In the UK, about 1 in 6 men will be diagnosed with prostate cancer in their lifetime. Most of those affected are aged 50 and over. The number of diagnoses is increasing: in 2018, there were 57,000 new prostate cancer diagnoses, exceeding those for breast, lung and bowel cancer. Now, prostate cancer is the most diagnosed cancer in the UK. As a result, the healthcare system has seen a 33% increase in hospital admissions for prostate cancer between 2014-15 and 2018-19.
NICE has produced several pieces of guidance about prostate cancer, including two quality standards, three clinical guidelines, 10 technology appraisals and 13 medical technology and interventional procedure guidance.
In our latest impact report, we look at the impact that NICE recommendations have had on the diagnosis and treatment of prostate cancer. We also highlight the importance of considering patient experience and areas where further improvement is needed.
One area of focus is supporting people to choose the right treatment for them. There are many options, and choice of treatment depends on the stage of cancer, the presence of comorbidities and individual preference. To aid this conversation, NICE endorsed the Predict Prostate patient decision aid produced by the University of Cambridge Academic Urology group. This follows NICE’s guideline on prostate cancer, comparing the outcomes of different treatment options for non-metastatic prostate cancer.
One form of treatment is radical prostatectomy, which can be performed using open, laparoscopic or robotically-assisted laparoscopic surgery. In 2014, we updated our guideline to recommend that commissioners of urology services should consider providing robotically assisted surgery to treat localised prostate cancer if they expect to carry out at least 150 such surgeries per year. The benefits of robotic surgery include less blood loss, reduced pain and shorter hospital stays. Since then, data from the National Prostate Cancer Audit shows an increase in the use of the robotic approach, from 74% of prostatectomies in 2017 to 85% in 2019.
The NICE guideline recommends that mpMRI (multi-parametric magnetic resonance imaging) is offered as the first-line specialist investigation for people with suspected clinically localised prostate cancer. This enables the identification of clinically significant cancer and reduces the diagnosis and overtreatment of clinically insignificant cancer, as well as reducing the number of people who need a biopsy, which has associated risks such as infection. The National Prostate Cancer Audit has seen a substantial increase in the proportion of mpMRIs performed before biopsy.
Another improvement in prostate cancer treatment is the increase in the use of the drug therapies abiraterone and enzalutamide which are recommended for the treatment of prostate cancer. Since we first recommended these drugs in our technology appraisal guidance in 2012 and in 2014, both drugs have seen an increase in prescribing.
It is more important than ever that treatments for prostate cancer are adaptable, especially as there is a risk of exposing already vulnerable people to Covid-19. By limiting visits to hospital, moving chemotherapy delivery to a separate unit and delivering medications to home addresses, services have been able to keep patients safe. These changes are underpinned by the NICE Covid-19 rapid guideline: delivery of systemic anticancer treatments. A shared learning example on maintaining a cancer service from one hospital during the Covid-19 pandemic, shows how NICE recommendations were implemented in practice within this centre. Within four months, the centre had 292 haematology and oncology patients reviewed through the new Covid-19 assessment unit.
Importantly, the impact report also looks at patient experience. It highlights NICE’s guideline on patient experience in adult NHS services which recommends that all staff involved in providing NHS services should provide information and support in an accessible format, and discuss decisions about investigations and treatment in a style and manner that enables the person to express their personal needs and preferences. The National Cancer Patient Experience Survey reports positive experiences in 2019; over 90% of people with prostate cancer reported they were treated with respect and dignity while in hospital, and 86% were given clear written information about what to do after leaving hospital.
Our quality standard on prostate cancer states that people with prostate cancer should have a discussion about treatment options and adverse effects with a named nurse specialist. Specialist nurses provide a contact for information, advice and support and can help people to feel reassured about being well informed and involved in decisions about their own care. However, data from the National Cancer Patient Experience Survey reveals only 68% of people with prostate cancer found their nurse specialist very easy or quite easy to contact; this is lower than the 76% reported for all cancer patients.
Although there is still some improvement needed, it is great to see the substantial improvements in the care and treatment of those with prostate cancer. It is clear to see the positive impact that NICE guidance has made, particularly in establishing active surveillance as an acceptable method of managing early prostate cancer, establishing centres with expertise in robotic prostatectomy and setting standards for the use of multiparametric MRI in the diagnosis of prostate cancer.