IS IT TIME TO MISS THE TARGET FOR PROSTATE CANCER?

Authors


Giles O. Hellawell, Department of Urology, NWLH NHS Trust, London HA1 3UJ, UK. e-mail: gileshellawell@hotmail.com

The global emphasis on improving health outcomes has led to the creation in many countries of chronological targets in the patient pathway. In the UK, time periods for urgent cancer referrals have been adopted and these have been modified, more recently, to create strict timelines for completion of treatment. The Department of Health now has a 2-month target from referral to treatment for all cancers, referred to as the ‘62-day target’. Patients enter this pathway via the referring primary care practitioner who adheres to the guidelines that dictate the criteria for an urgent cancer referral. The timescale for initial review and subsequent treatment applies uniformly to all cancers (except basal cell carcinoma). The creation of financial penalties that apply when a patient ‘breaches’ the targets has ensured the timelines are adhered to.

The uniformity of these targets ensures that a low-risk prostatic carcinoma is necessarily treated in the same timescale as a poorly differentiated bladder cancer. Radical treatment of both may ultimately be required but the timescale in which this should be achieved does not equate to the aggressiveness of each tumour type. The variety of treatments now available for prostate cancer ensures that a rapid treatment decision is rarely possible, nor appropriate. Historically, this was overcome by the artifice of ‘stopping the clock’ whilst further imaging was requested and thereby the time for reflection and appropriate decision making was created. The principal complaint of dissatisfied men undergoing treatment for localized prostate cancer has been a belief that they had been rushed into making a treatment decision [1]. The subsequent abolition of this loophole brought prostate cancer back into the 62-day target within the UK. In order to achieve compliance with such a limited timescale the guidelines regarding time-to-imaging (MRI) after biopsy are inevitably flouted and/or the option of a period of active surveillance as definitive management becomes inappropriately attractive. Inaccurate staging may result because prostate MRI should not ideally be performed for at least 8 weeks after biopsy as haemorrhage may interfere with interpretation of the images [2]. Early surgery may compromise outcomes as inflammation may impede dissection and influence nerve-sparing ability and subsequent outcomes [3].

Many contemporary studies have shown that a more circumspect approach can be undertaken safely in prostate cancer. A study by Friedland et al.[4] followed 895 men with low-risk prostate cancer for 5 years. They found that a delay of up to 180 days did not result in an increase in positive surgical margins or decrease the time to biochemical recurrence. A similar study by Phillips et al.[5] analysed 393 men with low-, intermediate- and high-risk localized prostate cancer who underwent radical treatment either before 3 months or later than 3 months and showed that a delay of up to 3 months had no adverse effect on biochemical recurrence-free survival. A study by Van den Bergh et al.[6] followed 217 patients with low-risk prostate cancer who underwent either immediate radical prostatectomy (within 0.5 years) or delayed radical prostatectomy (after 2.6 years). They also found no difference in frequencies of Gleason score >6, capsular penetration, positive margin rates, tumour volume or biochemical progression rates between the two groups.

Controversy currently surrounds the selection and verification of patients with low-risk prostate cancer who may be suitable for active surveillance management. The controversy pertains to the accuracy by which these low-risk tumours can be characterized using the techniques of MRI and prostatic mapping. The implementation of surveillance of patients as part of national guidelines whilst controversy exists over the diagnosis of such patients, highlights flaws in the legislation over targets that have scant supporting literature yet much to support the abolition or dramatic extension of the targets.

Whilst delay in treating any cancer may be counterintuitive, the data show that delaying treatment of prostate cancer by 3–12 months has no adverse effect on eventual outcome, whether it be in terms of positive surgical margins, higher Gleason scores or biochemical recurrence-free survival rates. The adoption of an extended period of 180 days between referral and treatment would permit timely imaging and enable a well-informed and timely decision to be made regarding treatment method. There may be an additional psychological morbidity associated with a delay in treatment and the associated uncertainty that merits further study, but, in the contemporary management of prostate cancer, with the involvement of a multidisciplinary team for whom accurate imaging and staging is key, a delay is justifiable and hence one must question the validity of chronological targets in the treatment of patients with prostate cancer.

CONFLICT OF INTEREST

None declared.

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