Fewer men receive potentially unnecessary treatments for prostate cancer.
Only 8% of men with low-risk prostate cancer received potentially unnecessary radical treatment aimed at curing the disease1 in 2015-16 according to the fourth Annual Report of the National Prostate Cancer Audit (NPCA) published by the Royal College of Surgeons today. This is an improvement on 2014-15 figures, when 12% of men treated by the NHS in England may have received unnecessary treatment for low risk disease. This reflects the international trend in this area of prostate cancer therapy.
Prostate cancer is the most frequently diagnosed cancer in men and the third most common cause of cancer-related mortality in the United Kingdom, with about 40,000 new cases each year resulting in 10,000 deaths.
Low-risk prostate cancer is confined to the prostate gland and has a low risk of spreading to other parts of the body. Some men with low-risk prostate cancer may choose surgical or radiotherapy treatment to remove the cancer, but many of these cancers need careful observation as their first treatment option. Increasingly clinicians are recommending “active surveillance”, in keeping with recent national clinical guidelines.2
Active surveillance is where a patient has regular tests, scans and frequent contact with their doctor to ensure their prostate cancer has not grown or spread. If there is evidence that the cancer is spreading, surgery or radiotherapy can be offered immediately.
Treatments with surgery or radiotherapy aim to get rid of the prostate cancer but they can also lead to side effects, including urinary incontinence, difficulties having erections, and bowel problems. By offering active surveillance, patients are avoiding, or at least delaying the need for treatment and its potential side effects. Evidence shows that about 50% of patients on active surveillance do not require treatment within 10 years following their diagnosis.3
The audit looked into the proportion of men with low-risk prostate cancer undergoing radical prostate cancer therapy. Those patients that did not go ahead with radical treatment will likely have taken part in active surveillance.
NICE guidance updated in 2015 says that men with low-risk prostate cancer must discuss treatment options, which can include more radical treatments as well as active surveillance and their potential adverse effects, with a nurse specialist.
Professor Noel Clarke, NPCA Urological Clinical Lead, representing British Association of Urological Surgeons, said:
“Improved understanding of the behaviour of low risk prostate cancer has resulted in more men with low-risk, localised prostate cancer being offered the option of active surveillance. However, there will always be patients who prefer to have surgery or radiotherapy straight away and some who have other risk factors which mean intervention treatment is better. Safe-guards should be in place to ensure all men are appropriately counselled on the advantages and disadvantages of active surveillance in this disease setting.
“For those patients who do require treatment to cure the disease, the audit has found that there are ongoing improvements in surgical and radiotherapy techniques used to treat prostate cancer which follow the best available international evidence and patient satisfaction with this is very high.”
Specific findings and other key recommendations from the audit include:
•There has been an increase in the use of pre-biopsy MRI scans in England. This is positive; however, there are concerns about the capacity of the NHS to continue to offer these scans as their usage increases.4
•The increase in the number of locally advanced prostate cancer patients having potentially curative treatment is encouraging. However, some healthy older men may be at risk of under treatment.5 Further work is required to understand what factors contribute to some healthier older men receiving treatment and others not.
Professor Heather Payne, NPCA Oncological Clinical Lead, representing British Uro-oncology Group, said:
“For the first time, we compare the quality of prostate cancer care provided by NHS providers in England identifying any potential outlying performance. The standard of care is increasing year on year and there is little regional variation.”
Professor Howard Kynaston, NPCA Urological Clinical Lead in Wales, said:
“The NPCA has now become a well-established audit in England and Wales examining the care that patients with prostate cancer receive. This report will drive improvements in services so that all men can receive the best available care in the UK.”
Results are presented in the National Prostate Cancer Audit (NPCA) 2017 annual report published by the Clinical Effectiveness Unit at the Royal College of Surgeons. The audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme.
The audit presents performance indicators assessing the quality of treatment men received following a diagnosis of prostate cancer between April 2015 and March 2016 in England and Wales. The indicators are being used to monitor the care provided in each prostate cancer centre and the outcomes of their patients.
1 Treatments that may combine surgery, radiotherapy, chemotherapy and hormonal treatments.
2 NICE, 2015. Prostate Cancer. NICE Quality Standard 91. Quality Statement 1: ‘men with low-risk prostate cancer for whom radical treatment is suitable are also offered the option of active surveillance’
3 Hamdy FC, Donovan JL, Lane JA et al. 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016;375:1415-1424
5 Droz et al. Management of prostate cancer in older patients: updated recommendations of a working group of the International Society of Geriatric Oncology. Lancet 2014; 15: e404-14.