Quality statement 2: Treatment options

Quality statement

Men with low‑risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable are also offered the option of active surveillance.

Rationale

Men 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 men 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 men 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, men can make an informed decision on their preferred option.

Quality measures

Structure

Evidence of local arrangements to ensure that men with low‑risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable are also offered the option of active surveillance.

Data source: Local data collection.

Process

Proportion of men with low‑risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable who are also offered the option of active surveillance.

Numerator – the number in the denominator who are also offered the option of active surveillance.

Denominator – the number of men with low‑risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable.

Data source: Local data collection.

Outcome

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

Data source: Local data collection.

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

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

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

Healthcare professionals ensure that they offer the option of active surveillance to men with low‑risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable.

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

What the quality statement means for patients and carers

Men whose cancer has not spread outside the prostate and whose future risk from the cancer is low are offered the option of having regular tests but no treatment (known as active surveillance) if surgery to remove the prostate (radical prostatectomy) or radiation treatment to destroy cancer cells (radiotherapy) would also be suitable treatments for them. This may delay or prevent the need for surgery or radiation treatment, which both have side effects.

Source guidance

  • Prostate cancer (2014) NICE guideline CG175, recommendations 1.3.7 and 1.3.8 (key priorities for implementation)

Definitions of terms used in this quality statement

Active surveillance

Part of a curative strategy for men with localised prostate cancer for whom radical treatments are suitable. It keeps these men 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 2 in prostate cancer (NICE guideline CG175).

[Prostate cancer (NICE guideline CG175) 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 Prostate cancer (NICE guideline CG175)]

Radical prostatectomy

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

[Prostate cancer (NICE guideline CG175) full guideline]

Radical radiotherapy

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

[Prostate cancer (NICE guideline CG175) full guideline]

Equality and diversity considerations

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

Gay and bisexual men, and transgender women have a risk of developing prostate cancer. Healthcare professionals should be aware of their psychosexual needs, lifestyle and the impact of different treatment options.