National Prostate Cancer Audit: Annual Report 2018

Health Quality Improvement Partnership | February 2019 | National Prostate Cancer Audit: Annual Report 2018

Health Quality Improvement Partnership (HQIP) have published the results of their national prostate cancer audit in the report National Prostate Cancer Audit: Annual Report 2018.

There are over 40,000 new diagnoses of prostate cancer every year in the UK and over 11,000 men die because of the disease. This makes prostate cancer the second most common cause of cancer-related death for men in the UK.

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Image source: hqip.org.uk

 

This report presents results for men diagnosed with prostate cancer between 1st April 2016 and 31st March 2017 in England and Wales. It reports on specific diagnostic, staging and treatment information as well as core performance indicators in order to compare diagnostic specialist MDTs or treatment centres. This is the first report which combines English and Welsh data as well as using patient-reported experience (PREMs) and outcome measures (PROMs) as performance indicators.

Reporting on a total of 14 performance indicators, the NPCA is the first national audit which is able to report on process and outcome measures from all aspects of the care pathway for men with prostate cancer (Source: HQIP).

Download it from HQIP

Radiotherapy benefits some men whose prostate cancer has spread to their bones

NIHR | January 2019 | Radiotherapy benefits some men whose prostate cancer has spread to their bones

An NIHR Signal highlights a trial part-funded by NIHR, published in October 2018, which compared the effects of standard care with or without radiotherapy to the prostate on overall survival for over 2000 men.  The standard treatment for men with metastatic prostate cancer is anti-androgen hormone therapy, and this is sometimes combined with chemotherapy. Radiotherapy of the prostate itself is only usually used for symptom relief.

The trial found that radiotherapy improved three-year survival rate from 73 to 81% in men with a limited number of metastases confined to the spine and pelvis. In this group, it also prevented any disease progression over three years in half of them compared to a third on standard care.

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STAMPEDE was a randomised controlled trial  that took place in more than 100 hospitals in Switzerland and the UK. Over 2,000 men with newly diagnosed prostate cancer with metastases, confirmed on a bone scan, were recruited to the study.

Participants were randomised to either standard care (lifelong anti-androgen hormone therapy, with or without chemotherapy using docetaxel) or standard care plus radiotherapy to the prostate.

This study adds further evidence that radiotherapy could benefit men with newly diagnosed prostate cancer with local metastases.

The trial used CT and bone scans to define low and high metastatic burden. PET scans, which can detect smaller cancer deposits, are becoming widely available and may allocate people differently.

Treating the primary once the cancer has metastasised has conventionally thought to be futile. This has been challenged by finding that in low metastatic burden prostate cancer, radiotherapy to the primary significantly improves survival and should become standard of care.

This study raises the issue whether this would apply to other cancers and interesting biological questions as to the mechanism. Is it an effect of debulking the primary?  Is it immunological?  Is it due to reducing secondary spread of aggressive clones?

It seems we have underestimated in prostate cancer, the impact of local control in the setting of metastatic disease

Professor Robert Huddart, Reader and Honorary Consultant, Royal Marsden NHS Foundation Trust 

(Source: NIHR)

NIHR Radiotherapy benefits some men whose prostate cancer has spread to their bones

 

 Parker, C.  et al | 2018| Radiotherapy to the primary tumour for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial|  The Lancet| 

 

Background
Based on previous findings, we hypothesised that radiotherapy to the prostate would improve overall survival in men with metastatic prostate cancer, and that the benefit would be greatest in patients with a low metastatic burden. We aimed to compare standard of care for metastatic prostate cancer, with and without radiotherapy.
Methods
We did a randomised controlled phase 3 trial at 117 hospitals in Switzerland and the UK. Eligible patients had newly diagnosed metastatic prostate cancer. We randomly allocated patients open-label in a 1:1 ratio to standard of care (control group) or standard of care and radiotherapy (radiotherapy group). Randomisation was stratified by hospital, age at randomisation, nodal involvement, WHO performance status, planned androgen deprivation therapy, planned docetaxel use (from December, 2015), and regular aspirin or non-steroidal anti-inflammatory drug use. Standard of care was lifelong androgen deprivation therapy, with up-front docetaxel permitted from December, 2015. Men allocated radiotherapy received either a daily (55 Gy in 20 fractions over 4 weeks) or weekly (36 Gy in six fractions over 6 weeks) schedule that was nominated before randomisation. The primary outcome was overall survival, measured as the number of deaths; this analysis had 90% power with a one-sided α of 2·5% for a hazard ratio (HR) of 0·75. Secondary outcomes were failure-free survival, progression-free survival, metastatic progression-free survival, prostate cancer-specific survival, and symptomatic local event-free survival. Analyses used Cox proportional hazards and flexible parametric models, adjusted for stratification factors. The primary outcome analysis was by intention to treat. Two prespecified subgroup analyses tested the effects of prostate radiotherapy by baseline metastatic burden and radiotherapy schedule.
Findings
Between Jan 22, 2013, and Sept 2, 2016, 2061 men underwent randomisation, 1029 were allocated the control and 1032 radiotherapy. Allocated groups were balanced, with a median age of 68 years (IQR 63–73) and median amount of prostate-specific antigen of 97 ng/mL (33–315). 367 (18%) patients received early docetaxel. 1082 (52%) participants nominated the daily radiotherapy schedule before randomisation and 979 (48%) the weekly schedule. 819 (40%) men had a low metastatic burden, 1120 (54%) had a high metastatic burden, and the metastatic burden was unknown for 122 (6%). Radiotherapy improved failure-free survival but not overall survival. Radiotherapy was well tolerated, with 48 (5%) adverse events (Radiation Therapy Oncology Group grade 3–4) reported during radiotherapy and 37 (4%) after radiotherapy. The proportion reporting at least one severe adverse event (Common Terminology Criteria for Adverse Events grade 3 or worse) was similar by treatment group in the safety population (398 [38%] with control and 380 [39%] with radiotherapy).
Interpretation
Radiotherapy to the prostate did not improve overall survival for unselected patients with newly diagnosed metastatic prostate cancer.

Prostate cancer ultrasound treatment as effective as surgery or radiotherapy

Using high energy ultrasound beams to destroy prostate cancer tumours may be as effective as surgery or radiotherapy, but with fewer side effects | European Urology | via ScienceDaily

A new study, carried out at six hospitals across the UK, tracked 625 men with prostate cancer who received a type of treatment called high-intensity focused ultrasound (HIFU).

The research, published in the journal European Urology, is the largest ever study of HIFU treatment used to target prostate tumours. The treatment is similar to a ‘lumpectomy’ for other cancers — where doctors remove only tumour cells, leaving as much healthy tissue as possible.

The findings, from a number of institutions including Imperial College London and University College London, found that after five years the cancer survival rate from HIFU was 100 per cent. Approximately, 1 in 10 men needed further treatment. The cancer survival rate from surgery and radiotherapy is also 100 per cent at five years.

The research also showed the risk of side effects of HIFU, such as urinary incontinence and erectile dysfunction, were lower than other treatment options, at 2 per cent and 15 per cent respectively.

Full story at ScienceDaily

Journal reference: Guillaumier, S. et al. | A Multicentre Study of 5-year Outcomes Following Focal Therapy in Treating Clinically Significant Nonmetastatic Prostate Cancer |European Urology, 2018

Trial of prostate cancer saliva test

A new test which uses saliva to identify men with a high risk of developing prostate cancer has been devised by international researchers led by scientists at the Institute of Cancer Research, London.  The DNA test which identifies the 1 per cent who are at highest risk of prostate cancer, and are also six times more likely to develop the disease than the general population. The scientists will now trial the test in 300 patients across three GP practices in London (via The Institute of Cancer Research).

This study has recently been published in Nature Genetics 
Related:

NHS England Time to talk about the prostate cancer risk in black men and what we can do about it

In the media:

The Independent Prostate cancer saliva test could identify men more likely to contract killer disease

BBC News Prostate cancer spit test is trialled
Mirror Simple £10 saliva test to identify the men with 50% chance of developing prostate cancer

Guardian Trials begin of a saliva test for prostate cancer

Rapid cancer diagnostic and assessment pathways

NHS England has published three rapid cancer diagnostic and assessment pathways.  These documents set out how diagnosis within 14 days and diagnosis within 28 days can be achieved for the colorectal, lung, and prostate cancer pathways:

Implementing a timed colorectal cancer diagnostic pathway:

This handbook sets out how the 28 day standard can be achieved in colorectal cancer patients, in preparation for full monitoring against the standard from April 2020.

Implementing a timed lung cancer diagnostic pathway:

This handbook sets out how the 28 day standard can be achieved for lung cancer patients, in preparation for full monitoring against the standard from April 2020.

Implementing a timed prostate cancer diagnostic pathway:

This handbook sets out how the 28 day standard can be achieved for prostate cancer patients, in preparation for full monitoring against the standard from April 2020.

 

PM announces funding for research into prostate cancer

NIHR | April 2018 | Prime minister announces £75 million to support new prostate cancer research

Prostate cancer is the most common cancer in men. It has recently overtaken breast cancer as the third most common cause of cancer deaths in the UK. Now, £75 million funding has been announced by the Prime Minister to support new research into early diagnosis and treatment of prostate cancer.  This will be used to complement and extend research undertaken over the past 15 years by the NIHR, Cancer Research UK, Prostate Cancer UK and the Medical Research Council.

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New studies will  test treatments such as more precise radiotherapy, high-intensity focused ultrasound, and cryotherapy, alongside supportive  interventions including exercise and dietary advice.

They will also particularly target groups at higher risk of prostate cancer, such as black men – one in four of whom will develop the disease – men aged 50 or over, and men with a family history of prostate cancer.

Dr Jonathan Sheffield, Chief Executive at the NIHR Clinical Research Network, said:

“Clinical research brings us closer to the development of new treatments for prostate cancer patients.

“The NIHR will work closely with the NHS, life sciences industry, charities and research funders to support the recruitment of 40,000 men into research studies over the next five years. This will provide more opportunities for earlier access to new drugs and therapies, which will ultimately lead to improved diagnoses and care in the future.”

Full story at NIHR 

In the media:

ITV News PM announces £75m for prostate cancer research

The Guardian Theresa May launches £75m drive against prostate cancer

 

PSA Screening for Prostate Cancer

This article by Scott Gavura discusses the findings of a recent study which concluded that PSA screening for prostate cancer offers no survival benefits | via Science based Medicine

In this article, the author discusses the controversy surrounding PSA testing, and the findings of a new study, “Effect of a Low-Intensity PSA-Based Screening Intervention on Prostate Cancer Mortality”

The study included over 400,000 British men aged 50-69. Men were randomized into an RN appointment, where they were offered information on a PSA test, and if they chose, the test. The other group didn’t invite men for testing. After a 10 year period, the study found that there were more prostate cancers detected from this one-time testing. However, this group was no less likely to die from prostate cancer.

Given there was no difference in mortality between the two groups Gavura asks the question as to whether to PSA screen or not?

PSA
Image source: Cancer Research UK

Full article: Gavura, S | PSA Screening for Prostate Cancer | Science based Medicine

Link to the research: Martin, R. et al .| Effect of a Low-Intensity PSA-Based Screening Intervention on Prostate Cancer MortalityThe CAP Randomized Clinical Trial  | JAMA | 2018 Vol 319(9) p883–895

 

Related: Why a one-off PSA test for prostate cancer is doing men more harm than good | Cancer Research UK