Northern Ireland Prostate Cancer Service Chris Hagan Consultant Urologist Clinical Director Urology and Transplant Belfast Trust (on behalf of Mr Nambi Rajan, NICaN Clinical Lead for Urology)
Incidence & mortality NICR Sept 2011 1072 new cases of prostate cancer in 2009 21% of all male cancers in NI Sharp rise from 593 in 2000 but mortality constant at approx 200 per year
PSA Tests and Prostate Biopsies 5.9% of over 50 s had new PSA test per annum for the period 1996-2006 (15,000 tests) Repeat PSA tests in 1996 occurred in 3000 men rising to 26,600 men in 2006 On average 1150 prostate histology reports were generated each year 1996-2006 (equivalent to 0.72% of all men over 60)
PSA testing in N. Ireland 80,000 Number of tests 60,000 40,000 20,000 In 2006 there were over 70,000 tests in N. Ireland 0 1994 1996 1998 2000 2002 2004 2006 Year
Risk of developing prostate cancer by age
Changing risk of developing prostate cancer by age Change significant for under 60 and under 75 age groups
How did patients with CaP present in 2006? 75% referred by GP 71% present as a new outpatient 20% had no symptoms at presentation Nocturia (59%), daytime frequency (41%), poor urine flow (39%) were the most common symptoms 5% had bone pain (40 patients per annum) One fifth of patients had another malignancy
Investigations in 2006 99% had a PSA test, 91% had a digital rectal examination, and 80% had a biopsy 68% of all patients received a bone scan The proportion of men having an MRI scan increased to 60% in 2006 from 20% in 2001 98% seen by a urologist compared to 48 % in 1996 64% discussed with oncologist compared to 14% in 1996 59% discussed in a multi-disciplinary team meeting, c/w 1% 1996
Treatment in 2006 17% Active surveillance 8% RRP 37% RT 74% hormone therapy 4% palliative RT
Observed survival of prostate cancer patients 100 80 2006 (n=819) % 60 40 2001 (n=565) 20 1996 (n=447) 0 0 2 4 6 8 10 12 Years since diagnosis Average age was 74.4 years in 1996, 72.9 in 2001, 70.5 in 2006 Survival has been increasing since 1996?lead time bias Mortality constant
NI Service: Urology Review 2009 Urology service in NI reconfigured into a 3 team model (East, N/West and South) 3 local MDMs established Belfast and South Eastern Western Northern Southern 1 Regional MDM (Belfast) established in 2003 Agreement to hold all MDM on Thursday pm to ensure links with specialist MDM Radical prostatectomies all carried out by single team at BCH in accordance with IOG
Prostate Pathways
Developing new pathways of care for cancer survivors - Numbers involved August 2011
Using available data and clinically led assumptions we estimate phases in the survivorship population Number of people Example Pathways 16
Estimating numbers for Northern Ireland Prostate cancer care pathway work in progress Newly diagnosed assumed need of acute sector care Surviving the first year assumed need of rehabilitation Up to 5 and 10 years from diagnosis designated as early monitoring Beyond 10 years from diagnosis designated later monitoring Incurable disease but not in last year of life assumed need more treatment and support End of life care in last year subset of deaths in first year of diagnosis * The numbers in the progressive illness group will be underestimated and the numbers in the monitoring groups be overestimated as estimates for significant late effects have not been made. 17
Case for change: current issues Routine hospital follow up is not as effective as it could be Increasing numbers of people living with cancer Increasing by 3.2% per annum Current model unsustainable Does not address survivorship needs 40% in NI have unmet needs 20% have moderate to severe late effects (Santin, 2011)
Current Issues cont d PSA testing for Prostate Cancer does not meet the well defined and internationally agreed criteria for a screening test There is no consistent criteria / information to GPs on referral back into the system for elevated PSA How do we follow up men with elevated PSA and negative biopsy? Prostate cancer mortality appears unchanged despite increased diagnostics
Literature review concerning current follow-up after cancer A poor evidence base and no consensus as to the intensity, duration, setting or type of follow up required for most common forms of cancer Evidence to inform the Cancer Reform Strategy: The clinical effectiveness and cost effectiveness of follow up services after cancer treatment ; York Centre for reviews and dissemination October 2007 (report available on request)