[NICE updated guideline] Prostate cancer: diagnosis and management [NG131]

NICE | December 2021 | Prostate cancer: diagnosis and management [NG131]

This guideline covers the diagnosis and management of prostate cancer in secondary care, including information on the best way to diagnose and identify different stages of the disease, and how to manage adverse effects of treatment. It also includes recommendations on follow-up in primary care for people diagnosed with prostate cancer.

 A table of NHS England interim treatment regimens gives possible alternative treatment options for use during the COVID-19 pandemic to reduce infection risk. This may affect decisions for patients with prostate cancer. See the COVID-19 rapid guideline: delivery of systemic anticancer treatments for more details.

In December 2021, NICE reviewed the evidence and updated the recommendations on risk stratification to refer to a 5-tier model. Other recommendations were amended to reflect this change. For more information, see the update information.

Full details from NICE

Cancer patient management: role of multidisciplinary teams

Luu, T.T. | 2021| Cancer patient management: role of multidisciplinary teams | BMJ Supportive & Palliative Care | doi: 10.1136/bmjspcare-2021-003039

Abstract

Objectives As a cancer model recommended by numerous governments and health care systems, multidisciplinary teams (MDTs) can improve clinical decision-making and overall patient care quality. This paper aims to discuss key elements and resources, as well as contingencies for effectiveness MDTs and their meetings.

Methods We derived elements, resources, and contingencies for effective MDTs by analyzing articles on the themes of MDTs and MDT meetings.

Results This paper identifies key elements comprising MDT characteristics, team governance, infrastructure for MDM, MDM organization, MDM logistics, and clinical decision-making in light of patient-centeredness. Resources that facilitate an MDM functioning consist of human resources and non-human resources. The paper further detects barriers to the sustainable performance of MDTs and provide suggestions for improving their functioning in light of patients’ and healthcare providers’ perspectives.

Conclusions MDTs are vital to cancer care through enabling healthcare professionals with diversity of clinical specialties to collaborate and formulate optimal treatment recommendations for patients with suspected or confirmed cancer.

Rotherham NHS staff can request a copy of this article from their Library service

Cancer trial recruitment drops by 60 per cent during pandemic

The Institute of Cancer Research | December 2021 | Cancer trial recruitment drops by 60 per cent during pandemic

Figures released by The Institute of Cancer Research (ICR) show recruitment to cancer trials fell by nearly 60 per cent during the first year of the pandemic, amid warnings that Covid-19 has compounded longstanding issues with trial funding, regulation and access. The statistics come from a report- conducted by the body during the early stages of the pandemic April to July 2020 

The report identifies the following barriers:

• There is an excessive administrative burden in setting up clinical trials, especially for innovative trial designs such as biomarker-driven studies for precision medicine.
• The NHS does not have systems in place for rapid genetic testing of patients to select them for precision medicine trials.
• Patients face a postcode lottery in access to the latest trials. Funding for doctors to carry out clinical research varies between hospitals – meaning some patients miss out on the latest treatments.
• Information about clinical trials for patients and doctors is inadequate – existing information is spread across multiple platforms, not kept up to date and often in a format that is difficult for patients to understand.

Image source: ICR Front cover of the publication, which shows a photo of a patient sitting with an NHS healthcare worker

The ICR, London, report collates data on cancer trials, and the views of patients and clinicians on how they can remove barriers to making trials more widely available. cer patients entering clinical trials has plummeted during the pandemic – denying many thousands the latest treatment options and delaying the development of cutting-edge drugs and technologies.

Clinical trials in cancer Barriers in access to clinical trials, especially in light of the Covid-19 pandemic [report]

Cancer trial recruitment drops by 60 per cent during pandemic [news release]

Earlier decisions on breast and ovarian surgery reduce cancer in women at high risk

Marcinkute, R. et al | 2021| Uptake and efficacy of bilateral risk reducing surgery in unaffected female BRCA1 and BRCA2 carriers | Journal of Medical Genetics | Published Online First: 10 February 2021. doi: 10.1136/jmedgenet-2020-107356

This NIHR Alert summarises the recent findings of a longitudinal study that followed more than 800 women who carry the BRCA1 or BRCA2 genes who have an increased risk of developing ovarian and breast cancers (as well as other cancers). After testing positive for these genes, the individuals were followed up twenty years later, where more than half (57.9 per cent) had a risk reducing mastectomy, and 77 per cent had elected for a bilateral salpingo-oophorectomy (RRSO).

Abstract

Background Women testing positive for BRCA1/2 pathogenic variants have high lifetime risks of breast cancer (BC) and ovarian cancer. The effectiveness of risk reducing surgery (RRS) has been demonstrated in numerous previous studies. We evaluated long-term uptake, timing and effectiveness of risk reducing mastectomy (RRM) and bilateral salpingo-oophorectomy (RRSO) in healthy BRCA1/2 carriers.

Methods Women were prospectively followed up from positive genetic test (GT) result to censor date. χ² testing compared categorical variables; Cox regression model estimated HRs and 95% CI for BC/ovarian cancer cases associated with RRS, and impact on all-cause mortality; Kaplan-Meier curves estimated cumulative RRS uptake. The annual cancer incidence was estimated by women-years at risk.

Results In total, 887 women were included in this analysis. Mean follow-up was 6.26 years (range equal to 0.01–24.3; total equal to4685.4 women-years). RRS was performed in 512 women, 73 before GT. Overall RRM uptake was 57.9 per cent and RRSO uptake was 78.6 per cent. The median time from GT to RRM was 18.4 months, and from GT to RRSO–10.0 months. Annual BC incidence in the study population was 1.28 per cent. Relative BC risk reduction (RRM versus non-RRM) was 94 per cent. Risk reduction of ovarian cancer (RRSO versus non-RRSO) was 100 per cent.

Conclusion Over a 24-year period, we observed an increasing number of women opting for RRS. We showed that the timing of RRS remains suboptimal, especially in women undergoing RRSO. Both RRM and RRSO showed a significant effect on relevant cancer risk reduction. However, there was no statistically significant RRSO protective effect on BC.

Uptake and efficacy of bilateral risk reducing surgery in unaffected female BRCA1 and BRCA2 carriers [abstract only]

NIHR Alert Earlier decisions on breast and ovarian surgery reduce cancer in women at high risk

Rotherham NHS staff can request this article from their Library

NHS backlogs and waiting times in England

National Audit Office | November 2021 | NHS backlogs and waiting times in England

This National Audit Office report published today (1 December 2021) looks in detail at backlogs and waiting times for elective and cancer care in the NHS in England. It explains how the current increased backlogs and waiting times have arisen, including the impact of the COVID-19 pandemic.

There have been ‘missing’ referrals for suspected cancer during the pandemic . As for elective care, this is likely to be for a combination of reasons: people avoiding healthcare settings because of fear of the virus or to reduce demand
on the NHS; people having difficulty getting appointments with GPs, consultants or diagnostic services; and also screening services not operating or operating a reduced service.

Early diagnosis and treatment of cancer are very important to increase the chances of successful recovery. The NHS started encouraging people with worrying symptoms to return to the NHS quite early in the pandemic, including through advertising campaigns.

The NAO looked in detail at two performance standards: two-week waits for urgent GP referrals and 31-day waits from diagnosis to first treatment. The NAO estimates that there were between 240 000 to 740 000 ‘missing’ urgent GP referrals for suspected cancer between March 2020 and September 2021, and between 35 000 and 60 000 ‘missing’ first treatments for cancer over the same period (Figures 26 and 27). The range in estimates of what we are calling ‘missing’ referrals and ‘missing’ first treatments relates to the different ways of estimating what normal demand for cancer care would have been if the pandemic had not happened. We recognise that there is inherent uncertainty about these estimates. There is also uncertainty about how many of the ‘missing’ patients will enter the system and over what timeframe. NHSE&I has told the NAO that it is targeting interventions across the country and for all tumour types where there is evidence of reduced diagnoses.
It urges all patients with potential symptoms of cancer to come forward (Source: NAO).

Images source: NAO Images present key facts from the report

See also:

NAO NHS backlogs and waiting times in England [press release]

NICE: Over 600 people set to benefit from innovative lung cancer treatment within the Cancer Drugs Fund

NICE| November 2021 | Over 600 people set to benefit from innovative lung cancer treatment within the Cancer Drugs Fund

NICE has today (30 November) announced that more than 600 people are set to benefit from innovative lung cancer treatment within the Cancer Drugs Fund as NICE publishes its final draft guidance recommending osimertinib .

Osimertinib (also known as Tagrisso and made by AstraZeneca) is recommended for people with early-stage (1b to 3a) non-small-cell lung cancer (NSCLC) who have had surgery to remove their tumour and who have epidermal growth factor receptor (EGFR) gene mutations.

Current clinical trial evidence shows that compared with active monitoring, adjuvant treatment with osimertinib reduces the risk of the disease coming back by 80%. It may also lower the risk of dying from their cancer. However, this evidence is uncertain because information from the trial was released early, and the data is still immature. For this reason the drug is recommended for use within the CDF rather than in routine NHS commissioning.

The CDF recommendation means people with this form of lung cancer will be able to have osimertinib on the NHS while further evidence is gathered on its clinical and cost-effectiveness.

See NICE for full details
NICE Over 600 people set to benefit from innovative lung cancer treatment within the Cancer Drugs Fund [news release]

Is stroke incidence increased in survivors of adult cancers? A systematic review and meta-analysis

Turner, M. et al. | 2021|  Is stroke incidence increased in survivors of adult cancers? A systematic review and meta-analysis| J Cancer Surviv | https://doi.org/10.1007/s11764-021-01122-7

The reviewers behind this systematic review and meta-analysis set out to describe and quantify stroke incidence in people living with and beyond cancer. To this end they conducted a systematic review (36 articles met the inclusion criteria) and meta-analysis (25 of the included articles calculated hazard ratios for the incidence of stroke; 7 studies were included for individual cancer types). These epidemiological studies comparing stroke incidence between individuals living with and beyond cancer and those without cancer (matched controls, controls from the general population, or using the general reference population of a region or country). They report that stroke incidence is significantly increased after diagnosis of certain cancers. The resulting paper has been published in the Journal of Cancer Survivorship where the reviewers outline their findings in further detail.

Is stroke incidence increased in survivors of adult cancers? A systematic review and meta-analysis [paper]

See also:

MedScape Increased Risk of Stroke in Cancer Patients and Survivors [clinical summary]

Life Special Issue “Prostate Cancer”

Life | nd | Life Special Issue “Prostate Cancer”

The prostate is the largest accessory gland of the male reproductive tract. Together with seminal vesicles and bulbourethral glands, the prostate is responsible for the production of an alkaline fluid that forms part of the seminal fluid. The prostate of men over 40 years of age is commonly affected by several pathologies, like benign prostate hyperplasia and cancer.

Prostate cancer is one of the most frequent cancers among men population worldwide. According to the World Health Organization (WHO), in the year 2018, prostate cancer affected approximately 1.28 million men and was responsible for the death of 358,989 of them. Prostate cancer development is associated with several risk factors, like older age, black ethnicity, a family history of disease, an increased body mass index and obesity. In this way, the risk of prostate cancer development may be reduced through the consumption of a healthy diet full of fruits and vegetables, practice of physical exercise and maintenance of a healthy weight.

Despite several approaches are available for prostate cancer treatment, the number of prostate cancer deaths is continuously increasing, which emphasizes the need to search for new methods for precocious diagnosis and more effective treatment. The animal models, including rodents, have greatly contributed to the study of biopathology, and the prevention and treatment of prostate cancer.

This Special Issue aims to publish original research works, case reports or reviews concerning the diagnosis, treatment and prognosis of prostate cancer, highlighting new advances in this field.  

Articles in this special edition include:

Prostate Cancer Aggressiveness Prediction Using CT Images

Association of Circulating Tumor Cells with Inflammatory and Biomarkers in the Blood of Patients with Metastatic Castration-Resistant Prostate Cancer

Site-Specific and Common Prostate Cancer Metastasis Genes as Suggested by Meta-Analysis of Gene Expression Data

Prostate Cancer Diagnostic Algorithm as a “Road Map” from the First Stratification of the Patient to the Final Treatment Decision

Full details from Life

The Urine Biomarker PUR-4 Is Positively Associated with the Amount of Gleason 4 in Human Prostate Cancers

Ball, R. Y. et al | 2021 | The Urine Biomarker PUR-4 Is Positively Associated with the Amount of Gleason 4 in Human Prostate Cancers | Life | 11 | 11| 1172|  https://doi.org/10.3390/life11111172

To understand how PUR-4- the highest-risk category in the The Prostate Urine Risk (PUR) biomarker, a four-group classifier related to the structure of the cancerous prostate, the researchers behind this study examined its relationship to the amounts and grade of tumor in biopsy-sampled prostates and in a series of radical prostatectomy specimens. A strong association was observed by the experts, between an increasing amount of Gleason pattern 4 cancer and increasing PUR-4 signal. These data suggest that the PUR-4 signature could provide useful additional information in determining the amount of clinically significant tumor within a prostate and thereby help guide the patient treatment pathway with essential information for triage, improved management and prognostic utility.

Abstract

The Prostate Urine Risk (PUR) biomarker is a four-group classifier for predicting outcome in patients prior to biopsy and for men on active surveillance. The four categories correspond to the probabilities of the presence of normal tissue (PUR-1), D’Amico low-risk (PUR-2), intermediate-risk (PUR-3), and high-risk (PUR-4) prostate cancer. In the current study we investigate how the PUR-4 status is linked to Gleason grade, prostate volume, and tumor volume as assessed from biopsy (n equal to 215) and prostatectomy (n equal to 9) samples. For biopsy data PUR-4 status alone was linked to Gleason Grade group (GG) (Spearman’s, ρ equal to 0.58, p less than 0.001 trend). To assess the impact of tumor volume each GG was dichotomized into Small and Large volume cancers relative to median volume. For GG1 (Gleason Pattern 3 + 3) cancers volume had no impact on PUR-4 status. In contrast for GG2 (3 + 4) and GG3 (4 + 3) cancers PUR-4 levels increased in large volume cancers with statistical significance observed for GG2 (p equal to 0.005; Games-Howell). These data indicated that PUR-4 status is linked to the presence of Gleason Pattern 4. To test this observation tumor burden and Gleason Pattern were assessed in nine surgically removed and sectioned prostates allowing reconstruction of 3D maps. PUR-4 was not correlated with Gleason Pattern 3 amount, total tumor volume or prostate size. A strong correlation was observed between amount of Gleason Pattern 4 tumor and PUR-4 signature (r equal to 0.71, p equal to 0.034, Pearson’s). These observations shed light on the biological significance of the PUR biomarker and support its use as a non-invasive means of assessing the presence of clinically significant prostate cancer. (Source: Ball et al, 2021).

The Urine Biomarker PUR-4 Is Positively Associated with the Amount of Gleason 4 in Human Prostate Cancers [paper]

This article is part of a special issue in Life focusing on prostate cancer

See also:

MedScape Urine Test for Prostate Cancer Signals Amount of Aggressive Tumor [news story]

NHS responds to highest number of 999 calls on record

NHS England | November 2021 | NHS responds to highest number of 999 calls on record

Figures show that the NHS 999 services had their busiest month on record in October 2021, as staff answered a record 1 012 143 calls.

Ambulance staff responded to more than 82 000 life threatening call-outs, an increase of more than 20,000 on the previous high for October in 2019 (61 561), as well as dealing with the surge in 999 calls.

Major A&Es treated over 1.4 million people during October – the highest ever for the month and third highest of all time.

The NHS COVID Vaccination Programme delivered more than 7.5 million lifesaving jabs in the same month, including more than 5.9 million top-up jabs.

The health service carried out 1.9 million diagnostic tests and 1.3 million patients started consultant-led treatment during September, that was compared with 1.7 million tests and 1.1 million treatments in the same month last year.

Latest monthly performance data also shows cancer referrals were at a near record high.

Some 231,421 people underwent urgent checks for cancer in September while 27,342 began treatment, up from 201,013 and 24,801 respectively in the same month last year.

The increase in activity came as NHS 111 also saw demand increase to an average of 63,000 calls a day in September, up almost 2,000 a day on the previous month. (Source: NHS England)

NHS England NHS responds to highest number of 999 calls on record