Quality statement 2: Treatment options

Quality statement

People with low-risk localised prostate cancer for whom radical treatment is suitable are offered a choice between active surveillance, radical prostatectomy or radical radiotherapy.

Rationale

People who are diagnosed with low‑risk localised prostate cancer can be offered different treatment options, including radical prostatectomy, radical radiotherapy and active surveillance. It is important that people for whom it is suitable know that active surveillance is also an option for low‑risk localised prostate cancer. This can reduce overtreatment and increase capacity for rapid treatment of high‑risk disease. It can also reduce the number of people unnecessarily having radical treatment and therefore experiencing adverse effects, and decrease the cost of treating and managing these adverse effects. By discussing all the treatment options available to them, people can make an informed decision on their preferred option.

Quality measures

Structure

Evidence of local arrangements to ensure that people with low‑risk localised prostate cancer for whom radical treatment is suitable are offered a choice between active surveillance, radical prostatectomy or radical radiotherapy.

Data source: Local data collection.

Process

Proportion of people with low‑risk localised prostate cancer for whom radical treatment is suitable who are offered a choice between active surveillance, radical prostatectomy or radical radiotherapy.

Numerator – the number in the denominator who are offered a choice between active surveillance, radical prostatectomy or radical radiotherapy.

Denominator – the number of people with low‑risk localised prostate cancer for whom radical treatment is suitable.

Data source: Local data collection.

Outcome

a) Rates of people with low‑risk localised prostate cancer on active surveillance.

Data source: Local data collection.

b) Rates of people with low‑risk localised prostate cancer satisfied with their chosen treatment option.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as hospitals, specialist urological cancer multidisciplinary teams and specialist prostate cancer services) ensure that systems are in place to offer a choice between active surveillance, radical prostatectomy or radical radiotherapy to people with low‑risk localised prostate cancer for whom radical treatment is suitable.

Healthcare professionals ensure that they offer a choice between active surveillance, radical prostatectomy or radical radiotherapy to people with low‑risk localised prostate cancer for whom radical treatment is suitable.

Commissioners (such as clinical commissioning groups and NHS England area teams) should monitor the treatment options offered to people with low‑risk localised prostate cancer.

People whose cancer has not spread outside the prostate and whose future risk from the cancer is low are offered a choice between having regular tests but no treatment (known as active surveillance), surgery to remove the prostate (radical prostatectomy) or radiation treatment to destroy cancer cells (radiotherapy).

Source guidance

Prostate cancer: diagnosis and management (2019) NICE guideline NG131, recommendations 1.3.7, 1.3.8 and 1.3.9

Definitions of terms used in this quality statement

Active surveillance

Part of a curative strategy for people with localised prostate cancer for whom radical treatments are suitable. It keeps these people within a 'window of curability' whereby only those whose tumours are showing signs of progressing or those with a preference for intervention are considered for radical treatment. Active surveillance may therefore avoid or delay the need for radiation or surgery.

Active surveillance follows the protocol outlined in table 4 in NICE's guideline on prostate cancer.

[NICE's guideline on prostate cancer, 2014 full guideline]

Low‑risk localised prostate cancer

Prostate‑specific antigen (PSA) less than 10 ng/ml, Gleason score 6 or below and clinical stage T1–T2A (confined to the prostate gland).

[Adapted from NICE's guideline on prostate cancer]

Radical prostatectomy

Removal of the entire prostate gland and lymph nodes by open surgery or a keyhole technique (laparoscopic or robotically assisted laparoscopic prostatectomy).

[NICE's guideline on prostate cancer, 2014 full guideline]

Radical radiotherapy

Radiation, usually X‑rays or gamma rays, used to destroy tumour cells, by external beam radiotherapy or brachytherapy.

[NICE's guideline on prostate cancer, 2014 full guideline]

Equality and diversity considerations

People of black African or Caribbean family origin are more likely to develop prostate cancer than others. Despite this, awareness of prostate cancer is low among people in these groups. Similarly, older people are at higher risk of developing prostate cancer than younger people, but may be less likely to continue to engage with health services even after the initial contact with the service. For people in these groups for whom active surveillance is suitable, healthcare professionals should highlight its importance as a treatment option.

People who are gay, bisexual or transgender have a risk of developing prostate cancer. Healthcare professionals should be aware of their psychosexual needs, lifestyle and the impact of different treatment options.