Prostate cancerImplementing NICE guidance

2008

NICE clinical guideline 58

What this presentation covers

Background

Key priorities for implementation

Costs and savings

Discussion

Find out more

Background

Prostate cancer is the most common cancer in men, it accounts for 24% of all new male cancer diagnoses

The annual incidence in England is about 29,000 cases

Evidence shows practice variation and patchy availability of treatments and procedures around the country

Treatment and care should take into account the man’s needs and preferences

Communication and support

Healthcare professionals should:

• inform men and their partners or carers about the effects of prostate cancer and the treatment options on their sexual function, physical appearance, continence and other aspects of masculinity

• support men and their partners or carers in making treatment decisions, taking into account the effects on quality of life as well as survival.

Diagnosing prostate cancer: definitions

Prostate specific antigen

A protein produced by the prostate gland which tends to be higher in men with prostate cancer

Gleason score

An internationally agreed grading system which gives an overall cell abnormality score to help predict prostate tumour progression

Clinical stage

A classification system (TNM) is used in prostate cancer to describe: - the extent of the primary tumour (T)- the absence or presence of spread to nearby lymph nodes (N)- the absence or presence of distant spread, or metastasis (M)

Diagnosing prostate cancer: biopsy

To help men decide, healthcare professionals should discuss with them their:

- prostate specific antigen (PSA) level

- digital rectal examination (DRE) findings

- comorbidities

- risk factors (age/ethnicity/family history)

- history of a previous negative biopsy

Serum PSA alone should not automatically lead to biopsy, as it is a poor discriminator of the presence of cancer

Localised prostate cancer: treatment options

Active surveillance

Men with low-risk localised prostate cancer who are considered suitable for radical treatment should first be offered active surveillance

Risk stratification criteria for men with localised prostate cancer

PSA (ng/ml)

Gleason score

Clinical stage

Low risk < 10 and ≤ 6 and T1−T2a

Intermediate risk

10−20 or 7 or T2b−T2c

High risk > 20 or 8−10 or T3−T4

Radical treatment (1)

Men undergoing radical external beam radiotherapy for localised prostate cancer should receive a minimum dose of 74 Gy to the prostate at no more than 2 Gy per fraction

This may also apply to some men with locally advanced prostate cancer

Radical treatment (2)

High-intensity focused ultrasound (HIFU) and cryotherapy

• Not recommended other than in controlled clinical trials

• NICE has had discussions with the British Association of Urological Surgeons (BAUS) and relevant research bodies

• HIFU trial recruiting (June 2008)

• Cryotherapy trial currently in design (June 2008)

Managing the side effects of treatment

Healthcare professionals should:

• ensure that men and their partners have early and ongoing access to specialist erectile dysfunction services

• ensure that men with troublesome urinary symptoms after treatment have access to specialist continence services

• refer men with intractable stress incontinence to a specialist surgeon for consideration of an artificial urinary sphincter.

Managing relapse after radical treatment

Biochemical relapse (rising prostate specific antigen) alone should not necessarily prompt an immediate change in treatment

Hormonal therapy is not routinely recommended for men with prostate cancer who have a biochemical relapse unless they have:

•symptomatic local disease progression, or•any proven metastases, or •a PSA doubling time < 3 months.

Metastatic prostate cancer: hormone-refractory disease

When men with prostate cancer develop biochemical evidence of hormone-refractory disease, their treatment options should be discussed by the urological cancer multidisciplinary team with a view to seeking an oncologist and/or specialist palliative care opinion, as appropriate

Metastatic prostate cancer: palliative care

Healthcare professionals should ensure that palliative care is available when needed and is not limited to the end of life

It should not be restricted to being associated with hospice care

Costs and savings per 100,000 male population

Recommendations with significant resource impact

Annual cost (saving)

£000

Decision whether or not to biopsy (9.0)

Offering active surveillance (4.1)

Course of radical external beam radiotherapy 23.8

Hormonal therapy (20.7)

Total saving (10.1)

Discussion

Which recommendations will require a change in practice for you?

Which existing practices that are no longer recommended allow the transfer of resources?

What is the current service provision for erectile dysfunction, specialist continence radiology and palliative care services?

How do we ensure that patients and staff understand the difference between watchful waiting, active surveillance and the choices of treatment?

How do we do effectively support patients in deciding whether to have a prostate biopsy?

Find out more

Visit www.nice.org.uk/cg058 for:

Other guideline formats

Costing report and template

Audit support

Implementation advice