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Prostate cancer

About

What is covered

This interactive flowchart covers the care of men referred to secondary care with suspected or diagnosed prostate cancer, including follow-up in primary care for men with diagnosed prostate cancer. It does not cover men with an abnormal PSA (prostate-specific antigen) level detected in primary care who have no symptoms and are not referred for subsequent investigation.

Updates

Updates to this interactive flowchart

22 August 2017 Biodegradable spacer insertion to reduce rectal toxicity during radiotherapy for prostate cancer (NICE interventional procedures guidance 590) added to radical treatment.
20 December 2016 Irreversible electroporation for treating prostate cancer (NICE interventional procedures guidance 572) added to interventions not recommended except in clinical trials.
27 September 2016 Radium-223 dichloride for treating hormone-relapsed prostate cancer with bone metastases (NICE technology appraisal guidance 412) added to bone metastases.
23 August 2016 Structure revised, and summarised recommendations replaced with full recommendations. Degarelix for treating advanced hormone-dependent prostate cancer (NICE technology appraisal guidance 404) added to treatment. Recommendations for cabazitaxel updated in treatment options after chemotherapy with a docetaxel regimen.
24 May 2016 Cabazitaxel for hormone-relapsed metastatic prostate cancer previously treated with a docetaxel-containing regimen (NICE technology appraisal guidance 391) added to treatment options after chemotherapy with a docetaxel regimen.
26 April 2016 Abiraterone for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated (NICE technology appraisal guidance 387) added to treatment options before chemotherapy is indicated.
26 January 2016
  • Enzalutamide for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated (NICE technology appraisal guidance 377) added to treatment options before chemotherapy is indicated.
  • Radium-223 dichloride for treating hormone-relapsed prostate cancer with bone metastases (NICE technology appraisal guidance 376) added to bone metastases.
9 November 2015 The dose of cyproterone acetate for managing hot flushes has been amended, and the reference to megestrol acetate has been removed because it is not available in the UK at the dose needed. The changes have been made at managing adverse effects of hormone therapy.
1 July 2015 Sipuleucel-T for treating asymptomatic or minimally symptomatic metastatic hormone-relapsed prostate cancer (NICE technology appraisal guidance 332) removed after the withdrawal of its marketing authorisation.
10 June 2015 Diagnosing prostate cancer: PROGENSA PCA3 assay and Prostate Health Index (NICE diagnostics guidance 17) added to diagnosis and prostate cancer (NICE quality standard 91) also added.
24 February 2015 Sipuleucel-T for treating asymptomatic or minimally symptomatic metastatic hormone-relapsed prostate cancer (NICE technology appraisal guidance 332) added to treatment options after chemotherapy with a docetaxel regimen.
22 July 2014 Enzalutamide for metastatic hormone-relapsed prostate cancer previously treated with a docetaxel-containing regimen (NICE technology appraisal guidance 316) added to treatment options after chemotherapy with a docetaxel regimen.
7 January 2014 Structure revised to include new recommendations from updated prostate cancer guideline (CG175).
23 October 2012 Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours (NICE technology appraisal guidance 265) added to treatment.
27 June 2012 Abiraterone for castration-resistant metastatic prostate cancer previously treated with a docetaxel-containing regimen (NICE technology appraisal guidance 259) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and treating prostate cancer in an interactive flowchart

What is covered

This interactive flowchart covers the care of men referred to secondary care with suspected or diagnosed prostate cancer, including follow-up in primary care for men with diagnosed prostate cancer. It does not cover men with an abnormal PSA (prostate-specific antigen) level detected in primary care who have no symptoms and are not referred for subsequent investigation.

Updates

Updates to this interactive flowchart

22 August 2017 Biodegradable spacer insertion to reduce rectal toxicity during radiotherapy for prostate cancer (NICE interventional procedures guidance 590) added to radical treatment.
20 December 2016 Irreversible electroporation for treating prostate cancer (NICE interventional procedures guidance 572) added to interventions not recommended except in clinical trials.
27 September 2016 Radium-223 dichloride for treating hormone-relapsed prostate cancer with bone metastases (NICE technology appraisal guidance 412) added to bone metastases.
23 August 2016 Structure revised, and summarised recommendations replaced with full recommendations. Degarelix for treating advanced hormone-dependent prostate cancer (NICE technology appraisal guidance 404) added to treatment. Recommendations for cabazitaxel updated in treatment options after chemotherapy with a docetaxel regimen.
24 May 2016 Cabazitaxel for hormone-relapsed metastatic prostate cancer previously treated with a docetaxel-containing regimen (NICE technology appraisal guidance 391) added to treatment options after chemotherapy with a docetaxel regimen.
26 April 2016 Abiraterone for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated (NICE technology appraisal guidance 387) added to treatment options before chemotherapy is indicated.
26 January 2016
  • Enzalutamide for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated (NICE technology appraisal guidance 377) added to treatment options before chemotherapy is indicated.
  • Radium-223 dichloride for treating hormone-relapsed prostate cancer with bone metastases (NICE technology appraisal guidance 376) added to bone metastases.
9 November 2015 The dose of cyproterone acetate for managing hot flushes has been amended, and the reference to megestrol acetate has been removed because it is not available in the UK at the dose needed. The changes have been made at managing adverse effects of hormone therapy.
1 July 2015 Sipuleucel-T for treating asymptomatic or minimally symptomatic metastatic hormone-relapsed prostate cancer (NICE technology appraisal guidance 332) removed after the withdrawal of its marketing authorisation.
10 June 2015 Diagnosing prostate cancer: PROGENSA PCA3 assay and Prostate Health Index (NICE diagnostics guidance 17) added to diagnosis and prostate cancer (NICE quality standard 91) also added.
24 February 2015 Sipuleucel-T for treating asymptomatic or minimally symptomatic metastatic hormone-relapsed prostate cancer (NICE technology appraisal guidance 332) added to treatment options after chemotherapy with a docetaxel regimen.
22 July 2014 Enzalutamide for metastatic hormone-relapsed prostate cancer previously treated with a docetaxel-containing regimen (NICE technology appraisal guidance 316) added to treatment options after chemotherapy with a docetaxel regimen.
7 January 2014 Structure revised to include new recommendations from updated prostate cancer guideline (CG175).
23 October 2012 Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours (NICE technology appraisal guidance 265) added to treatment.
27 June 2012 Abiraterone for castration-resistant metastatic prostate cancer previously treated with a docetaxel-containing regimen (NICE technology appraisal guidance 259) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Prostate cancer: diagnosis and management (2014) NICE guideline CG175
Improving outcomes in urological cancers (2002) NICE guideline CSG2
Degarelix for treating advanced hormone-dependent prostate cancer (2016) NICE technology appraisal guidance 404
Irreversible electroporation for treating prostate cancer (2016) NICE interventional procedures guidance 572
Focal therapy using cryoablation for localised prostate cancer (2012) NICE interventional procedures guidance 423
Transperineal template biopsy and mapping of the prostate (2010) NICE interventional procedures guidance 364
Laparoscopic radical prostatectomy (2006) NICE interventional procedures guidance 193
Cryotherapy as a primary treatment for prostate cancer (2005) NICE interventional procedures guidance 145
Low dose rate brachytherapy for localised prostate cancer (2005) NICE interventional procedures guidance 132
Cryotherapy for recurrent prostate cancer (2005) NICE interventional procedures guidance 119
High-intensity focused ultrasound for prostate cancer (2005) NICE interventional procedures guidance 118
Prostate cancer (2015) NICE quality standard 91
Hormone-sensitive metastatic prostate cancer: docetaxel (2016) NICE evidence summary ESUOM50
Erectile dysfunction: avanafil (2014) NICE evidence summary ESNM45
Prostate cancer: triptorelin (Decapeptyl SR) (2014) NICE evidence summary ESNM30

Quality standards

Prostate cancer

These quality statements are taken from the prostate cancer quality standard. The quality standard defines clinical best practice for prostate cancer care and should be read in full.

Quality statements

Discussion with a named nurse specialist

This quality statement is taken from the prostate cancer quality standard. The quality standard defines clinical best practice in prostate cancer care and should be read in full.

Quality statement

Men with prostate cancer have a discussion about treatment options and adverse effects with a named nurse specialist.

Rationale

Nurse specialists are key points of contact for men with prostate cancer. They provide information about treatment options, answer questions or concerns and support men to make decisions about their care. This is particularly important immediately after diagnosis and when difficult choices about treatment need to be made. Nurse specialists also provide personalised care plans and information about support services.

Quality measures

Structure
Evidence of local arrangements to ensure that men with prostate cancer have a discussion about treatment options and adverse effects with a named nurse specialist.
Process
Proportion of men with prostate cancer who have a recorded discussion about treatment options and adverse effects with a named nurse specialist.
Numerator – the number in the denominator who have a recorded discussion about treatment options and adverse effects with a named nurse specialist.
Denominator – the number of men with prostate cancer.
Outcome
Rates of men with prostate cancer satisfied with the discussion about treatment options and adverse effects.
Data source: Local data collection and National Cancer Patient Experience Survey 2014.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, specialist prostate cancer multidisciplinary teams and specialist prostate cancer services) ensure that men with prostate cancer have a discussion about treatment options and adverse effects with a named nurse specialist.
Healthcare professionals ensure that men with prostate cancer have a discussion about treatment options and adverse effects with a named nurse specialist.
Commissioners (such as clinical commissioning groups and NHS England area teams) ensure that the services they commission have sufficient nurse specialists available to offer a discussion about treatment options and adverse effects to men with prostate cancer.

What the quality statement means for patients and carers

Men with prostate cancer have a discussion about treatment options and adverse effects with a named nurse with experience in prostate cancer. The man can then feel informed about his treatment options and their side effects, and supported to make decisions about his treatment.

Source guidance

Definitions of terms used in this quality statement

Adverse effects
Adverse effects of prostate cancer treatment may include:
  • sexual dysfunction
  • loss of libido
  • impotence
  • urinary incontinence
  • radiation-induced enteropathy
  • hot flushes
  • osteoporosis
  • cardiovascular complications
  • gynaecomastia
  • fatigue
  • weight gain
  • metabolic syndrome.
[Adapted from Prostate cancer (NICE guideline CG175)]
Nurse specialist
A nurse with a urology or oncology background who is a specialist in the management of prostate cancer.
[Expert opinion]
Support services
Supportive care includes a number of services, both generalist and specialist, that may be required to support people with cancer and their carers.
[Adapted from Improving supportive and palliative care for adults with cancer (NICE cancer service guidance)]

Equality and diversity considerations

Men of black African or Caribbean family origin are more likely to develop prostate cancer than other men. Despite this, awareness of prostate cancer is low among men in these groups and the nurse specialist should be aware of this when discussing prostate cancer with these men.
Similarly, older men are at higher risk of developing prostate cancer than younger men, but may be less likely to continue to engage with health services after the initial contact. The nurse specialist should be aware of this when discussing prostate cancer with older men.
Gay and bisexual men, and transgender women have a risk of developing prostate cancer. Healthcare professionals should be aware of their psychosexual needs, lifestyle and the impact of different treatment options.

Treatment options

This quality statement is taken from the prostate cancer quality standard. The quality standard defines clinical best practice in prostate cancer care and should be read in full.

Quality statement

Men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable are also offered the option of active surveillance.

Rationale

Men who are diagnosed with low-risk localised prostate cancer can be offered different treatment options, including radical prostatectomy, radical radiotherapy and active surveillance. It is important that men for whom it is suitable know that active surveillance is also an option for low-risk localised prostate cancer. This can reduce overtreatment and increase capacity for rapid treatment of high-risk disease. It can also reduce the number of men unnecessarily having radical treatment and therefore experiencing adverse effects, and decrease the cost of treating and managing these adverse effects. By discussing all the treatment options available to them, men can make an informed decision on their preferred option.

Quality measures

Structure
Evidence of local arrangements to ensure that men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable are also offered the option of active surveillance.
Data source: Local data collection.
Process
Proportion of men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable who are also offered the option of active surveillance.
Numerator – the number in the denominator who are also offered the option of active surveillance.
Denominator – the number of men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable.
Data source: Local data collection.
Outcome
a) Rates of men with low-risk localised prostate cancer on active surveillance.
Data source: Local data collection.
b) Rates of men with low-risk localised prostate cancer satisfied with their chosen treatment option.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, specialist urological cancer multidisciplinary teams and specialist prostate cancer services) ensure that systems are in place to offer the option of active surveillance to men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable.
Healthcare professionals ensure that they offer the option of active surveillance to men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable.
Commissioners (such as clinical commissioning groups and NHS England area teams) should monitor the treatment options offered to men with low-risk localised prostate cancer.

What the quality statement means for patients and carers

Men whose cancer has not spread outside the prostate and whose future risk from the cancer is low are offered the option of having regular tests but no treatment (known as active surveillance) if surgery to remove the prostate (radical prostatectomy) or radiation treatment to destroy cancer cells (radiotherapy) would also be suitable treatments for them. This may delay or prevent the need for surgery or radiation treatment, which both have side effects.

Source guidance

  • Prostate cancer (2014) NICE guideline CG175, recommendations 1.3.7 and 1.3.8 (key priorities for implementation)

Definitions of terms used in this quality statement

Active surveillance
Part of a curative strategy for men with localised prostate cancer for whom radical treatments are suitable. It keeps these men within a ‘window of curability’ whereby only those whose tumours are showing signs of progressing or those with a preference for intervention are considered for radical treatment. Active surveillance may therefore avoid or delay the need for radiation or surgery.
Active surveillance follows the protocol outlined in table 2 in prostate cancer (NICE guideline CG175).
[Prostate cancer (NICE guideline CG175) full guideline]
Low-risk localised prostate cancer
Prostate-specific antigen (PSA) less than 10 ng/ml, Gleason score 6 or below and clinical stage T1–T2A (confined to the prostate gland).
[Adapted from Prostate cancer (NICE guideline CG175)]
Radical prostatectomy
Removal of the entire prostate gland and lymph nodes by open surgery or a keyhole technique (laparoscopic or robotically assisted laparoscopic prostatectomy).
[Prostate cancer (NICE guideline CG175) full guideline]
Radical radiotherapy
Radiation, usually X-rays or gamma rays, used to destroy tumour cells, by external beam radiotherapy or brachytherapy.
[Prostate cancer (NICE guideline CG175) full guideline]

Equality and diversity considerations

Men of black African or Caribbean family origin are more likely to develop prostate cancer than other men. Despite this, awareness of prostate cancer is low among men in these groups. Similarly, older men are at higher risk of developing prostate cancer than younger men, but may be less likely to continue to engage with health services even after the initial contact with the service. For men in these groups for whom active surveillance is suitable, healthcare professionals should highlight its importance as a treatment option.
Gay and bisexual men, and transgender women have a risk of developing prostate cancer. Healthcare professionals should be aware of their psychosexual needs, lifestyle and the impact of different treatment options.

Combination therapy

This quality statement is taken from the prostate cancer quality standard. The quality standard defines clinical best practice in prostate cancer care and should be read in full.

Quality statement

Men with intermediate- or high-risk localised prostate cancer who are offered non-surgical radical treatment are offered radical radiotherapy and androgen deprivation therapy in combination.

Rationale

Androgen deprivation therapy and radiotherapy are 2 of the treatment options available for men with intermediate- or high-risk localised prostate cancer. Combining androgen deprivation therapy with radical radiotherapy can increase the effectiveness of treatment and the chances of survival compared with either androgen deprivation therapy or radical radiotherapy alone.

Quality measures

Structure
Evidence of local arrangements to ensure that men with intermediate- or high-risk localised prostate cancer who are offered non-surgical radical treatment are offered radical radiotherapy and androgen deprivation therapy in combination.
Data source: Local data collection.
Process
Proportion of men with intermediate- or high-risk localised prostate cancer receiving non-surgical radical treatment, who receive radical radiotherapy and androgen deprivation therapy in combination.
Numerator – the number in the denominator who received radical radiotherapy and androgen deprivation therapy in combination.
Denominator – the number of men with intermediate- or high-risk localised prostate cancer receiving non-surgical radical treatment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, specialised urological cancer multidisciplinary teams and specialised prostate cancer services) ensure that healthcare professionals know that radical radiotherapy and androgen deprivation therapy should be used only in combination for men with intermediate- or high-risk localised prostate cancer.
Healthcare professionals ensure that men with intermediate- or high-risk localised prostate cancer who are offered non-surgical radical treatment receive radical radiotherapy and androgen deprivation therapy in combination.
Commissioners (such as clinical commissioning groups and NHS England area teams) monitor whether men with intermediate- or high-risk localised prostate cancer offered non-surgical radical treatment are offered radical radiotherapy and androgen deprivation therapy in combination. Commissioners may wish to ask providers for evidence of practice.

What the quality statement means for patients and carers

Men whose cancer has not spread outside the prostate and whose future risk from the cancer is medium or high are offered treatment of combined radiation treatment to destroy the cancer cells (called radiotherapy) and a drug that blocks the production of androgen, a hormone that helps cancer cells to grow (called androgen deprivation therapy). Having radiotherapy together with androgen deprivation therapy usually works better than having just one of these treatments on its own.

Source guidance

  • Prostate cancer (2014) NICE guideline CG175, recommendation 1.3.19 (key priority for implementation)

Definitions of terms used in this quality statement

Androgen deprivation therapy
Treatment with a luteinising hormone-releasing hormone agonist such as goserelin to lower testosterone levels.
[Adapted from Prostate cancer (NICE guideline CG175) full guideline]
High-risk localised prostate cancer
Prostate-specific antigen (PSA) greater than 20 ng/ml, Gleason score 8–10 or clinical stage T2C or greater.
[Prostate cancer (NICE guideline CG175)]
Intermediate-risk localised prostate cancer
PSA 10–20 ng/ml, Gleason score 7 or clinical stage T2B.
[Prostate cancer (NICE guideline CG175)]
Radical radiotherapy
Radiation, usually X-rays or gamma rays, used to destroy tumour cells by external beam radiotherapy or brachytherapy.
[Prostate cancer (NICE guideline CG175) full guideline]

Equality and diversity considerations

Some older men may have previously been offered androgen deprivation therapy alone. Focusing on the benefits of combination therapy for older men with intermediate- or high-risk localised prostate cancer should help to reduce such inequalities.
Gay and bisexual men, and transgender women have a risk of developing prostate cancer. Healthcare professionals should be aware of their psychosexual needs, lifestyle and the impact of different treatment options.

Managing adverse effects of treatment

This quality statement is taken from the prostate cancer quality standard. The quality standard defines clinical best practice in prostate cancer care and should be read in full.

Quality statement

Men with adverse effects of prostate cancer treatment are referred to specialist services.

Rationale

Treatments for prostate cancer have various adverse effects that can continue after the treatment is completed. Adverse effects include sexual dysfunction, loss of libido, impotence, urinary incontinence, radiation-induced enteropathy, hot flushes, osteoporosis, cardiovascular complications, gynaecomastia and fatigue. These adverse effects can also have an emotional and psychological impact on men. Specialist services that provide interventions such as counselling, drug therapy, radiotherapy, physiotherapy and aerobic exercise can help to manage adverse effects of treatment and substantially improve the man’s quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that men with adverse effects of prostate cancer treatment are referred to specialist services.
Data source: Local data collection and the National Prostate Cancer Audit.
Process
Proportion of men with adverse effects of prostate cancer treatment who use specialist services.
Numerator – the number in the denominator who use specialist services.
Denominator – the number of men with adverse effects of prostate cancer treatment.
Data source: Local data collection and the National Prostate Cancer Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, specialist urological cancer multidisciplinary teams and specialist prostate cancer services) ensure that systems are in place for men with adverse effects of prostate cancer treatment to be referred to specialist services.
Healthcare professionals refer men with adverse effects of prostate cancer treatment to specialist services.
Commissioners (such as clinical commissioning groups and NHS England area teams) have pathways in place to ensure that men with adverse effects of prostate cancer treatment are referred to specialist services.

What the quality statement means for patients and carers

Men who have side effects from prostate cancer treatment are referred to specialist services (such as erectile dysfunction or continence services) to help stop or ease the side effects.

Source guidance

  • Prostate cancer (2014) NICE guideline CG175, recommendations 1.3.31 (key priority for implementation), 1.3.34, 1.3.37 (key priority for implementation), 1.4.3, 1.4.8, 1.4.13, 1.4.14, 1.4.16, 1.4.18 and 1.4.19

Definitions of terms used in this quality statement

Adverse effects
Adverse effects include:
  • sexual dysfunction
  • loss of libido
  • impotence
  • urinary incontinence
  • radiation-induced enteropathy
  • hot flushes
  • osteoporosis
  • cardiovascular complications
  • gynaecomastia
  • fatigue
  • weight gain
  • metabolic syndrome.
[Adapted from Prostate cancer (NICE guideline CG175)]
Specialist services
The specialist services include erectile dysfunction services, continence services and psychosexual counselling.
[Adapted from Prostate cancer (NICE guideline CG175)]

Equality and diversity considerations

Older men may need encouragement to engage with specialist services as they tend not to use the health service as much as other people.
Gay and bisexual men, and transgender women have a risk of developing prostate cancer. Healthcare professionals should be aware of their psychosexual needs, lifestyle and the impact of different treatment options.

Hormone-relapsed metastatic prostate cancer

This quality statement is taken from the prostate cancer quality standard. The quality standard defines clinical best practice in prostate cancer care and should be read in full.

Quality statement

Men with hormone-relapsed metastatic prostate cancer have their treatment options discussed by the urological cancer multidisciplinary team (MDT).

Rationale

Discussion by the urological cancer MDT is a means of ensuring that an opinion from an oncologist and/or palliative care specialist is obtained. Having a variety of opinions from experts who are aware of all current treatment options means that there is a better chance to identify the best options for the man. Those options can then be discussed with the man.

Quality measures

Structure
Evidence of local arrangements to ensure that men with hormone-relapsed metastatic disease have their treatment options discussed by the urological cancer MDT.
Data source: Local data collection and the National Prostate Cancer Audit.
Process
Proportion of men with hormone-relapsed metastatic disease who have their treatment options discussed by the urological cancer MDT.
Numerator – the number in the denominator who have their treatment options discussed by the urological cancer MDT.
Denominator – the number of men with hormone-relapsed metastatic prostate cancer.
Data source: Local data collection and the National Prostate Cancer Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as hospitals, specialist urological cancer MDTs and specialist prostate cancer services) ensure that systems are in place for men with hormone-relapsed metastatic prostate cancer to have their treatment options discussed by the urological cancer MDT.
Healthcare professionals ensure that men with hormone-relapsed metastatic prostate cancer have their treatment options discussed by the urological cancer MDT.
Commissioners (such as clinical commissioning groups and NHS England area teams) monitor whether providers have systems in place to ensure that men with hormone-relapsed metastatic prostate cancer have their treatment options discussed by the urological cancer MDT.

What the quality statement means for patients and carers

Men with cancer that has spread outside the prostate and whose drug treatment (to block the production of hormones that help cancer cells to grow) has stopped working have their treatment options discussed by a specialist team of healthcare professionals with different kinds of expertise in prostate cancer. This is to make sure that all the different treatment options are discussed and all suitable treatments are offered.

Source guidance

Definitions of terms used in this quality statement

Hormone-relapsed prostate cancer
Prostate cancer after failure of primary androgen deprivation therapy.
[Prostate cancer (NICE guideline CG175) full guideline]
Urological cancer MDT
A team that includes specialists in urology, oncology, pathology, radiology, palliative care, diet and nursing.
[Adapted from Prostate cancer (NICE guideline CG175) full guideline and MDT (multi-disciplinary team) guidance for managing prostate cancer (British Uro-Oncology Group and British Association of Urological Surgeons)]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Do not offer bisphosphonates for the prevention of bone metastases in men with prostate cancer.
Men with prostate cancer who have chosen a watchful waiting regimen with no curative intent should normally be followed up in primary care in accordance with protocols agreed by the local urological cancer MDT and the relevant primary care organisation(s). Their PSA should be measured at least once a year.

Glossary

androgen deprivation therapy
atypical small acinar proliferation
digital rectal examination
Eastern Cooperative Oncology Group
An internationally recognised grading system, based on examination of tissue obtained by prostate biopsy, in which a pathologist allocates an overall cell abnormality score that can help predict prostate tumour behaviour. A low Gleason score (6 or lower) indicates a relatively non-aggressive cancer; a high Gleason score (8 or higher) indicates a relatively aggressive cancer.
high-grade prostatic intra-epithelial neoplasia
multidisciplinary team
multidisciplinary teams
phosphodiesterase type 5
prostate-specific antigen

Paths in this pathway

Pathway created: October 2011 Last updated: August 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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