West Midlands has best survival figures for prostate cancer and East Midlands the worst. What does this mean?

Mr Alan Doherty

Men with prostate cancer have the best survival chances if they live in Birmingham and the Black Country, a report has shown.

The report, by Macmillan Cancer Support, highlights some striking differences in survival, depending upon where patients live.

Focusing on prostate cancer, the figures show five year survival at 86.3 per cent in the Birmingham and the Black Country and by comparison, 70.9 per cent in Derbyshire and Nottinghamshire. Nationally, the two Midland neighbours have respectively the best and the worst survival rates.

What are we to make of this disparity, highlighted in figures produced by the Office for National Statistics?

The first point to make is that this is a significant and serious disparity. The population samples used in the study took account of age, ethnicity and socio-economic status; factors which influence who is most at risk of prostate cancer.

This study reflects not who gets prostate cancer but what happens next. In this context, a difference in five year survival of nearly 16 per cent is concerning.

What could cause this disparity? The authors, Macmillan Cancer Support, cite the variation in delays in diagnosis and unequal access to treatment as causes of the postcode lottery.

Unlike breast cancer, where of course there is a national screening programme, the detection of prostate cancer is often influenced by individual decision making; a man’s determination to have a PSA test and/or a GP’s willingness to support monitoring and make the referral at the right time.

If a PSA is elevated (above the level we would expect for a man’s age) what is needed is an assessment to decide if a prostate biopsy is necessary. My NHS practice is at the Queen Elizabeth Hospital, the largest urology service within the region. We have at our disposal most of the latest diagnostic and therapeutic modalities for prostate cancer. At the Birmingham Prostate Clinic, some patients will have an enhanced MRI scan and or a urinary PCA-3 gene test before we decide whether or not to proceed to biopsy.

This enables us to more effectively identify aggressive, clinically significant prostate cancer and equally, to avoid unnecessary biopsies. But in other parts of the country, access to MRI scans vary enormously and will reflect resources and established pathways rather than what may be best for the patient.

Although it is reassuring that there are increasingly good palliative treatments for prostate cancer (used when the cancer has spread out of the prostate), most patients are keen to offered curative treatments. For early prostate cancers, the ideal “curative window” is not known. I am increasingly of the view, that early treatment, especially when surgery is the chosen modality, is the best option, as long as the surgery is done to a very high standard. This means:

– Knowing the patient has prostate cancer that is clinically significant and predicted to spread

– The prostate cancer is localised. This means it has not yet broken into the capsule that surrounds the prostate, nor into the seminal vesicles (this is defined medically as a T2 tumour)

This scenario allows for the ideal treatment because:

– We can undertake curative surgery with the highest probability of effectively removing all cancer

– The likelihood of needing radiotherapy after surgery is minimal

– We can most effectively nerve spare during surgery. This means if the cancer is confined to the prostate, it is possible to achieve safe and full cancer clearance while also sparing the nerves lying close to the prostate which control erections and minimising damage to the bladder. Thus the patient has the best chances of an optimal outcome – full cancer clearance and no long term complications of treatment

I am regularly referred patients who have missed the opportunity for ideal curative treatment. Typically, they have been on active monitoring for several years and although this can be an appropriate choice, it requires careful management, strong diagnostic tools and counselling of patients to ensure they are aware of possible implications of this approach.

There is of course much that we can do to treat and help patients outside the ideal curative window. But it is important to note that the stage at which they have treatment is likely to have an impact on their outcome.

It is difficult to influence outcomes for men who unfortunately have their first PSA test at a point when their prostate cancer is advanced, perhaps after experiencing urinary symptoms or pain. But there are many thousands of patients who enter the prostate cancer ‘pathway’ at an early stage and we need to scrutinise what happens to these patients and whether their pathway and the decision-making process is achieving the best possible survival outcomes for them.

One of the original reports on the variations in prostate cancer outcomes can be found here:

http://www.telegraph.co.uk/news/health/news/11569219/Lottery-of-cancer-survival-revealed.html