1. Prostatectomy operations in England South West Public Health Observatory www.swpho.nhs.uk Trends in the use of radical prostatectomy in England Sean McPhail 1*, Caroline Trotter 1,2 Tanya Cross 1, Roy Maxwell 1,2, and Julia Verne 1 1: South West Public Health Observatory, 2: Department of Social Medicine, University of Bristol *sean.mcphail@swpho.nhs.uk Background In England, prostate cancer is the most commonly diagnosed cancer in men and the second most common cause of cancer death. Despite this the progress of the disease and the best way of managing it clinically are not well understood. Current NICE Guidance states that radical prostatectomy should be discussed with men whose tumours are confined to the prostate and who would be expected to live for more than 10 years if they did not have prostate cancer (1). This guidance allows radical prostatectomy for a wide range of patients. Given the rapidly changing nature of prostate cancer care following the spread of PSA testing it is uncertain whether current practices are appropriate. Conclusions The number of men diagnosed with prostate cancer increased rapidly with the spread of PSA testing. This rise has been tracked by the increase in prostatectomy procedures, strongly implying that many PSA-detected cases are being treated with prostatectomy. Not enough is known about the outcome of different prostate cancer treatments, including radical prostatectomy. Crucial results from randomised clinical trials, such as the ProtecT study (7), will not be available for several years. Prostatectomy carries a risk of serious post operative morbidity, and in the absence of strong evidence of benefit, the continued rise in the number of prostatectomy operations risks doing more harm than good. Clinically significant and insignificant cancers Some types of prostate cancer grow slowly and will not become a problem during a man’s lifetime (clinically insignificant) but other types are more aggressive and are potentially life-threatening (clinically significant). The health implications of a diagnosis of prostate cancer depend on a man’s age and the stage of the cancer at diagnosis (2). A recent study has suggested that the risk of death over 15 years for men diagnosed with low grade prostate cancer is less than 1% (3). References (1) NICE. Improving Outcomes in Urological Cancers, 2002 (2) Albertsen P et al. 20 year outcomes following conservative management of clinically localized prostate cancer, JAMA 2005 293:2095-2101 (3) Parker C et al. A model of the natural history of screen-detected prostate cancer, and the effect of radical treatment on overall survival. British Journal of Cancer 2006, 94: 1361-1368 (4) Hospital Episode Statistics, http://www.hesonline.org.ukhttp://www.hesonline.org.uk Prostate cancer incidence and mortality Potential side effects of prostatectomy As a serious operation, prostatectomy carries a risk of significant surgical morbidity of 16.5%, and a 0.3% risk of mortality (5). Long term side effects include: Impotence - approximately 65% long term compared to approximately 25% in a similar control group (6) Incontinence - approximately 15% long term compared to 5% or less in a similar control group (6) The number of operations performed has more than doubled between 1997/98 and 2004/05 (4). The number of men diagnosed with prostate cancer per year increased abruptly with the widespread use of PSA testing in the late 1990’s. However the mortality due to prostate cancer has not changed significantly in the last decade. The PSA test The Prostate Specific Antigen test measures the level of an enzyme in the blood. An increasing amount is present when the prostate enlarges due to the presence of a tumour. The test is cheap and easy to administer but unfortunately it does not discriminate between clinically significant and insignificant cancer. Therefore many men with very low grade prostate cancer test positive and are subsequently drawn into clinical management of their cancer. (5) British Association of Urological Surgeons. Analyses of 2004 Complex Operation data. http://www.baus.org.uk/Display.aspx?item=319http://www.baus.org.uk/Display.aspx?item=319 (6) Miller DC et al. Long-term outcomes Among Localized Prostate Cancer Survivors.Journal of Clinical Oncology 2003, 23:2772-2780 (7) Donovan J et al. Prostate testing for cancer and treatment (ProtecT) feasibility study. Health Technol Assess 2003, 7: 1-88 0 5000 10000 15000 20000 25000 30000 1992199419961998200020022004 MortalityIncidence Incidence and Mortality in England Number of cases/deaths Prostatectomy operations in England (all types) 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 1997- 1998 1998- 1999 1999- 2000 2000- 2001 2001- 2002 2002- 2003 2003- 2004 2004- 2005 Number of operations