Impact of cancer service centralisation on the radical treatment of men with high‐risk and locally advanced prostate cancer: A national cross‐sectional analysis in England

Abstract

In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high‐risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high‐risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co‐ordinating centre (‘hub’), for having surgery by the presence of surgical services on‐site, and for receiving high dose‐rate brachytherapy (HDR‐BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91–1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10–1.40), and more likely to receive additional HDR‐BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94–12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities.

Risk stratification for prostate cancer management: value of the Cambridge Prognostic Group classification for assessing treatment allocation

“…We also found that by using the CPG classification, the rates of surgery exceed radiotherapy only in men with CPG1 and CPG2 disease. Interestingly, in a prior publication, we showed an association between being diagnosed at a hospital with surgical services onsite and being more likely to receive surgery for their prostate cancer, than if these services were not available onsite [24].…”

“…The proportion of men diagnosed with CPG5 aged 70 or older was double that of those diagnosed with CPG1, indicating a clear progression of prostate cancer stage with age and that age at diagnosis is a major risk factor for aggressive disease. This observation highlights the complexity of the association of age and disease aggressiveness on the one hand and treatment selection on the other [23,24], given the clinical imperative to avoid early surgical complications in older patients and to reduce the need for later salvage treatments in patients with higher risk disease [25].…”

Comparison of the treatment of men with prostate cancer between the US and England: an international population-based study

“…For more aggressive disease (CPG4 and 5) surgery was more commonly used in the US compared to radiotherapy in England, indicating that factors, such as healthcare organisation and funding, may be influencing treatment decisions. Treatment selection in both the US and England has been shown to be dependent on the services available (33,34). Mandatory multidisciplinary team (MDT) working for all newly-diagnosed patients with cancer and the use of joint urology/oncology clinics in England may affect patient selection and patient choice compared to the US.…”

An observational study of volume–outcome effects for robot‐assisted radical prostatectomy in England

“…There has already been a significant degree of centralisation of prostatectomy service in the UK following the publication of the national cancer plan in 2000 [24]. The benefits of any further centralisation must be weighed against its potential negative impacts on access to treatment for patients, out-ofpocket costs for patients' families, and the viability of urology services at non-centralised hospitals [1,25,26]. Moreover, training opportunities for junior healthcare professionals must be considered as part of any reorganisation.…”