 98% of Trusts/Health Boards. However, the national uptake of docetaxel in metastatic prostate cancer was lower than hoped. Our results showed that only one in every four men with newly diagnosed metastatic disease received docetaxel.

This proved to be an important discussion point during the workshop and highlighted to the importance of reporting this through the NPCA. Participants agreed that a proportion of the apparent under-treatment could be assigned to limited ‘fitness’ for treatment, but that certainly 75% of men not receiving this treatment was concerning. It is vital to assess annual trends going forward to see if the national uptake of docetaxel improves over the next few years. If this doesn’t happen, further discussions will need to take place to understand why not, and to find potential ways for provision to improve.

Significant changes have been made in how radiotherapy is delivered for prostate cancer and we have incorporated these changes into this year’s report. Our organisational survey of radiotherapy centres has confirmed that rotational Intensity Modulated Radiation Therapy (e.g. RapidArc volumetric modulated arc therapy) is almost universally available in England and Wales. Importantly, we also report on the use of hypofractionated radiotherapy: a type of radiotherapy that delivers larger doses of radiotherapy each day over a shorter time period than conventional radiotherapy​. This seems to have been adopted widely for men with intermediate-risk disease.

Another significant finding was the availability of high dose rate brachytherapy for high-risk/locally advanced disease: an additional treatment (“brachytherapy boost”) to supplement conventional external beam radiotherapy treatment in which a source of radiation is placed temporarily in the prostate. Approximately one in two specialist MDTs have a referral pathway for this therapy. There is wide variation between Trusts, however, with seven sMDTs using it more frequently than the remaining 40. This variation highlights the need to consider how this treatment can become more widely accessible (e.g. through additional referral pathways).

Since prospective data collection began in 2014, we have reported the potential ‘over-treatment’ of men with low-risk disease where men who could be managed safely on active surveillance have radical treatment straight away. Conversely, we have also monitored the potential ‘under-treatment’ of men with high-risk/locally advanced disease who are eligible for radical treatment but do not receive this potentially curative treatment option. Encouragingly, very few men with low-risk disease are undergoing radical treatment (this has remained static over the last few years at around 4%), and are therefore avoiding unnecessary side effects. However, approximately one third of men with high-risk or locally advanced disease do not receive treatment. This proportion has declined markedly since the start of the NPCA, but now seems to be levelling off. The finding proved to be quite surprising to participants at the QI workshop. Although many of these patients will have been deemed ‘unfit’ for treatment, the proportion of potential under-treatment is still high compared to what the clinicians in the room expected. Further NPCA investigations are planned into the reasons behind the management decisions taken that might lead to these results.

The NPCA also reports on treatment-related complications. Based on indicator development by the NPCA team, we report on gastrointestinal complications within two years of radiotherapy and genitourinary complications within two years of surgery. Encouragingly, these have remained static at around 10% over the last three years since these indicators were included as part of the NPCA Annual Report. It will be important to continue measuring these trends and check that improvements can be made after ongoing engagement with the outlier process.

All the latest results and details of the outlier process can be viewed on our website.

See you all next year for the latest results and hopefully more discussion about ways to help improve prostate cancer care in England and Wales!

Last updated: 9 November 2020, 10:01pm