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Observations on the National Prostate Cancer Audit 2018

Steve Allen, a prostate cancer patient who represents Tackle on various clinical matters eg NICE, reviews the findings of the 2018 National Prostate Cancer Audit in England and Wales.

The Audit is prepared by a team of clinicians, audit experts and cancer information specialists based at the Royal College of Surgeons of England, the British Association of Urological Surgeons and the British Uro-oncology Group.  Its findings are entirely independent and are generally regarded as the most recent and reliable source of information on current practice and outcomes related to the treatment of prostate cancer.

The latest report (NPCA Annual Report 2018) was published in February 2019 and is the fifth year that such a report has been published. At 62 pages, it is very detailed. A patient summary is expected to be published soon.

Below are some of the main facts that come from the Report.  My personal comments are added in italics.

Patient characteristics: (Data for England quoted.  Data for Wales fairly similar)

42,975 men diagnosed with PCa   (41,739 in 2015/16)

12% men aged under 60 yrs

33% men aged 60 – 70

37% men aged 70 – 80

17% men over 80 yrs of age

Great efforts are being made to raise awareness of PCa in men over the age of 50.  However, the statistics above represent the numbers of men actually diagnosed.  What they do not show is how many in each group were actually tested.  It is possible that many men in the lower age range were tested but that no cancers were found. 

Overall, prostate cancer remains a cancer of the older man but one where diagnosis in younger men is increasing – an age group where side effects of treatment and adverse events can have devastating consequences on quality of life.

There is still a large number of men being diagnosed over the age of 80 despite the consensus opinion that PSA testing is not always appropriate in this age group.

The report does not identify the severity of disease diagnosed in each age group.  It would be interesting to know if younger men coming for PSA testing were more likely to present with more aggressive disease than other age groups.  My perception from involvement with many support groups is exactly that:  younger, often asymptomatic, men seem to be diagnosed with more aggressive disease than in older age groups.  But, of course, perception is not always reality.

Stage of cancer at diagnosis:

Data was available in 94% patients diagnosed:

16% had metastatic disease at the time of diagnosis

39% had locally advanced disease

3% mixture of above

35% had intermediate disease

7% had low risk disease

These figures are similar to those in the previous year’s report.

It would appear that men are still not being diagnosed early enough.  Only 7% had low risk disease, 58% had metastatic or locally advanced disease. We cannot afford to reduce our efforts at raising awareness of PCa.

The earlier PCa is diagnosed , the better the clinical outcome.

It has been estimated that the cost of early ‘curative’ treatment is €15,000 compared with €300,000 for the long term treatment of advanced disease.

Use of Multiparametric MRI (mpMRI):

This continues to increase.  58% of all scans performed were mpMRI. 

In England, 80% of all of these mpMRI scan were performed before biopsy.   (Figures for Wales show only 41%)

Tackle, along with other groups, have championed the use of mpMRI earlier in the diagnostic pathway and before biopsy.  This is now undoubtedly coming into routine use.  It is now supported in the recently updated NICE Guideline for PCa.

Use of prostate biopsy:

Trans-rectal ultrasound guided (TRUS) biopsy remains the most common technique used.  There appear to be  differences in practice in England and Wales – however the data for England was only available for 54% of patients diagnosed, 100% in Wales but where the overall total numbers were very much lower

England                                           Wales

88%                TRUS                        96%

12%                Trans-Perineal         4%

Template biopsy giving multiple samples is perhaps the commonest reason for using the perineal approach.  It normally requires a general anaesthetic and may explain the low uptake.

With the increased use of mpMRI and the more accurate localisation of tumour tissue within the prostate, the use of the trans-perineal route for targeted biopsies may well increase in the future.

Arguably the trans-perineal biopsy route may have a lower incidence of adverse events than the trans-rectal route.  In a few centres, trans-perineal sampling (not a full template biopsy) may be performed under local anaesthesia.  The current data for England is split equally between template biopsy and trans-perineal sampling.

Are we improving the treatment of patients?

Low-risk disease:

4% men ‘over-treated’ 1916 /17

8% men ‘over-treated’ 1915/16

A major cause for concern in raising awareness of PCa and increasing the uptake of PSA testing has always been the possibility of over-diagnosis and over-treatment.  The latest figures show a continuing downward trend of this occurring and demonstrates the accuracy and efficacy of the diagnostic pathway in current use.

Locally advanced disease:

33% men ‘under-treated’ 1916/17

27% men ‘under-treated’ 1915/16

‘Under-treatment’ is suggested here when men with locally advanced disease are treated with ADT (hormone) therapy alone rather than combined with additional radiotherapy or surgery.  Under-treatment’ would appear to be more common in older, otherwise healthy, men.

Surgical techniques used:

As one might expect, robotically assisted surgery is now overwhelmingly the most common type of radical prostatectemy performed.

England                                            Wales

   81%             Robotic                       63%

    9%              Laparoscopic              4%

  10%              Open                            23%

The data were collected from April 2016 to March 2017.  It is likely that more procedures will now be being performed using robotic assistance as surgical experience increases. It is too early to have data comparing the number of procedures performed using the newer ‘Cave of Retzius Sparing’ technique.

However, there will always be patients for whom open surgery is required because of medical or technical reasons.

Radiotherapy:

The vast majority of all external beam radiotherapy now uses Intensity Modulated Radiotherapy (IMRT).

90% (England) and 100% (Wales) patients were treated using IMRT. 

For this Audit, no specific data were recorded for treatment involving brachytherapy.

The older 3D-conformal technique is likely to disappear as older radiotherapy equipment is phased out. This should potentially further reduce the incidence of both short-term adverse events and longer-term ones now being identified from treatment given many years previously. 

The use of shorter courses of treatment which use higher doses at each session (hypo-fractionated radiotherapy) may well be increasing but this is not captured in the Audit.

Estimation of Quality of Life

Information was obtained from a Patient Survey sent by the NPCA to men who were diagnosed with prostate cancer from 1st April 2015 to 30th September 2016.  (This is a slightly different time period to that used for data collection from hospital and other records for other parts of the Audit).

Of 35.162 surveys sent out, results were obtained from 25.490 men – a response rate of 73%

Estimations of quality of life were measured using Patient Reported Experience Measures (PREMs) and Patient Reported Outcome Measures (PROMs).

Overall Experience:

90% men said they were given ‘the right amount of information’ concerning their condition and treatment

72% men felt they were involved as much as they wanted in decision making

83% were given the name of a Clinical Nurse Specialist

89% men rated their overall care as 8/10 or above

These are undoubtedly good results – and perhaps better than some of us closely involved with support groups and their members might have expected.  (But support groups by their very nature will attract more people who have experienced problems than those who have not).

However, we should not become complacent.  23% patients did not complete the survey and the figures are incomplete.  It could, perhaps, be argued that these non-responders overall rated their treatment experience highly.  Are those who have with problems more likely to respond than those who have not and will this subsequently influence the overall results?

Side effects / Adverse events:

No treatment for prostate cancer is without the potential for side effects or adverse events.

Of the 25,490 men who responded: 

23% treated with radical prostatectemy  (at 56 surgical centres)

44% treated with External beam Radiotherapy  (at 55 Radiotherapy centres)

Outcome measures were scored on a 0 – 100 scale  (0 bad to 100 good)

After Radical Prostatectemy:

Mean continence score                71 / 100

Mean sexual function score       23 / 100

After External Beam Radiotherapy:

Mean Bowel function score        85 / 100

Mean sexual function score       17 / 100

These are overall estimations of a few outcome measures and only in two treatments used. They evaluate the current status of the patient and do not specifically compare that with how the patients were prior to their treatment.  One assumes a number of patients would not have always scored 100 / 100 on each measure prior to their treatment. However, the Audit uses a well validated questionnaire giving reliable data which allows comparison to be made from one Audit Report to another, and between different forms of treatment.

In Conclusion…….

The full report contains a vast amount of information and I have only highlighted some of the major points that I feel the most relevant for patients.