Tag: Prostate cancer

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Editorial – Prostate cancer surgery vs radiation: has the fat lady sung?

February 26, 2014/by Tony Costello

The current article by Sun et al. [1] representing a number of institutions involved in prostate cancer treatment provision is thought-provoking and hypothesis-generating. The authors contention when mining Surveillance, Epidemiology and End Results data for 67 000 men who had localized prostate cancer between 1988 and 2005 is that those with a life expectancy >10 years had less likelihood of prostate cancer death when treated with surgery rather than by radiotherapy or being left to observation. The Scandinavians have already shown, in the randomized study by Hugosson et al. [2], that if you have your prostate cancer removed you have less likelihood of symptomatic local recurrence, lower likelihood of metastasis and progression, and a 29% reduced likelihood of prostate cancer death. The current study asks the question ‘Is radiation therapy less likely to provide a long-term cure for prostate cancer than surgery?’ and gives an answer in the affirmative.

The current paper, in its way, neatly encapsulates the contemporary angst generated in the community when prostate cancer screening, diagnosis and therapy are discussed. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial [3] allegedly shows no benefit from treatment over observation and contends perhaps that we surgeons and radiation oncologists are harm-workers, not life-savers. The PLCO has a 52% PSA contamination in its control arm [3]. That flawed trial compared screening with de facto screening and produced, in my view, a null hypothesis. How do we explain the paradox of a 44% reduction in prostate cancer-specific mortality between 1993 and 2009? How do we explain the disconnect between these trials and the facts? What do we do with the data not yet considered by the expert panels showing that early PSA testing at age <50 years is highly predictive of subsequent lethal prostate cancer? [4]

Clinicians are rapidly moving to an era of judicious risk assessment. This can only be done after biopsy is performed. We now frequently enrol patients with apparently indolent prostate cancer into surveillance protocols [5]. So the question should be ‘If the disease found on biopsy is moderate to high risk, and potentially lethal for that man, should we remove his prostate surgically or radiate it with intensity-modulated radiation therapy, brachytherapy, proton therapy, +/- hormone therapy?’.

As a surgeon I have an inherent dislike of combining hormone therapy in primary treatment. At least 50% of men in high-risk prostate cancer cohorts who receive radiation therapy also receive hormone therapy as adjuvant or neoadjuvant treatment [6]. Hormone therapy has a myriad of side effects. Even if the playing field was level between surgery and radiation therapy, the avoidance of hormone therapy as a first-line treatment gives surgery a seductive advantage.

The authors of the current report show a significant survival advantage in the cohort for surgery over radiation therapy and observation. There will never be a randomized trial between the two potentially curative treatment methods surgery and radiation. The scourge of commercial interest with spurious claims of superiority of one form of therapy over another, proton beam vs intensity-modulated radiation therapy, robotics vs high-intensity focused ultrasonography, means that we risk having our decisions regarding appropriate therapy formed by multibillion dollar technology companies with powerful marketing capacity. The current paper confirms what is self-evident: untreated localized prostate cancer can be lethal. Surgery and radiation therapy lower the morbidity and mortality from prostate cancer. Which is the better method of curative therapy is moot, but we do know that cure is very much predicated on the expertise and location of the practitioner.

We know mostly when and who to treat and what treatments work well. In my view, the prostate cancer testing debate resonates with the contemporary discussion about childhood immunization for infectious diseases. Some parents now, who clearly cannot remember the devastating epidemics of polio and other childhood illnesses, refuse to immunize their children. Prostate cancer practitioners who did not live in the quite recent era where the initial presentation of prostate cancer was bone metastasis +/− crush fracture to the vertebra and sometimes paraplegia, may be unknowingly steering us backwards.

At the recent 2013 AUA meeting, Adams et al. [7] reported on the fate of men not screened for prostate cancer, i.e. those men who presented with a PSA >100 ng/mL. There was a 3-year survival rate of 9.7%, a 19.7% cord compression rate and a 64% hospitalization rate. Those who do not learn the lessons of history are condemned to repeat them.

Anthony J. Costello
Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia

Read the full article

References

Sun M, Sammon JD, Becker A et al. Radical prostatectomy vs radiotherapy vs observation among older patients with clinically localized prostate cancer: a comparative effectiveness evaluation. BJU Int 2014; 113: 200–208
Hugosson J, Carlsson S, Aus G et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010; 11: 725–732
Andriole GL, Crawford ED, Grubb RL 3rd et al. Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. J Natl Cancer Inst 2012; 104: 125–132
Vickers AJ, Ulmert D, Sjoberg DD et al. Strategy for detection of prostate cancer based on relation between prostate specific antigen at age 40–55 and long term risk of metastasis: case-control study. BMJ 2013; 346: f2023
Evans SM, Millar JL, Davis ID et al. Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011. Med J Aust 2013; 198: 540–545
Cooperberg MR, Vickers AJ, Broering JM, Carroll PR. Comparative risk-adjusted mortality outcomes after primary surgery, radiotherapy, or androgen-deprivation therapy for localized prostate cancer. Cancer 2010; 116: 5226–5234
Adams W, Elliott CS, Reese JH. The fate of men presenting with PSA over 100 ng/mL: what happens when we do not screen for prostate cancer? AUA 2013. Abstract 2696

February #urojc summary: complications arising from radical treatment of prostate cancer

February 11, 2014/2 Comments/by Kate Linton

February 2014 twitter-based international urology journal club #urojc continued with the theme of prostate cancer. This time the discussion was based around the complications arising from radical treatment, and the paper was available open access courtesy of Lancet Oncology. Nam et al [1]
reported on a population based retrospective cohort study of men who underwent surgery or radiotherapy alone for prostate cancer in Ontario, Canada between 2002 to 2009. Instead of the traditional outcomes that usually include urinary incontinence and erectile dysfunction, they evaluated five other treatment related complications, hospital admissions; urological, rectal or anal procedures, open surgical procedures and secondary malignancies.

First author of the manuscript Rob Nam joined the discussion using the urojcguest twitter account. The journal club kicked off on Sunday 2^nd February at 8pm GMT time, quick off the mark was the ‘Queen of uro-twitter’.

There was quick agreement.

Patients who underwent surgery were more likely to undergo minimally invasive urological procedures, most commonly diagnostic cystoscopy, was this due to easy access to it for urologists?

However, there was comment from Canada where the study was performed that this may not necessarily be the case.

One of the limitations of the study was noted,

Stacy Loeb commented

and the lead author Robert Nam explained

The question was posed how much emphasis was placed on non ED, non urinary incontinence adverse events when counseling patients regarding prostate cancer treatment.

Ben Davies (the self-proclaimed King of uro-twitter) commented that bladder neck contracture was rare in the robotic prostatectomy era, which was the experience of others.

It was noted that the risk of secondary malignancy is probably underplayed due to the relatively short follow up in the study,

and secondary malignancies may sway the decision-making balance towards surgery

Stacy Loeb changed her avatar and commented that the study may not be generalizable to patients treated in the active surveillance era

The timing and severity of complications post treatment was discussed

It was commented that this is likely ‘real world’ data.

The side effects and their likely effects on quality of life were commented on, (from a surgical perspective).

In the same way that surgeons get different results for the same procedure, do radiation oncologists results differ.

A radiation oncologist joined in the discussion.

There was discussion regarding the mode of radiotherapy and variability in outcomes.

We were reminded that not all prostate cancer requires radical treatment.

Final thoughts in the last few minutes of the journal club came from Stacy Loeb.

Thanks to all who participated, looking forward to next months #urojc. Best tweet prize was won by @VMisrai and is complimentary registration to #WCE14 courtesy of @EndourolSoc. His tweet provided a particularly useful link alerted us to an article published on line ahead of print in the ESTRO Green Journal within hours of his tweet. Special acknowledgement again to Rob Nam who contributed as an author and also to brave attendance by Matt Katz whose insightful tweets gave us urologists much to think about.

Kate. D. Linton is a consultant urological surgeon at Sheffield Teaching Hospitals/Barnsley Hospital, UK. Twitter @linton_kate

Reference

Nam RK, Cheung P, Herschorn S, et al. Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study. Lancet Oncol 2014; 15: 223-31

Article of the Month: The Melbourne Consensus Statement

February 5, 2014/1 Comment/by admin Z.9

Every month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, we feature a video from Tony Costello and Declan Murphy discussing the Melbourne Statement.

If you only have time to read one article this month, it should be this one.

The Melbourne Consensus Statement on the early detection of prostate cancer

Declan G. Murphy^1,2,3, Thomas Ahlering⁴, William J. Catalona⁵, Helen Crowe^2,3, Jane Crowe³, Noel Clarke¹⁰, Matthew Cooperberg⁶, David Gillatt¹¹, Martin Gleave¹², Stacy Loeb⁷, Monique Roobol¹⁴, Oliver Sartor⁸, Tom Pickles¹³, Addie Wootten³, Patrick C. Walsh⁹ and Anthony J. Costello^2,3

¹Peter MacCallum Cancer Centre, ²Royal Melbourne Hospital, University of Melbourne, ³Epworth Prostate Centre, Australian Prostate Cancer Research Centre, Epworth Healthcare Richmond, Melbourne, Vic., Australia, ⁴School of Medicine, University of California, Irvine, ⁵Northwestern University Feinberg School of Medicine, Chicago, IL, ⁶Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, ⁷New York University, ⁸Tulane University School of Medicine, Tulane, ⁹The James Buchanan Brady Urological Institute, Johns Hopkins University, USA, ¹⁰The Christie Hospital, Manchester University, Manchester, ¹¹Bristol Urological Institute, University of Bristol, Bristol, UK, ¹²The Vancouver Prostate Centre, ¹³BC Cancer Agency, University of British Columbia, Vancouver, Canada, and ¹⁴Erasmus University Medical Centre, Rotterdam, The Netherlands

Read the full article

• Various conflicting guidelines and recommendations about prostate cancer screening and early detection have left both clinicians and their patients quite confused. At the Prostate Cancer World Congress held in Melbourne in August 2013, a multidisciplinary group of the world’s leading experts in this area gathered together and generated this set of consensus statements to bring some clarity to this confusion.

• The five consensus statements provide clear guidance for clinicians counselling their patients about the early detection of prostate cancer.

Read Previous Articles of the Week

Video: Why the Melbourne Statement?

February 5, 2014/by admin Z.9

The Melbourne Consensus Statement on the early detection of prostate cancer

Read the full article

• The five consensus statements provide clear guidance for clinicians counselling their patients about the early detection of prostate cancer.

Article of the week: PCa-specific mortality increased in older men with low-risk disease

January 22, 2014/1 Comment/by admin Z.9

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Aizer discussing his paper.

If you only have time to read one article this week, it should be this one

Initial management of prostate-specific antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer

Ayal A. Aizer*, Ming-Hui Chen^‡, Jona Hattangadi* and Anthony V. D’Amico^†

*Harvard Radiation Oncology Program, Boston, MA, ^†Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA, and, ^‡Department of Statistics, University of Connecticut, Storrs, CT, USA

Read the full article

OBJECTIVE

• To evaluate whether older age in men with low-risk prostate cancer increases the risk of prostate cancer-specific mortality (PCSM) when non-curative approaches are selected as initial management.

PATIENTS AND METHODS

• The study cohort consisted of 27 969 men, with a median age of 67 years, with prostate-specific antigen (PSA)-detected, low-risk prostate cancer (clinical category T1c, Gleason score ≤6, and PSA ≤10) identified by the Surveillance, Epidemiology and End Results programme between 2004 and 2007.

• Fine and Gray’s competing risk regression analysis was used to evaluate whether management with non-curative vs curative therapy was associated with an increased risk of PCSM after adjusting for PSA level, age at diagnosis and year of diagnosis.

RESULTS

• After a median follow-up of 2.75 years, 1121 men died, 60 (5.4%) from prostate cancer.

• Both older age (adjusted hazard ratio [AHR] 1.05; 95% confidence interval (CI) 1.02–1.08; P < 0.001) and non-curative treatment (AHR 3.34; 95% CI 1.97–5.67; P < 0.001) were significantly associated with an increased risk of PCSM.

• Men > the median age experienced increased estimates of PCSM when treated with non-curative as opposed to curative intent (P< 0.001); this finding was not seen in men ≤ the median age (P = 0.17).

CONCLUSION

• Pending prospective validation, our study suggests that non-curative approaches for older men with ‘low-risk’ prostate cancer result in an increased risk of PCSM, suggesting the need for alternative approaches to exclude occult, high grade prostate cancer in these men.

Read Previous Articles of the Week

Editorial: The age old question: who benefits from prostate cancer treatment?

January 22, 2014/by Stacy Loeb

Widespread PSA-based screening has dramatically altered the profile of newly diagnosed prostate cancer in many countries. Although screening effectively decreases the rates of metastatic disease and prostate cancer death [1], the increasing proportion of low-risk disease necessitates a critical assessment of the need for aggressive therapy.

Active surveillance and watchful waiting are potential alternatives to delay or avoid the need for treatment in carefully selected patients. The key issue is determining which patients are appropriate for conservative management. Although these approaches are often targeted toward elderly men, such men are more likely to be diagnosed with high-risk disease. A recent study by Scosyrev et al. [2] raised concern about excess prostate cancer mortality attributable to under-treatment in the elderly.

Overall, there is very little Level 1 evidence to guide prostate cancer treatment selection. One such trial, the Swedish Prostate Cancer Group 4 (SPCG-4), showed that radical prostatectomy significantly improved survival compared with watchful waiting [3]; however, that study examined a primarily clinically detected population from the 1990s. Subsequently, the Prostate Cancer Intervention versus Observation Trial (PIVOT) randomized US male veterans diagnosed with prostate cancer from 1994 to 2002 to radical prostatectomy vs observation [4]. At 10 years, they reported no significant difference in overall survival between the two arms in the intent-to-treat analysis (hazard ratio 0.88; 95% CI 0.71–1.08, P = 0.22). However, that study was smaller than anticipated owing to difficulty with recruitment and there was a high rate of crossovers between the intervention and observation arms. Per-protocol analysis was not reported for PIVOT and the prostate cancer landscape has continued to change in the past decade, raising unanswered questions over what the results would be if we compared contemporary men who were actually treated to those who were not.

This is the knowledge gap addressed by Aizer et al. [5] who used Surveillance, Epidemiology and End Results (SEER) data for 27 969 US men diagnosed with low-risk prostate cancer from 2004 to 2007. Overall, 67.1% of these men received radical prostatectomy or radiation therapy, while >30% underwent active surveillance or watchful waiting. Using competing risks regression, they showed that both age and non-curative treatment were associated with a significantly higher short-term prostate cancer-specific mortality. These results should be interpreted with caution, however, since they comprise observational data with great potential for confounding. Interestingly, at a short median follow-up of only 2.75 years, 5.4% of these men with presumed low-risk disease died from prostate cancer. Recently, there has been debate over whether Gleason 6 disease should really be considered a cancer [6], but these data highlight the limitations of current clinical staging, such that even presumed low-risk disease may be understaged. The authors suggest that use of a more extended biopsy scheme before active surveillance might reduce the risk of early progression due to undersampling. MRI represents another potential non-invasive treatment method to improve clinical staging and patient selection for active surveillance in the future [7].

Stacy Loeb
Department of Urology, New York University, New York, NY, USA

Read the full article

References

Schroder FH, Hugosson J, Roobol MJ et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012; 366: 981–990
Scosyrev E, Messing EM, Mohile S et al. Prostate cancer in the elderly: frequency of advanced disease at presentation and disease-specific mortality. Cancer 2012; 118: 3062–3070
Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2011; 364: 1708–1717
Wilt TJ, Brawer MK, Jones KM et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012;367: 203–212
Aizer AA, Chen MH, Hattangadi J, D’Amico AV. Initial management of prostate-specific-antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer. BJU Int 2014; 113: 43–50
Carter HB, Partin AW, Walsh PC et al. Gleason score 6 adenocarcinoma: should it be labeled as cancer? J Clin Oncol 2012; 30:4294–4296
Vargas HA, Akin O, Afaq A et al. Magnetic Resonance Imaging for Predicting Prostate Biopsy Findings in Patients Considered for Active Surveillance of Clinically Low Risk Prostate Cancer. J Urol 2012; 188: 1732–1738

Video: PCa in older men, is it really low-grade disease?

January 22, 2014/by admin Z.9

Initial management of prostate-specific antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer

Ayal A. Aizer*, Ming-Hui Chen^‡, Jona Hattangadi* and Anthony V. D’Amico^†

Read the full article

OBJECTIVE

• To evaluate whether older age in men with low-risk prostate cancer increases the risk of prostate cancer-specific mortality (PCSM) when non-curative approaches are selected as initial management.

PATIENTS AND METHODS

RESULTS

• After a median follow-up of 2.75 years, 1121 men died, 60 (5.4%) from prostate cancer.

CONCLUSION

Another new year, but evidently no new overall survivability for patients presenting with metastatic prostate cancer

January 20, 2014/by Christopher Bayne

The first International Journal Club of 2014 pulled momentum from December’s discussion on treatment of metastatic prostate cancer. The study reported retrospective review of the California Cancer Registry (CCR) from 1988 to 2009 and found no significant improvement in overall or disease-specific survival in men presenting with metastatic prostate cancer. [1] Senior author Marc Dall’Era (@mdallera) led the Twitter #urojc chat.

Fresh into a new year, the crowd was giddy.

… and turned toward more important current events, like the U.S. Preventative Services Task Force’s prostate cancer screening recommendations from 2012.

Ultimately, Dall’Era reigned in the masses. His study sought to investigate whether improvement in patients with metastatic prostate cancer have contributed to the overall decline in prostate cancer mortality since the introduction prostate-specific antigen (PSA). The authors identified 19,336 men through the CCR who presented with de novo metastatic prostate cancer between 1988 and 2009. Over the entire study time period, median age of diagnosis decreased significantly from 73 years to 71 years.

The authors separated the men into chronologic cohorts: 1988-1992, 1993-1997, 1998-2003, and 2004-2009. Men in the recent era showed no significant overall survival (OS) or disease-specific survival (DSS) improvements versus earlier cohorts after 1988. Interestingly, on multivariate analysis controlling for baseline patient characteristics, OS was better for men in the 1988, 1993, and 1998 cohorts versus the 2004 cohort. DSS did improve with time when comparing the 2004 cohort with patients presenting in all earlier years.

If there have been no changes in overall survival in patients with de novo metastatic prostate cancer, might this support the effect of PSA screening?

Tweeters discussed prostate cancer screening selecting out a more biologically aggressive metastatic disease. Dall’Era explained the theory.

The overwhelming question chat participants asked is whether the lack of survival benefit over time is truly accurate, a false reflection of treatment advancements made in recent years, or an artifact created from limitations of the study.

Future studies should attempt to control for the different metastatic disease profiles, namely those patients diagnosed after clinical symptom workup versus those who are asymptomatic on presentation. Examining and comparing tumor biology is another future step.

Ultimately, it’s important not to lose sight of the two dramatic trends over the past decade: the decline in prostate cancer-specific mortality and incidence of metastatic disease. The next steps are solidifying which low-risk patients to treat and developing advanced methods to treat the most aggressive diseases.

The Best Tweet prize for January goes to Parth Modi from New Brunswick, NJ, which goes to show that even Urology residents are in with a chance to win. The January prize has been kindly been donated by European Urology.

Thank you, Marc Dall’Era, for joining the chat. Your interaction made the January chat particularly lively and insightful. Thank you, European Urology for generously providing the Best Tweet prize.

Finally, here are the Symplur.com analytics for the chat.

[1] Wu JN, Fish KM, Evans CP, deVere White RW, Dall’Era MA. No improvement noted in overall or cause-specific survival for men presenting with metastatic prostate cancer over a 20-year period. Cancer 2013. In Press. doi: 10.1002/cncr.28485

Christopher Bayne is a PGY-3 urology resident at The George Washington University Hospital in Washington, DC and tweets @cbaynemd.

Avoiding treatment in prostate cancer: time and money, please?

January 13, 2014/1 Comment/by Peter Acher

It seems impossible to say anything regarding prostate cancer without inciting emotionally charged controversy, even when based on high-level evidence. The updated prostate cancer guidelines from the National Institute of Clinical Health and Excellence (NICE) this week sparked media attention that focused on the role of active surveillance for low and intermediate risk groups.

The newspaper headlines state that patients with prostate cancer have been told to avoid immediate treatment. Whether patients are to go against advice given by their doctor or whether this is an attempt by the government to save money is unclear if the online comments are anything to go by. On a local level, patients who are awaiting treatment are questioning their choices.

The sensational implication is that active surveillance is a novel management strategy that was previously not considered. In fact, the equally controversial guidelines from 2008 promoted this alternative: the phrase “suitable for all options including active surveillance” is expressed frequently throughout the country when discussing individual cases at multidisciplinary team meetings.

There is no doubt that a proportion of men who undergo radical treatments may not benefit. The challenges arise in determining who these men are within the constraints of NHS pathways. A standard pathway for a UK man is to request a PSA blood test from his GP, commonly sparked by concerned relatives or friends and endorsed by high-profile survivors and campaigners. A raised result then triggers a “two-week” urgent suspected cancer referral and a clock ticks with diagnosis, staging and treatment to be completed within a 62-day target.

Inevitably, the urgency of referral will influence patient beliefs regarding the seriousness of their condition. A quick online search of comments on recent mainstream articles will throw up anecdotes from men who have sadly failed “wait and see” policies by progressing and finding themselves with incurable disease. A well informed patient will know that a standard transrectal biopsy will have under-estimated his risk in a third of cases. In this emotional state and limited time-frame, our patients are expected to make a rational decision regarding complex management choices – definitive treatment with associated side effects but the knowledge that every effort has been made to “cure” the disease, or what may be a lifetime of repeated, potentially dangerous, biopsies, blood tests and prostate examinations with risk of failure and “living with cancer”. Active surveillance is hardly an attractive option when considered in these terms.

What’s the answer? Detailed evaluation of prostate disease can be achieved with improved imaging with multiparametric MRI in conjunction with a modern transperineal biopsy technique that evaluates the prostate more thoroughly. Suitable patients for active surveillance (and radical treatment) can then be potentially better selected and counseled with higher confidence. Of course, resources are required for this, but shouldn’t this be what we should be campaigning for? And time to deliver this.

Benjamin Disraeli said, “He who gains time gains everything” and perhaps this is the greatest gift we can give to our patients. The lack of time pressure in terms of clinical urgency in low risk prostate cancer gives ample opportunity to get it right in these patients.

I can’t agree that the NICE guidelines are designed to cut NHS costs (active surveillance may cost the same as surgery) but I do fear that without better resources and the reduction in target pressures for low risk prostate cancer, active surveillance will remain an under-utilized management option for many who would benefit from it.

Peter Acher

Prostate cancer survivorship: a new way forward

January 8, 2014/by Sanchia Goonewardene

Over 2 million people in England have a diagnosis of cancer. This is such a large problem, the Department of Health is spending £750 million on improving earlier diagnosis and prevention of cancer, yet at the same time, £20 billion of efficiency savings must be made. One arm of post-cancer care is survivorship. Survivorship care was initially developed in the USA 20 years ago, starting with breast cancer patients. Prostate cancer survivorship care has been lagging far behind.

Survivorship care involves risk profiling of patients, supported by community based teams and developing shared care/decision making. More often than not, they are fit and well, requiring PSA follow-up only. Yet no guidance relates to survivorship management.

Cancer survivorship encompasses the “physical, psychosocial, and economic issues of cancer from diagnosis until the end of life.” There are significant concerns that current follow-up methods are unsuitable. Concerns regarding permanent physical, psychosocial, and economic effects of cancer treatment have been highlighted and give us good landmarks for survivorship care. These include monitoring for recurrence, metastases, side effects and coordination between secondary and primary care and impact on quality of life. If we examine what patients expect, this includes a full assessment of needs, discussion on side effects of treatment and a personalised care plan post-treatment. Patients also report not knowing who to contact for their care out of hours. Five key phases to survivorship care were identified: care via primary treatment from diagnosis, enable as rapid and full a recovery as possible, ensure recovery is sustained, manage side effects of treatment and monitor for recurrence or disease progression. As part of a National Cancer Survivorship Initiative, a recovery package was developed. This includes a holistic needs assessment and care planning at key points of the care pathway, a treatment summary, a cancer care review, a patient education and support event.

Based on these facts, we have developed a new survivorship model – this was set up as a National Cancer Survivorship Initiative. This programme was initially devised when it was identified specific areas of care were lacking in this cohort, when followed up on a clinic basis. It aims to address the holistic need of the survivorship cohort, and at the same time, allow monitoring for acute recurrence and follow-up care as well as community based follow-up and patient support.

Our Survivorship programme is for patients post-curative therapy for organ confined disease (surgery, external beam radiotherapy or brachytherapy). Patients are offered the option of entering into the survivorship programme and discharged from clinic (Figure 1). Inclusion criteria specify patients must be two years post-radical prostatectomy with an unrecordable PSA, or three years post-radiotherapy or brachytherapy with a stable PSA. We currently have over five hundred patients on this programme. The patients’ demographic, disease and treatment details are entered onto a password protected web based database. The IT programme allows patients to be monitored for recurrence via automatic extraction of PSA results from the hospital database. It is a bespoke database. Alerts are automatically generated if the PSA is above a previously set range. The clinical nurse specialist (CNS) running the programme will contact the responsible consultant once an alert is generated with the patient reviewed in clinic, if required. The CNS will also go through a ‘Distress Thermometer’ with patients on admission to the programme, to identify areas where the patient needs support, psychological, social etc. The specialist nurse would act as the patients’ keyworker, should they develop any side effects of treatment, or any recurrence.

At its initial inception, a focus group of patients was conducted, as part of participatory action research, to find out what they wanted as part of this programme – a user led system. Specifically, they mentioned a conference where they have access to health care professionals and specific topics covered including diet and exercise, nutrition, psychosexual counselling. This conference is held annually, with a range of healthcare professionals advising on identified patient issues e.g. psychological care, health promotion, research, and welfare. The conference allows patients to draw on their strengths and share experiences with each other. Topics such as identification of recurrence, long-term complications, rehabilitation services, quality-of-life issues, pain and symptom management and treatment of recurrent cancer are examples of areas covered.

There are over 600 patients currently on the programme, a mixture of post-surgery, radiotherapy and brachytherapy. Of these patients, 29 have been referred back to clinic. When asked at the pilot conference if it was worth attending, 100% said yes. As a result of the initial focus group, comments have been made in support this programme.

Whilst this programme is currently only for patients post curative treatment, the next steps forward are to see if patients undergoing active surveillance or hormone therapy can be followed-up using this programme.

Further information:

National Cancer Survivorship Initiative

Worcestershire Prostate Cancer Survivorship Conference

Worcestershire Prostate Cancer Survivorship Programme

Goonewardene SS*, Persad R^†,Nanton V^‡, Young A^‡, Makar A^¶*Homerton University Hospital, London, ^†North Bristol NHS Trust, ^‡Warwick University, ^¶Worcestershire Acute Hospitals