Birmingham Prostate Clinic response to the new NICE guidelines on prostate cancer treatment

Updated guidance from the National Institute for Health and Care Excellence (Nice) states men with “intermediate” and “low risk” prostate cancer should consider having regular check-ups (active monitoring) rather than surgery or radiotherapy.

We welcome this focus upon the complex question of when and how to treat prostate cancer, particularly the new protocols published on how to manage men on active monitoring, standardising what tests they are offered and how often.

We particularly welcome the fact that the guidance gives new weight to multi-parametric MRI as an alternative to biopsy. This is the protocol we have used for the past three years and the benefits have been clearly evident.

However, in the reporting of these new guidelines, the reader could get the impression that up until now, there has been a ‘conveyor-belt’ carrying men with low grade disease on to unnecessary treatment and inevitable side-effects.

Certainly at Birmingham Prostate Clinic and many other services across the UK, we have always strived to avoid unnecessary treatment and have a high proportion of patients on active monitoring. This is why we place such a strong emphasis upon the diagnostic tools in prostate cancer, as the first in the region to introduce the PCA3 test, routinely using enhanced multiparametric MRI before deciding whether to proceed to a biopsy. Recently we have also introduced the Prolaris Score designed to assess prostate cancer at a molecular level, measure aggressiveness and thus predict how the cancer is likely to spread over time.

Offering this wide range of diagnostic tools is vital because it better enables us to judge exactly what degree of prostate cancer risk each man faces. Overtreatment, to a large extent, has been due to limited and outdated methods of assessing prostate cancer, with an over-reliance upon PSA result followed by biopsy as an inevitable step.

At BPC, a third of our patients are currently on active monitoring. The judgement to choose this option encompasses factors including age, overall health and personal preferences. Critically, as medical professionals, we must be as confident as possible in our judgement that an individual is truly low or moderate risk. This is often not a simple judgement.

Particularly in certain groups – men aged under 65 at diagnosis, Afro-Caribbean men and those with a family history – localised disease can still be very aggressive. Treatment at an early stage before there is any cancer spread to the margins of prostate means we are better placed to perform an optimal nerve-sparing prostatectomy and thereby avoid long term erectile dysfunction and incontinence.

Herein lies the complexity: one of the main contentions in the new guidelines is that over-treatment leads to unnecessary side-effects and in some cases, this is certainly true. However conversely, we regularly see patients who should have been referred for treatment earlier and while they may be able to have surgery with a curative intent, their disease has spread too far for effective nerve sparing to be an option. We would welcome further guidelines to cover the importance of measuring outcomes, improving surgical techniques and reflecting the fact that a well done prostatectomy with localised cancer has very low long term complication rates.

In conclusion, these new guidelines are very welcome, bringing new protocols for active monitoring and helpful reflection on which patients should proceed to radiotherapy or surgery. They underline how much we need to continually strive for improved diagnostic tools and evidence, so we can have greater assurance about each patient’s prostate cancer risk.