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National Collaborating Centre for Cancer (UK). Prostate Cancer: Diagnosis and Treatment. Cardiff (UK): National Collaborating Centre for Cancer (UK); 2008 Feb. (NICE Clinical Guidelines, No. 58.)

1Epidemiology

1.1. Introduction

Prostate cancer is perhaps the most enigmatic malignancy in men. If men lived long enough, they would almost all die with histological evidence of the disease being present (Selly et al. 1997). However, only 3% of men die as a consequence of prostate cancer.

This chapter sets out the basic epidemiology of prostate cancer, its relevance to the men in whom it is diagnosed and its impact on health services. The full epidemiology report appears on the CD-ROM that accompanies this guideline.

1.2. Incidence

Prostate cancer is the most common cancer in men and now makes up approximately 25% of the new diagnoses of malignant cancer in men in England and Wales. The incidence appears to be rising (Figure 1.1).

Figure 1.1. Directly Age Standardised Rate (ASR) of prostate cancer incidence in England and Wales (to European standard population). Data source: Office of National Statistics MB1 series and Welsh Cancer Intelligence unit and Surveillance (WCISU).

Figure 1.1

Directly Age Standardised Rate (ASR) of prostate cancer incidence in England and Wales (to European standard population). Data source: Office of National Statistics MB1 series and Welsh Cancer Intelligence unit and Surveillance (WCISU).

Between 1996 and 2004 the age standardised incidence rate of prostate cancer increased in all cancer networks in England and Wales1. In England the average increase was 20% whilst in Wales it was 49%. There was a range of increases in individual networks between 1% and 66%. These increased rates may result from differences in local policy for PSA testing.

From age 50 the incidence increases approximately linearly with age and data indicates that 1% of all men in England and Wales aged 85 or over are diagnosed with prostate cancer each year (Figure 1.2). This increase is largest in the 65–69 age band indicating that the uptake of PSA testing and subsequent diagnosis of cancer is higher than in younger men.

Figure 1.2. Rate of diagnosis of prostate cancer by 5-year age band. Data source: cancer registries of England and Wales.

Figure 1.2

Rate of diagnosis of prostate cancer by 5-year age band. Data source: cancer registries of England and Wales.

Since 1996 the proportion of new diagnoses with a total Gleason score of 6 or less has decreased. This is explained by a shift in pathological reporting practice (University of Liverpool, 2003). The proportion of tumours with a Gleason score of 8 or more has remained approximately constant at between 20 and 25% but the proportion of Gleason score 7 tumours is increasing, from less than 20% in 1996 to more than 30% in 2005 (Figure 1.3).

Figure 1.3. Stacked plot of prostate cancer diagnoses broken down by Gleason score (where the score is recorded) for the South West of England. Data source: British Association of Urological Surgeons registry database and South West Public Health Observatory.

Figure 1.3

Stacked plot of prostate cancer diagnoses broken down by Gleason score (where the score is recorded) for the South West of England. Data source: British Association of Urological Surgeons registry database and South West Public Health Observatory.

There is a higher incidence of prostate cancer in the less socio-economically deprived areas, which is assumed to be due to higher rates of prostate specific antigen (PSA) testing among affluent men2.

There is strong evidence to support a higher incidence in men of African or Caribbean origin (GLOBOCAN 2002). There is a significant, 3-fold increase in the incidence of prostate cancer in black men compared to white men irrespective of the country of origin of the black man (Ben-Shlomo et al. 2007).

1.3. Mortality

Prostate cancer accounts for the second highest number of deaths of any male with cancer in England and Wales below only lung cancer. Between 1996 and 2005 it comprised 13% of all cancer deaths in men.

There has been a statistically significant decline in the age standardised mortality rate between 1993 and 2005 (Figure 1.4). However the number of deaths annually has remained roughly stable. This indicates that the declining mortality rate is counteracted by the ageing of the population.

Figure 1.4. Directly Age Standardised mortality Rate (to European Standard population) and number of deaths from prostate cancer in England and Wales 1984–2005. Data source: Office of National Statistics.

Figure 1.4

Directly Age Standardised mortality Rate (to European Standard population) and number of deaths from prostate cancer in England and Wales 1984–2005. Data source: Office of National Statistics.

There is no observable effect on the mortality of the large rise in incidence since the year 2000.

There is a variation in mortality across cancer networks in England and Wales during the period of decline in national mortality rate, although there is no consistent regional variation3.

The majority of men who die of prostate cancer do so at an advanced age when the probability of death from other causes is high. Therefore any treatment that delays their death can plausibly reduce the apparent mortality due to prostate cancer.

Data from the American Surveillance, Epidemiology and End Results (SEER) database (www.seer.cancer.gov/) and the UK PROCESS study (Ben-Schlomo, Personal communication June 2007) show that prostate cancer mortality varies significantly by race. Prostate cancer mortality is higher in black men than white men, driven by the markedly higher incidence. The fatality ratio however is not significantly different.

1.4. Survival

In most cases prostate cancer has a long preclinical phase between onset and the appearance of clinical symptoms. The survival time after a symptomatic diagnosis is also long. Therefore the measured survival time for prostate cancer is easily confounded by lead time bias, introduced by bringing forward the point of diagnosis with the extended use of biochemical screening.

Any measure of prostate cancer survival, especially one taken on a population basis, reflects changes in patient prognosis and a lead-time effect due to changes in diagnostic practice. Differences in survival between countries are therefore more likely to be the result of differences in diagnostic practice than the clinically relevant experience of the patient.

1.5. Diagnosis and Investigations

Four procedures are commonly used to diagnose prostate cancer: digital rectal examination (DRE), the PSA blood test, trans-rectal ultrasound (TRUS) and needle biopsy. DRE procedures are not well recorded in any centralised data source.

The level of PSA testing is not centrally monitored in England and Wales. However, several surveys of GP practices and pathology laboratories have been carried out in recent years. There has been a significant increase in the rate of PSA testing from 1999 to 2002 (Melia et al. 2003; Melia et al. 2004). The rate of PSA testing decreased with increasing socio-economic deprivation, and independently decreased with increasing proportion of either black or Asian populations. Approximately 50% of PSA tests are ordered by GPs with a third of these tests being in asymptomatic men.

The number of needle biopsies performed nationally is also not well recorded as they are commonly performed as outpatient procedures and the data may not be reliably captured. An estimate of the number of needle biopsies performed in England and Wales is between 56,000 and 89,000 per year. This is equivalent to 1 million cores needing histological assessment in undiagnosed men.

1.6. Surgery

The primary curative surgical procedure for prostate cancer is the total removal of the prostate, known as prostatectomy. The number of radical prostatectomy operations on men with prostate cancer more than trebled between 1997–98 and 2004–05 (Figure 1.5), with a significant rise in all age groups. The number of operations is rising most quickly in the 60–64 and 65–69 age groups.

Figure 1.5. Numbers of all radical prostatectomy and orchidectomy operations on prostate cancer patients in England. Prostatectomies defined by OPCS code M61, Orchidectomies are defined by OPCS codes N05 and N06. Data source: HES data provided by NATCanSAT.

Figure 1.5

Numbers of all radical prostatectomy and orchidectomy operations on prostate cancer patients in England. Prostatectomies defined by OPCS code M61, Orchidectomies are defined by OPCS codes N05 and N06. Data source: HES data provided by NATCanSAT.

Metastatic prostate cancer can be treated by the surgical removal of the testes, otherwise known as orchidectomy (Cancer Research UK). This suppresses the level of testosterone in the body and retards the growth of prostate tumours. Surgical orchidectomy is becoming a less common way of treating prostate cancer (see Figure 1.5). From 1997–98 to 2003–04 the number of operations which took place on men with metastatic prostate cancer reduced by 75%. Medical castration, using hormonal therapy, has replaced orchidectomy in most cases.

There is a 4-fold regional variation in the radical prostatectomy rate between cancer networks. After age-standardising the rates of radical prostatectomy, there is still a large variation which confirms that the observed trends are not due to age difference between networks or changes in the age structure of the population.

The majority of prostatectomies recorded on the British Association of Urological Surgeons (BAUS) cancer registry are performed on men with a Gleason score of 6 or 7 (i.e. lower grade tumours)4. This fraction has remained approximately constant (linear regression shows no significant trend) even while the number of prostatectomies has doubled.

The total number of consultants to which surgical episodes containing either a prostatectomy or cystectomy, in patients diagnosed with prostate or bladder cancer, are registered is approximately constant over the eight years of recorded data. There is a significant drop in the number of consultants with fewer than ten such episodes between 1997–98 and 2004–05, from 86% to 56%. However this is a linear trend with no obvious effect following the publication of the NICE guidance on ‘Improving outcomes in urological cancers’ (NICE 2002). It is therefore likely that the increasing total volume of prostatectomies is driving the reduction in the number of consultants performing a small number of procedures per year. The number of consultants performing these procedures has stayed remarkable consistent, between 371 and 387.

1.7. Hormonal Therapy

Hormonal therapy prescriptions have increased dramatically since the mid-1980s5. Anti-androgen prescriptions rose from zero prior to 1983 to approximately 150,000 per annum in 2004. Prescriptions for luteinising hormone-releasing hormone agonists (LHRHa) increased from zero prior to 1986 to over 300,000 in 2004. These increases are due to medical castration, using hormonal therapy, replacing orchidectomy in most cases. Oestrogen prescriptions declined between the 1970s and mid 1990s, falling to a minimum of 14,000 prescriptions in 1996 but increased between 1996 and 2004.

Hormonal therapy constitutes the biggest single area of cancer drug spending. The total cost of all prescriptions recorded by the NHSBSA PPD in 2004 was £8.1 billion (Department of Health 2004). Of this £292 million was recorded under BNF section 8, ‘Malignant Disease & Immuno-suppression’ with hormone treatment for prostate cancer making up approximately 40%.

1.8. Radiotherapy

The large number of radiotherapy procedures carried out on patients with Gleason score 6 and 7 tumours suggests that radical radiotherapy is a more common treatment than prostatectomy6. Clear differences in the patterns of dose and fractionation occur across NHS trusts, indicating a variation in practice7.

1.9. The Findings of Cancer Peer Review of Urology Cancer Teams in England 2004 – 2007

Following the publication of the NICE guidance on ‘Improving outcomes in urological cancers’ (NICE 2002), a process was put in place in England (as for other cancer sites covered by Service Guidance from the Department of Health or NICE) to monitor the progress made in implementing the changes in service organisation and delivery which had been recommended. Each cancer network in England and all the designated local and specialist urological cancer teams were reviewed by a team of clinical peers between November 2004 and May 2007.

The findings of these reviews were that the implementation of the guidance was slow and incomplete with almost one third of networks not having compliant action plans for the implementation of the guidance. This was mostly due to the designated specialist urology cancer teams serving populations of less than 1 million. Some networks have still not submitted agreed plans. There was also frequent failure to comply with the key recommendation about surgeons performing fewer than five radical prostatectomies per year.

Local urology cancer teams performed particularly poorly for attendance of core members at multidisciplinary team (MDT) meetings, cover arrangements, referral guidelines, patient experience and service improvement. One quarter of teams did not have complete core membership, most notably for clinical oncology (11%). Oncology attendance at MDT meetings was deficient in 23% of teams. Attendance of radiologists and pathologists was also relatively low.

Overall levels of compliance with the guidance were lower for urology teams than for all other reviewed cancer sites (e.g. breast, colorectal and gynaecology).

The average workload of clinical nurse specialists (CNS) in areas excluding urology is 110 new cases per year per CNS while in Urology it is 203 new cases per year per CNS (Honnor et al. 2006).

Since the key recommendations of the 2002 ‘Improving outcomes in urological cancers’ guidance there has been a rapid increase in the number of patients accrued to clinical trials, which can be attributed mainly to the creation of the NCRI and the NCRN.

References

  1. Ben-Shlomo Y, et al. The Risk of Prostate Cancer amongst Black Men in the United Kingdom: The PROCESS Cohort Study. European Urology. 2007;Mar 1 [Epub ahead of print] [PubMed: 17368710]
  2. Cancer Research UK. Orchidectomy for Prostate Cancer. Available online at www​.cancerhelp.org.uk/help/default​.asp?page=2875.
  3. Department of Health. Prescription Cost Analysis: England 2004 Department of Health. 2004. [accessed 8 April 2005]. Available online at www​.dh.gov.uk/en/Publicationsandstatistics​/Publications/PublicationsStatistics​/DH_4107504.
  4. GLOBOCAN. Data held by the Descriptive Epidemiology Groups of IARC and provided by CANCER. Mondial. 2002. Available online at www-dep​.iarc.fr/
  5. Honnor C, Trevett P. Clinical Nurse Specialist Workforce Mapping. Presented at the National Prostate Cancer Conference 2006; London. 2006.
  6. Melia, et al. Study to assess the rate of PSA testing in men with no previous diagnosis of prostate cancer. Report to the Department of Health. 2003. available online at: www​.cancerscreening.nhs​.uk/prostate/psa-mapping.doc.
  7. Melia, et al. Rates of prostate-specific antigen testing in general practice in England and Wales in asymptomatic and symptomatic patients: a cross-sectional study. BJU International. 2004;94:51–56. [PubMed: 15217430]
  8. National Institute for Health and Clinical Excellence. NICE cancer service guidance. London: National Institute for Health and Clinical Excellence; 2002. Improving Outcomes in Urological Cancers.
  9. Selley S, Donovan J, Faulkner A, Coast J, Gillatt D. Diagnosis, management and screening of early localised prostate cancer. Health Technology Assessment. 1997;1(2) [PubMed: 9414541]
  10. University of Liverpool. Towards a Consensus Protocol on Prostate Biopsies: Indications, Techniques and Assessment. Conference Report; 6th June 2003; 2003. p. 21. Available at www​.cancerscreening.nhs​.uk/prostate/conference-report.pdf.

Data Source: cancer registries of England and Wales.

Data Source: cancer registries of England and Wales.

Data Source: Office of National Statistics and Ordnance Survey.

Data source: BAUS cancer registry.

Data Source: IMS Health Medical Data Index, London.

Data Source: South West Public Health Observatory and RES dataset provided by NatCanSAT.

Data Source: RES data provided by NATCanSAT.

Footnotes

1

Data Source: cancer registries of England and Wales.

2

Data Source: cancer registries of England and Wales.

3

Data Source: Office of National Statistics and Ordnance Survey.

4

Data source: BAUS cancer registry.

5

Data Source: IMS Health Medical Data Index, London.

6

Data Source: South West Public Health Observatory and RES dataset provided by NatCanSAT.

7

Data Source: RES data provided by NATCanSAT.

Copyright © 2008, National Collaborating Centre for Cancer.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licenses issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Cover of Prostate Cancer
Prostate Cancer: Diagnosis and Treatment.
NICE Clinical Guidelines, No. 58.
National Collaborating Centre for Cancer (UK).

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