Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Determinants of variation in radical local treatment for men with high-risk localised or locally advanced prostate cancer in England

Prostate Cancer and Prostatic Diseases volume 26, pages 257–263 (2023)Cite this article

Subjects

Abstract

Background

Many factors are implicated in the potential ‘under-treatment’ of prostate cancer but little is known about the between-hospital variation.

Methods

The National Prostate Cancer Audit (NPCA) database was used to identify high-risk localised or locally advanced prostate cancer patients in England, between January 2014 and December 2017, and the treatments received. Hospital-level variation in radical local treatment was explored visually using funnel plots. The intra-class correlation coefficient (ICC) quantified the between-hospital variation in a random-intercept multivariable logistic regression model.

Results

53,888 men, from 128 hospitals, were included and 35,034 (65.0%) received radical local treatment. The likelihood of receiving radical local treatment was increased in men who were younger (the strongest predictor), more affluent, those with fewer comorbidities, and in those with a non-Black ethnic background. There was more between-hospital variation (P < 0.001) for patients aged ≥80 years (ICC: 0.235) compared to patients aged 75–79 years (ICC: 0.070), 70–74 years (ICC: 0.041), and <70 years (ICC: 0.048). Comorbidity and socioeconomic deprivation did not influence the between-hospital variation.

Conclusions

Radical local treatment of high-risk localised or locally advanced prostate cancer depended strongly on age and comorbidity, but also on socioeconomic deprivation and ethnicity, with the between-hospital variation being highest in older patients.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2
Fig. 3: Funnel plots showing the proportion of men with high-risk/locally advanced disease who receive radical local treatment within 12 months of diagnosis at each hospital, adjusted for all patient factors in Table 1.

Similar content being viewed by others

Data availability

The cancer registry data used for this study are based on information collected and quality assured by Public Health England’s National Cancer Registration Service (www.ncras.nhs.uk). Access to the data was facilitated by the Public Health England’s Office for Data Release. Hospital Episode Statistics were made available by the NHS Digital (www.digital.nhs.uk); all rights reserved. MGP had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. Data are not available to other researchers as it uses existing national data sets.

References

  1. National Prostate Cancer Audit. Annual Report 2019: Results of the NPCA prospective audit in England and Wales for men diagnosed from 1 April 2017–31 March 2018. 2019. https://www.npca.org.uk/reports/npca-annual-report-2019/.

  2. European Association of Urology. Guidelines on prostate cancer. 2017. http://uroweb.org/guideline/prostate-cancer/.

  3. Cooperberg MR, Broering JM, Carroll PR. Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol. 2010;28:1117–23.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Denberg TD, Glode LM, Steiner JF, Crawford ED, Hoffman RM. Trends and predictors of aggressive therapy for clinical locally advanced prostate carcinoma. BJU Int. 2006;98:335–40.

    Article  PubMed  Google Scholar 

  5. Lowrance WT, Elkin EB, Yee DS, Feifer A, Ehdaie B, Jacks LM, et al. Locally advanced prostate cancer: a population-based study of treatment patterns. BJU Int. 2012;109:1309–14.

    Article  PubMed  Google Scholar 

  6. Meltzer D, Egleston B, Abdalla I. Patterns of prostate cancer treatment by clinical stage and age. Am J Public Health. 2001;91:126–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. National Prostate Cancer Audit. Third year annual report—Results of the NPCA prospective audit and patient survey. 2016. https://www.npca.org.uk/content/uploads/2017/11/NPCA-2016-Annual-Report-Final_131216.pdf.

  8. NHS Digital. Hospital Episode Statistics (HES). 2021. https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics.

  9. National Cancer Registration and Analysis Service. National Radiotherapy Dataset (RTDS). 2010. https://www.ncin.org.uk/collecting_and_using_data/rtds.

  10. Brierley J, Gospodarowicz M, Wittekind C. TNM classification of malignant tumours. 8th edn. Chichester: John Wiley & Sons; 2017.

    Google Scholar 

  11. Noble M, McLennan D, Wilkinson K, Whitworth A, Dibben C, Barnes H. The English indices of deprivation 2007. 2008. http://geoconvert.mimas.ac.uk/help/imd-2007-manual.pdf.

  12. Public Health England. Cancer registration data dictionary. 2020. https://www.gov.uk/government/publications/accessing-public-health-england-data.

  13. Armitage JN, van der Meulen JH. Identifying co-morbidity in surgical patients using administrative data with the Royal College of Surgeons Charlson Score. Br J Surg. 2010;97:772–81.

    Article  CAS  PubMed  Google Scholar 

  14. Ministry of Housing CLG. English indices of deprivation 2015. 2015. https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015.

  15. NHS Digital. NHS Classifications Service: OPCS Classifications of Interventions and Procedures Version 4.4. 2007. http://systems.digital.nhs.uk/data/clinicalcoding/codingstandards/opcs4.

  16. Knol MJ, Le Cessie S, Algra A, Vandenbroucke JP, Groenwold RH. Overestimation of risk ratios by odds ratios in trials and cohort studies: alternatives to logistic regression. CMAJ 2012;184:895–9.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Gutierrez RG. Parametric frailty and shared frailty survival models. Stata J. 2002;2:22–44.

    Article  Google Scholar 

  18. Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley and Sons; 2004.

    Google Scholar 

  19. Spiegelhalter DJ. Funnel plots for comparing institutional performance. Stat Med. 2005;24:1185–202.

    Article  PubMed  Google Scholar 

  20. Pietro GD, Chornokur G, Kumar NB, Davis C, Park JY. Racial differences in the diagnosis and treatment of prostate cancer. Int Neurourol J. 2016;20(Suppl 2):S112–9.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Fung C, Dale W, Mohile SG. Prostate cancer in the elderly patient. J Clin Oncol. 2014;32:2523–30.

    Article  PubMed  Google Scholar 

  22. Boyle HJ, Alibhai S, Decoster L, Efstathiou E, Fizazi K, Mottet N, et al. Updated recommendations of the International Society of Geriatric Oncology on prostate cancer management in older patients. Eur J Cancer. 2019;116:116–36.

    Article  CAS  PubMed  Google Scholar 

  23. Daskivich TJ, Fan KH, Koyama T, Albertsen PC, Goodman M, Hamilton AS, et al. Effect of age, tumor risk, and comorbidity on competing risks for survival in a U.S. population-based cohort of men with prostate cancer. Ann Intern Med. 2013;158:709–17.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Kutikov A, Cooperberg MR, Paciorek AT, Uzzo RG, Carroll PR, Boorjian SA. Evaluating prostate cancer mortality and competing risks of death in patients with localized prostate cancer using a comprehensive nomogram. Prostate Cancer Prostatic Dis. 2012;15:374–9.

    Article  CAS  PubMed  Google Scholar 

  25. Hoffman RM, Koyama T, Albertsen PC, Barry MJ, Daskivich TJ, Goodman M, et al. Self-reported health status predicts other-cause mortality in men with localized prostate cancer: results from the prostate cancer outcomes study. J Gen Intern Med. 2015;30:924–34.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet 2013;382:1121–9.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Boyle JM, Kuryba A, Cowling TE, Aggarwal A, Hill J, van der Meulen J, et al. Determinants of variation in the use of adjuvant chemotherapy for stage III colon cancer in England. Clin Oncol. 2020;32:e135–44.

    Article  CAS  Google Scholar 

  28. Benitez Majano S, Di Girolamo C, Rachet B, Maringe C, Guren MG, Glimelius B, et al. Surgical treatment and survival from colorectal cancer in Denmark, England, Norway, and Sweden: a population-based study. Lancet Oncol. 2019;20:74–87.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Puts MT, Tapscott B, Fitch M, Howell D, Monette J, Wan-Chow-Wah D, et al. A systematic review of factors influencing older adults’ decision to accept or decline cancer treatment. Cancer Treat Rev. 2015;41:197–215.

    Article  PubMed  Google Scholar 

  30. Barbiere JM, Greenberg DC, Wright KA, Brown CH, Palmer C, Neal DE, et al. The association of diagnosis in the private or NHS sector on prostate cancer stage and treatment. J Public Health. 2012;34:108–14.

    Article  CAS  Google Scholar 

  31. Burns EM, Rigby E, Mamidanna R, Bottle A, Aylin P, Ziprin P, et al. Systematic review of discharge coding accuracy. J Public Health. 2012;34:138–48.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We thank NHS staff for their support in collecting the clinical data, the National Cancer Registration and Analysis Service (www.ncras.nhs.uk) for providing cancer registry and radiotherapy data and NHS Digital (www.digital.nhs.uk) for providing Hospital Episode Statistics. MGP, JN, MM, TC, AS, BB, PC, NWC, HP, AA and JvdM are members of the Project Team of the National Prostate Cancer Audit (www.npca.org.uk). The National Prostate Cancer Audit is commissioned by the Healthcare Quality Improvement Partnership (www.hqip.org.uk) as part of the National Clinical Audit and Patient Outcomes Programme, and funded by NHS England and the Welsh Government. Neither HQIP nor NHS England or the Welsh Government had any involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The researchers had full independence from the Healthcare Quality Improvement Partnership.

Funding

MGP was supported by a Doctoral Research Fellowship from the National Institute for Health Research (DRF-2018-11-ST2-036). BB was partly supported by an Academic Clinical Fellowship from the National Institute for Health Research. HP was supported by the University College London Hospitals/University College London Comprehensive Biomedical Research Centre. JvdM was partly supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North Thames. The views expressed in this article are solely those of the authors.

Author information

Author notes

  1. These authors contributed equally: Jan van der Meulen, Heather Payne, Noel W. Clarke.

Authors and Affiliations

  1. Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK

    Matthew G. Parry, Jemma M. Boyle, Melanie Morris, Brendan Berry & Jan van der Meulen

  2. Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK

    Matthew G. Parry, Jemma M. Boyle, Julie Nossiter, Melanie Morris, Arunan Sujenthiran & Brendan Berry

  3. Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

    Paul Cathcart

  4. Department of Cancer Epidemiology, Population, and Global Health, King’s College London, London, UK

    Ajay Aggarwal

  5. Department of Radiotherapy, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

    Ajay Aggarwal

  6. Department of Oncology, University College London Hospitals, London, UK

    Heather Payne

  7. Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK

    Noel W. Clarke

Authors
  1. Matthew G. Parry
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jemma M. Boyle
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Julie Nossiter
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Melanie Morris
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Arunan Sujenthiran
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Brendan Berry
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Paul Cathcart
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ajay Aggarwal
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Jan van der Meulen
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Heather Payne
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Noel W. Clarke
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Designed the work: MGP, JvdM, HP and NWC. Analysed and interpreted data: MGP, JMB, JvdM, HP and NWC. Drafted article: MGP, JvdM, HP and NWC. Provided critical revision: All authors. Approved final version to be published: All authors.

Corresponding author

Correspondence to Matthew G. Parry.

Ethics declarations

Competing interests

JvdM reports a contract with the Healthcare Quality Improvement Partnership for the provision of the National Prostate Cancer Audit (www.npca.org.uk) funded by the Healthcare Quality Improvement Partnership (www.hqip.org.uk). HP has attended and received honoraria for advisory boards, travel expenses to medical meetings, and served as a consultant for AstraZeneca, Astellas, Janssen, Sanofi Aventis, Takeda, Ipsen, Ferring, Sandoz, and Novartis. NWC has attended and received honoraria for advisory boards, travel expenses to medical meetings, and served as a consultant for AstraZeneca, Astellas, Bayer, Janssen, Sanofi Aventis, Takeda, Ipsen and Ferring.

Ethics approval and consent to participate

This study was exempt from NHS Research Ethics Committee approval because it involved analysis of pseudonymised linked data collated for the purpose of service evaluation as part of the National Prostate Cancer Audit.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Parry, M.G., Boyle, J.M., Nossiter, J. et al. Determinants of variation in radical local treatment for men with high-risk localised or locally advanced prostate cancer in England. Prostate Cancer Prostatic Dis 26, 257–263 (2023). https://doi.org/10.1038/s41391-021-00439-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41391-021-00439-9

This article is cited by

Search

Advanced search

Quick links