How the research was conducted
• The major databases and bibliographic sources were searched for
relevant articles together with meetings with specialists.
Research findings
Epidemiology
• The incidence of prostate cancer is increasing worldwide due to the growing
elderly population and because of increased testing for prostate cancer.
Aetiology
• Dietary factors and heredity (<10%) may be risk factors but more research is needed.
Pathogenesis and natural
history
• Many prostate tumours are slow growing. Histological grade is the best predictor
of progression.
Diagnosis
• General practitioners (GPs) initially attempt to differentiate between benign
prostatic hyperplasia (BPH) and cancer. The use of diagnosis tests is believed to be
increasing. Patients with severe BPH or suspected cancer are referred to hospital
specialists.
• Hospital diagnostic tests include prostate specific antigen (PSA), transrectal
ultrasound and core-needle biopsy.
• Transurethral resection of the prostate (TURP) for the relief of BPH has
developed without evaluation of its effect on increasing the diagnosis of latent cancer.
Treatment of localised disease
• There is a lack of good quality evidence about the relative effectiveness of the
three main treatment options: radical prostatectomy, radiotherapy, and conservative
management (monitoring and treatment of symptoms).
• Current trials comparing the three main methods will take many years to
determine which is the most effective treatment.
Treatment of advanced disease
• Much more research has been conducted into the treatment of advanced disease
than localised disease. Androgen deprivation (surgical or medical castration) is the
standard treatment.
• Progression of disease can be slowed down by starting androgen deprivation as
soon as advanced disease is diagnosed.
• The additional cost and side-effects of combined treatment (castration and
anti-androgens) has yet to be shown to be cost-effective.
Screening
• There is no evidence about the number of deaths that could be prevented by
screening asymptomatic men, and a lack of evidence about the best way to treat early
disease. It is therefore not possible to estimate the cost-effectiveness of screening.
• Screening can cause additional morbidity from biopsy and treatment side-effects.
• Ad hoc PSA testing is believed to be increasing rapidly, leading to the
diagnosis of early stage prostate cancer for which the effectiveness of treatment is not
known.
Economic issues/burden on the health services
• Only direct costs to the health care system were considered. From the available
data, prostate cancer in England and Wales costs the health service at least £45
million/year, although the true costs are likely to be more than £55 million/year.
• If 1.4% of men aged 45–84 years had one PSA diagnostic test per year, these
tests alone could cost £1.2 million/year. Subsequent costs include additional diagnostic
tests and unproven treatments.
Main recommendations
• More information about pathological TNM staging and clinical staging should be
recorded, and national cancer registries established.
• Opportunistic screening should be discouraged.
• PSA testing could be limited to certain specialities (e.g. urologists, clinical
oncologists).
• If PSAtesting becomes widespread, a national computerised information system
should be established to analyse the number of PSA tests, indications tested for, and the
results.
• GPs and the public should be educated about the potential disadvantages and
uncertainties of PSA testing.
• Policies on core-needle biopsy procedure and criteria for performing histology
of TURP are needed.
• The cost of different diagnostic procedures needs further investigation.
• For men with <10 years life expectancy and those with a T1a Gleason grade
< 4 tumour, “watchful waiting” is probably the most appropriate treatment
option because of the low incidence of side-effects.
• Radical prostatectomy should only be conducted by specialist urologists and a
system for auditing complications arising from this procedure should be set up.
• Recruitment to the on-going MRC trial PR06 needs to be encouraged.
Main research suggestions
• Further basic research is required to identify prognostic disease markers.
• Further research is required to determine the effect of diet, hormone levels and
exercise on the aetiology and prevention of prostate cancer.
• Priority should be given to a randomised controlled trial of PSA screening in
the UK which should include assessment of possible alternative criteria for referral,
quality of life measures, resource costs and evaluation of treatment.
Overall conclusion
• The number of men requiring care for prostate cancer and the burden of the
disease on all sectors of health care will increase over the next decade. The
effectiveness of screening is not proven, and a national screening programme is not
justified on current evidence. In addition, the effectiveness of different methods of
management of localised disease is not known, so any randomised trial of screening should
also address the question of treatment.
Publications
Chamberlain J, Melia J, Moss S, Brown J. The diagnosis, management, treatment and costs of
prostate cancer in England and Wales. Health Technology Assessment 1997; 1
(3).
British Journal of Urology supplement (Summer 1997).
NHS R&D HTA Programme
The overall aim of the NHS R&D Health Technology Assessment (HTA)
programme is to ensure that high-quality research information on the costs, effectiveness
and broader impact of health technologies is produced in the most efficient way for those
who use, manage and work in the NHS. Research is undertaken in those areas where the
evidence will lead to the greatest benefits to patients, either through improved patient
outcomes or the most efficient use of NHS resources. The Standing Group on Health
Technology advises on national priorities for health technology assessment. Six advisory
panels assist the Standing Group in identifying and prioritising projects. These
priorities are then considered by the HTA Commissioning Board supported by the National
Coordinating Centre for HTA.
This report is one of a series covering acute care, diagnostics and
imaging, methodology, pharmaceuticals, population screening, and primary and community
care.
Series Editors:
Dr Andrew Stevens and Dr Ruairidh Milne National Coordinating Centre for
HTA
©1997 Crown Copyright
The editors and publisher have tried to ensure the accuracy of this report but do not accept liability for damages or losses arising from material published in this report.
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