Prostate cancer: only one in four men with metastatic disease gets recommended chemotherapy
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m120 (Published 13 January 2020) Cite this as: BMJ 2020;368:m120
A national audit shows that only one in four men with advanced prostate cancer receives life prolonging chemotherapy despite its recommendation by the National Institute for Health and Care Excellence (NICE).
The National Prostate Cancer Audit’s annual report 2019 for England and Wales,1 published by the Royal College of Surgeons, reported for the first time on the use of primary docetaxel in metastatic disease. It found that only 27% of men with widespread disease received docetaxel, ranging from 0% to 39% by NHS providers in England.
Noel Clarke, consultant urological surgeon, and Heather Payne, consultant clinical oncologist, who were joint clinical leads for the audit, said that the shortfall in giving docetaxel was surprising. “This should be offered to all men with prostate cancer who have widespread disease and who are fit to receive it following their initial diagnosis,” they said. “The reasons for this are unclear, but it could be some men are choosing not to have chemotherapy because of the potential side effects. That is one hypothesis that the NPCA [National Prostate Cancer Audit] will now investigate, as it’s important that a greater proportion of patients receive this best practice treatment in the future.”
MRI improvements
The audit found that 42 668 men had prostate cancer diagnosed in England and Wales from 1 April 2017 to 31 March 2018. The proportion of men presenting with metastatic disease at diagnosis was 16%, unchanged since the previous audit.
Multiparametric magnetic resonance imaging (MRI)—a more effective way of imaging the prostate—is now available at 98% of NHS hospitals in England and Wales. This is a significant improvement, as in 2018 it was available for only 80% of men in England and 41% of men in Wales. Trans-perineal biopsy is performed in 77% of the diagnosing trusts in England and Wales, and its use has also increased considerably since 2018.
The rate of over-treatment of men with low risk disease has remained low at 4%. And the potential under-treatment of men with high risk/locally advanced disease has decreased slightly to 32%, the audit found.
Urinary complications after surgery have improved since last year, down from 11% to 9% of patients. However, bowel complications after radiotherapy have remained static at 10%.
The audit reported for the first time on the use of hypofractionated radiotherapy. It found that it was used in 91% of intermediate risk cases and 59% of high risk/locally advanced cases but with substantial national variation. The report called for radiotherapy centres to continue to increase the use of hypofractionated radiotherapy, especially in intermediate risk disease.
Brachytherapy boost, also reported on for the first time, is used in only 5% of high risk/locally advanced cases, most of which were restricted to a few specialist units. The report recommended that brachytherapy in combination with external beam radiotherapy should become more widely accessible for patients with intermediate or high risk prostate cancer.
The availability of support services was very good, as 98% of specialist multidisciplinary teams offered sexual function and continence services, and all offered psychological counselling. However, less than half of radiotherapy centres had a specialist gastrointestinal service.
The audit was commissioned by the Healthcare Quality Improvement Partnership and was funded by NHS England and the Welsh government as part of the National Clinical Audit and Patient Outcomes Programme.
References
Log in
Log in using your username and password
Log in through your institution
Subscribe from £173 *
Subscribe and get access to all BMJ articles, and much more.
* For online subscription
Access this article for 1 day for:
£38 / $45 / €42 (excludes VAT)
You can download a PDF version for your personal record.