NIHR | September 2020 |More precise classification of risk in prostate cancer reveals a huge variation in treatment
A new study identifies huge variation in the treatment of prostate cancer in English hospitals. in some hospitals, almost all are offered radiotherapy or surgery. In other hospitals, they are much more likely to be monitored with active surveillance and spared the possible effects of treatment. The researchers included more than 60000 men diagnosed with prostate cancer in almost 130 English hospitals between 2014 and 2017.
Current NICE guidelines classify prostate cancers in three tiers: low, intermediate or high risk. These are broad tiers, and not all men in the intermediate group are at the same risk of their cancer spreading. Therefore, some can potentially avoid treatment.
The Cambridge Prognostic Group (CPG) classification splits both intermediate- and high-risk groups in two, giving five tiers in total. Intermediate-risk cancers are divided into tumours with favourable and unfavourable outlooks. This study uses the CPG classification, categorising the patients into its’ five risk groups.
As expected, men in the low-risk group were least likely to have been treated with surgery or radiotherapy and most likely to have been on active surveillance. Men in the higher risk groups were most likely to have had surgery or radiotherapy. Variation between different hospitals’ approaches is not obvious in the broad intermediate category used by NICE. But when the researchers used the more detailed, five-tier CPG classification, they were able to consider those with favourable and unfavourable outlooks separately.
They found huge variations between hospitals in the treatments offered to men with intermediate-risk cancer. This was especially true for men with favourable intermediate-risk cancer. In some hospitals, less than a quarter of these men (23%) had surgery or radiotherapy. In others, almost all (97%) had surgery or radiotherapy. This suggests there is little agreement between hospitals in how these men should be managed.
NICE issued guidelines in 2019 which used the traditional three groupings of low-, intermediate- and high-risk prostate cancer. The guidelines do not divide intermediate-risk cancers into favourable and unfavourable groups. NICE recommends that men with intermediate-risk cancers should be offered surgery or radiotherapy.
Despite growing evidence in favour of active surveillance for favourable intermediate-risk prostate cancer, this approach is not recommended by NICE as initial treatment. But the guidelines state that it can be considered for men who choose not to have immediate radical treatment.
This work suggests that some men who received treatment for prostate cancer could have been managed with active surveillance. This piece of research also underlines how differences in treatment practices in men with intermediate-risk disease (CPG2 and CPG3) and in men with high-risk disease (CPG4 and CPGP5) that are not visible when using the traditional three-tiered risk classification (Source: NIHR).
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Read the published paper Risk stratification for prostate cancer management: value of the Cambridge Prognostic Group classification for assessing treatment allocation from BMC Medicine