Prostate Cancer in the West Midlands

West Midlands Cancer Intelligence Unit Prostate Cancer in the West Midlands k Supporting the fight against cancer through timely, high quality information provision Report Number R12/4 October 212 Author: TE Last updated: 19/4/1 T:\Reports\Authored\Site Specific Reports\REPORTS\Prostate 211 report\5 REPORT\Prostate_Final.docx Version: 1.1

For any enquires regarding the information in this report please contact: Dr Tim Evans West Midlands Cancer Intelligence Unit Public Health Building The University of Birmingham Birmingham B15 2TT Tel: 121 414 4274 Fax: 121 414 7712 E-mail: tim.evans@wmciu.nhs.uk Copyright WMCIU 212 This report is available to download in pdf form from our website http://www.wmciu.nhs.uk Author: TE/CB/GL Last updated: 2/1/12

TABLE OF CONTENTS EXECUTIVE SUMMARY... 1 1. INTRODUCTION... 2 1.1 Prostate Cancer... 2 1.2 Risk Factors... 2 1.3 Health Geography in the West Midlands... 3 1.4 The West Midlands Cancer Intelligence Unit... 3 2. INCIDENCE AND MORTALITY... 4 2.1 Prostate Cancer Incidence and Mortality in England and the West Midlands... 4 2.2 Prostate Cancer Incidence Trends in the West Midlands... 5 2.3 Variation in Prostate Cancer Incidence with Deprivation... 5 2.4 Prostate Cancer Incidence in the Top Tier Local Authorities... 6 2.5 Prostate Cancer Mortality Trends in the West Midlands... 6 2.6 Variation in Prostate Cancer Mortality with Deprivation... 7 2.7 Prostate Cancer Mortality in the Top Tier Local Authorities... 7 2.8 Prostate Cancer Mortality/Incidence Rate Ratios in the Top Tier Local Authorities... 8 3. SURVIVAL... 9 3.1 Trends in Survival in the West Midlands... 9 3.1.1 Prostate cancer survival in the West Midlands... 9 3.1.2 Variation in Prostate Cancer Survival with Deprivation... 9 3.2 Prostate Cancer Survival in the Top Tier Local Authorities... 1 4. REFERRAL PATTERNS... 11 4.1 Referral Patterns to Acute Trusts... 11 4.2 Referral Patterns of Trust First Seen to Trust of Radiotherapy... 12 5. TREATMENT... 12 5.1 Types of Treatment... 12 5.2 Prostate Cancer Treatment Patterns... 13 5.2.1 Variation in Prostate Cancer Treatment with Age... 13 5.2.2 Variation in Prostate Cancer Treatment with Deprivation... 13 5.2.3 Variation in Prostate Cancer Treatment with Trust First Seen... 14 5.2.4 Treatment in Each Top Tier Local Authority... 15 6. SURGICAL CASELOAD... 15 6.1 Trust Caseload... 15 6.2 Consultant Surgical Caseload... 16 7. STAGE AT DIAGNOSIS... 18 7.1 Histological Confirmation of Prostate Cancer... 18 7.2 Variation in Stage Completeness with Trust First Seen... 18 8. TRUST-BASED 3-DAY MORTALITY AND SURVIVAL... 2 8.1 3-day Post Operative Mortality... 2 8.2 Variation in Prostate Cancer Survival with Trust of Surgery... 21 APPENDIX... 22 THE WEST MIDLANDS CANCER INTELLIGENCE UNIT... 23 Author: TE/CB/GL Last updated: 2/1/12

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INCIDENCE AND MORTALITY EXECUTIVE SUMMARY In 28-21, 11,33 cases of prostate cancer were diagnosed in the West Midlands, and 2,833 people died of the disease. Prostate cancer is most common in the elderly; very few cancers are diagnosed in the under 5s. Prostate cancer incidence has increased by 7% between 21-3 and 28-1, while mortality rates due to prostate cancer have decreased by 16%. Prostate cancer incidence varies with deprivation; incidence rates are highest in Solihull and lowest in Telford & Wrekin. Mortality rates do not vary significantly across the region. SURVIVAL Prostate cancer survival rates are good compared with other cancers, with 97% of patients surviving 1 year after diagnosis and more than 85% of patients surviving 5 years. Deprivation plays a statistically significant role in 5-year survival following a prostate cancer diagnosis; with 93% of patients in the least deprived group surviving for 5 years compared to 8% in the most deprived group. This may reflect differing uptake of PSA testing in each group. REFERRAL PATTERNS Most prostate cancer patients are diagnosed in Trusts in the cancer network where they live. Prostate cancer patients are referred to each of the five Trusts with radiotherapy facilities. Two Trusts that fall outside the West Midlands also serve patients for whom these Trusts may be geographically closer than those in the West Midlands. TREATMENT The proportion of patients receiving surgical treatment decreases with age and the proportion of patients with no record of treatment rises rapidly with age. For many prostate cancer patients, watchful wait monitoring is appropriate as surgical interventions may confer little additional life-expectancy whilst presenting patients with other life-style complications. The Burton Hospitals NHS Trust had a high proportion of patients who had no treatment recorded and a low proportion of patients receiving surgery. This may be due to the incomplete provision of treatment data for patients who are referred on to out of region Trusts. SURGICAL CASELOAD With the exception of Heart of England NHS Foundation Trust and the Worcestershire Acute Hospitals NHS Trust, the majority of prostate cancer surgery is undertaken by a single lead clinician in most West Midlands Trusts. Ten consultants were recorded as performing fewer than 1 urological resections in 21 in the West Midlands region. STAGE AT DIAGNOSIS Staging data were provided to the WMCIU for only 55% of prostate cancers. The Mid Staffordshire NHS Foundation Trust provided a stage for more than 8% of its patients. TRUST BASED 3-DAY MORTALITY AND SURVIVAL Seven prostate cancer patients died within 3 days of their elective surgical treatment. One, two and five-year relative survival rates following surgery were at or above 1% in the main hospitals where surgery was undertaken. This is likely to be due to the nature of the cohort selected for surgical treatment as well as the efficacy of the treatment. Author: TE/CB/GL Page 1 of 23 Last updated: 2/1/12

1. INTRODUCTION 1.1 Prostate Cancer Prostate cancer is the most common cancer in men in England, and after lung cancer is the second most common cause of male cancer death in England 1. This report presents an analysis of prostate cancer incidence, mortality and survival in the West Midlands, together with information on referral and treatment patterns. The majority of invasive malignant cancers of the prostate (ICD-1 code C61) are adenocarcinomas; that is malignant cancers that arise in the cells of glandular tissue. Figure 1.1 illustrates the location of the prostate gland in the male body. Figure 1.1: Anatomical location of the prostate 2 1.2 Risk Factors Reproduced courtesy of NHS Choices A number of risk factors are thought to influence the likelihood of an individual developing prostate cancer, but for many the evidence is inconclusive 3. Age, family history and ethnicity are established risk factors. Age is the strongest known causative link with prostate cancer; with risk increasing noticeably in men aged over 5 years. Where there is a family history of prostate cancer, the risk is greater; approximately 5-1% of all prostate cancers are caused by inherited genetic factors 4. If a man has an immediate relative diagnosed with prostate cancer, then the risk of being diagnosed with prostate cancer is 2-3 times greater. Black Caribbean and Black African men have an estimated 2-1 UKCIS, (register for use http://www.ncin.org.uk/cancer_information_tools/ukcis.aspx#register ) 2 Courtesy of NHS Choices http://www.nhs.uk/conditions/cancer-of-the-prostate/pages/introduction.aspx (Accessed 2/4/212) 3 Cancer Research UK, Prostate Cancer- risk factors. http://info.cancerresearchuk.org/cancerstats/types/prostate/riskfactors/ (Accessed 16/2/212) 4 Cancer Research UK, Family history and prostate cancer risk. http://info.cancerresearchuk.org/cancerstats/types/prostate/riskfactors/#family (Accessed 16/2/212) Author: TE/CB/GL Page 2 of 23 Last updated: 2/1/12

3 times greater risk of a prostate cancer diagnosis compared to White men. Asian men have a lower than average risk of developing prostate cancer 5. Though evidence for other risk factors is mixed, foods containing lycopene and selenium are thought to have a protective effect, whilst high levels of calcium consumption may increase the risk of prostate cancer 6. 1.3 Health Geography in the West Midlands This report covers prostate cancers diagnosed and/or treated within the West Midlands. A document containing information about the Cancer Networks, Local Authorities and acute Trusts providing cancer services in the West Midlands is available on the WMCIU s website 7. For easy reference, a summary of the population characteristics for the top-tier Local Authorities is included in Table 1.1. There are relatively high proportions of people aged over 7 years in Herefordshire and Shropshire (15% and 13% respectively) compared with Birmingham and Telford & Wrekin (1%). The proportion of people with Black and Asian ethnic origin is highest in Birmingham, Wolverhampton and Sandwell (28%, 2% and 19% respectively) and lowest in Herefordshire and Shropshire (1%). Stoke-on-Trent has the highest levels of obesity and smoking (31% and 3% respectively. Obesity levels are lowest in Birmingham (23%) and smoking levels are lowest in Solihull (2%). Birmingham has the highest levels of deprivation in the West Midlands with a deprivation score of.26, while Warwickshire has the lowest level of deprivation in the West Midlands with a deprivation score of.1. Table 1.1: Top Tier Local Authority population characteristics, 21 TTLA Age profile 21 Ethnicity profile Health profile Mean Age (Years) % over 7 % White % Asian % Black 21 Coventry 38 1 81 11.9 3.1 4.5 28 27.19 Warwickshire 42 11 94 3.6.8 2. 26 22.1 Dudley 41 13 92 4.8 1.4 2.1 27 25.17 Shropshire 44 11 97.9.4 1.4 27 21.11 Staffordshire 42 13 96 2.1.6 1.4 27 22.11 Stoke-on-Trent 39 13 93 4.3.9 2. 31 3.21 Telford & Wrekin 39 12 94 3.4.8 2.3 28 25.18 Wolverhampton 39 16 76 14.8 4.8 4.2 29 25.24 Birmingham 36 1 67 2.7 6.6 5.4 23 25.26 Sandwell 39 15 77 15. 4.3 3.3 28 29.25 Solihull 42 11 91 4.5 1.6 2.6 24 2.12 Walsall 4 13 85 11. 1.9 2.5 28 26.22 Herefordshire 44 13 98.7.4 1. 27 21.11 Worcestershire 42 13 96 2..7 1.6 26 21.11 West Midlands 4 12 89 7.3 2. 2. 26 24.17 This report uses abbreviations for the names of the acute Trusts in the West Midlands in tables and figures; these are defined in Table A.1 in the Appendix. 1.4 The West Midlands Cancer Intelligence Unit % Mixed, Chinese or Other % Obese % Smoking Deprivation score Income Domain IMD The West Midlands Cancer Intelligence Unit (WMCIU) houses the regional cancer registry that serves West Midlands residents. A short description of the WMCIU, the data collected by the registry and the typical work of the registry is included in the Appendix at the end of this report. 5 Cancer Research UK, Ethnicity and prostate cancer risk. http://info.cancerresearchuk.org/cancerstats/types/prostate/riskfactors/#ethnicity (Accessed 16/2/212) 6 Cancer Research UK, Diet and prostate cancer risk. http://info.cancerresearchuk.org/cancerstats/types/prostate/riskfactors/#diet (Accessed 16/2/212) 7 West Midlands Cancer Intelligence Unit, Health Geography of the West Midlands, 211. http://www.wmciu.nhs.uk/documents/wm_geographies_212.pdf (Accessed 16/2/212) Author: TE/CB/GL Page 3 of 23 Last updated: 2/1/12

-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ Number of cases/ deaths Crude rates per 1, population 2. INCIDENCE AND MORTALITY 2.1 Prostate Cancer Incidence and Mortality in England and the West Midlands There were 11,33 cases of prostate cancer diagnosed in the West Midlands in the 3-year period 28-21, and 2,833 deaths. Prostate cancer mortality rates in the West Midlands are the same as those for England as a whole (23.9 per 1, male population). The 27-29 incidence data presented for England are the most recent available, and can be used for broad comparisons with the 28-21 West Midlands data. Prostate cancer agestandardised incidence rates are significantly higher in the West Midlands than in England (17.8 compared to 14.1 per 1, male population). However, as the incidence of prostate cancer is highly dependent on the use of prostate specific antigen (PSA) testing which has changed over time and varies considerably throughout England, comparative data should be interpreted with care. Table 2.1: Prostate cancer incidence and mortality in the West Midlands and England Statistic Geography Year Incidence Mortality Number of cases/ deaths Crude rate per 1, population Age-standardised rate per 1, European standard population West Midlands 28-21 11,33 141.3 17.8 ( 15.8-19.9 ) England 27-29 98,898 13.2 14.1 ( 13.4-14.7 ) West Midlands 28-21 2,833 35.3 23.9 ( 23. - 24.9 ) England 28-21 26,54 35.2 23.9 ( 23.6-24.2 ) Cancer is a disease of the elderly, no more so than for prostate cancer. The number of prostate cancers diagnosed is highest in men aged 65-69 and 7-74 years. Crude incidence rates peak in males aged 75-79 at just over 8 cases per 1, males (Figure 2.1). Very few prostate cancers are diagnosed in men aged under 5 years. Deaths due to prostate cancer rise steadily with age; with the numbers of deaths and the crude mortality rate peaking in those age 85 years and over. Figure 2.1: Age profile for prostate cancer incidence and mortality, West Midlands, 28-21 2,5 1, 2, 8 1,5 1, 5 6 4 2 Age group No. of tumours No. of deaths Crude incidence rate Crude mortality rate Author: TE/CB/GL Page 4 of 23 Last updated: 2/1/12

Age-standardised incidence rate per 1, population 21-23 22-24 23-25 24-26 25-27 26-28 27-29 28-21 Age-standardised incidence rate per 1, population 2.2 Prostate Cancer Incidence Trends in the West Midlands Prostate cancer age-standardised incidence rates have increased significantly from 11 per 1, males (CI 99,13) in 21-23 to 18 per 1, males (CI 16,11) in 28-21 (Figure 2.2). Figure 2.2: Prostate cancer incidence trends, West Midlands Dotted lines indicate 95% confidence intervals 14 12 1 8 6 4 2 Diagnosis year 2.3 Variation in Prostate Cancer Incidence with Deprivation Figure 2.3 shows how the incidence of prostate cancer varies with deprivation. Prostate cancer is more common in males in the least deprived quintile; with age-standardised incidence rates 19% higher in males in the least deprived quintile compared with males in the most deprived quintile. Figure 2.3: Prostate cancer incidence by ID21 deprivation quintile, West Midlands, 28-21 14 12 1 8 6 4 2 Least deprived Average Most deprived Deprivation quintile Author: TE/CB/GL Page 5 of 23 Last updated: 2/1/12

21-23 22-24 23-25 24-26 25-27 26-28 27-29 28-21 Age-standardised mortality rate per 1, population Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire Age-standardised incidence rate per 1, population 2.4 Prostate Cancer Incidence in the Top Tier Local Authorities Figure 2.4 shows how prostate cancer age-standardised incidence rates in 28-21 varied between top tier Local Authorities (TTLA). Local authorities are grouped according to cancer network in the order Arden, Greater Midlands, Pan Birmingham and 3-Counties. Prostate cancer incidence was significantly higher in the TTLAs of Solihull, Birmingham, Dudley and Worcestershire compared to the West Midlands average. Significantly lower incidence rates were observed in the TTLAs of Telford & Wrekin, Shropshire, Stoke-on-Trent and Walsall. A number of factors, including levels of deprivation, ethnicity profile and the level of PSA testing undertaken may be the cause of differences in age-standardised incidence rates between TTLAs. Figure 2.4: Prostate cancer incidence in top tier Local Authorities, West Midlands, 28-21 16 14 12 1 8 6 4 2 Top Tier Local Authority West Midlands WM confidence interval 2.5 Prostate Cancer Mortality Trends in the West Midlands Figure 2.5: Prostate cancer mortality trends, West Midlands Dotted lines indicate 95% confidence intervals 4 35 3 25 2 15 1 5 Year death registered Author: TE/CB/GL Page 6 of 23 Last updated: 2/1/12

Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire Age-standardised mortality rate (per 1, population) Age-standardised mortality rate per 1, population In contrast to incidence rates, prostate cancer mortality rates have steadily decreased since 21-23 (Figure 2.5). Mortality rates in 28-21 are significantly lower than those in 21-23 (24 deaths per 1, males (CI 23, 25) and 28 per 1, males (CI 27, 29) respectively). 2.6 Variation in Prostate Cancer Mortality with Deprivation Figure 2.6 illustrates mortality due to prostate cancer, stratified by deprivation. For the period 28-21, there were no differences in mortality rates between males in the different deprivation quintiles. Figure 2.6: Prostate cancer mortality by ID21 deprivation quintile, West Midlands, 28-21 4 3 2 1 Least deprived Average Most deprived Deprivation quintile 2.7 Prostate Cancer Mortality in the Top Tier Local Authorities Figure 2.7: Prostate cancer mortality by Top Tier Local Authority, West Midlands, males, 28-21 4 35 3 25 2 15 1 5 Top Tier Local Authority West Midlands WM confidence interval Age-standardised mortality rates from prostate cancer in 28-21 did not vary significantly between top tier Local Authorities and the West Midlands (Figure 2.7). The wider confidence intervals for Telford & Wrekin are due to the small number of deaths registered between 28-21. Author: TE/CB/GL Page 7 of 23 Last updated: 2/1/12

Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire Mortality/incidence rate ratio 2.8 Prostate Cancer Mortality/Incidence Rate Ratios in the Top Tier Local Authorities The relationship between the mortality and incidence of a disease can be measured with reference to mortality incidence ratios (M:I) for cases occurring in equivalent time periods. For cancers typically characterised by short-term survival, for example lung and liver cancer, a M:I ratio of close to one is not unusual. In contrast, for breast and prostate cancer where survival is usually very good, M:I ratios are generally much lower than one. In rare situations, M:I ratios of greater than one are observed; this is likely to reflect under-recording of new cases, and/or inaccurate mortality statistics 8. Figure 2.8 shows the mortality/incidence ratio for prostate cancers in top tier Local Authorities in 28-21. Telford & Wrekin and Shropshire had significantly higher mortality incidence ratios compared to the West Midlands. This is due to the significantly low incidence rates in these TTLAs (Telford & Wrekin has the lowest incidence in the whole of the West Midlands), and the slightly higher than average mortality rates. Solihull had a significantly lower mortality/incidence ratio, explained by its significantly high incidence and lower than average mortality rate (Solihull had the lowest mortality rate in the West Midlands). A number of factors, including level of deprivation, ethnicity profile, the level of PSA testing undertaken and tumour stage at presentation may be the cause of differences in incidence and mortality rates between TTLAs. The lower than average mortality/incidence ratio in Solihull may be related to high levels of PSA testing in this relatively affluent TTLA. Figure 2.8: Prostate cancer mortality/incidence rate ratios by Top Tier Local Authority, West Midlands, males, 28-21.6.4.2. Top Tier Local Authority West Midlands West Midlands CI 8 Belgian Cancer Registry, Cancer Incidence in Belgium, 28. http://kankerregister.nettools.be/media/docs/stk_publicatie.pdf (Accessed 26/3/212) Author: TE/CB/GL Page 8 of 23 Last updated: 2/1/12

Relative survival rate 3. SURVIVAL 3.1 Trends in Survival in the West Midlands Figure 3.1 shows one-, five- and ten-year relative survival rates for prostate cancer in the West Midlands. Survival from a prostate cancer diagnosis is usually very high and has been rising since the mid 199s. One-year relative survival has risen significantly from 89% for cases diagnosed in 1996-2 to 97% for cases diagnosed in 26-21. Five-year relative survival has risen more rapidly from 67% in 1996-2 cases to 85% in 22-26 cases. Ten-year relative survival has also increased significantly from 57% in 1996-2 to 63% in 1997-21. 3.1.1 Prostate cancer survival in the West Midlands Figure 3.1: Prostate cancer survival trends, West Midlands, males Dotted lines indicate 95% confidence intervals 1% 8% 6% 4% 2% % 1996-2 1997-21 1998-22 1999-23 2-24 21-25 Diagnosis year 22-26 23-27 24-28 25-29 26-21 One-year relative survival Five-year relative survival Ten-year relative survival Increases in survival are likely to reflect the effects of earlier detection, in particular the use of PSA testing, and are perhaps less reflective of significant improvements in treatment. However, prostate cancer mortality rates have fallen since 21-23, indicating either that some advancement in treatment has occurred, in particular the targeted use of radiotherapy, or improvements in the stage at diagnosis through earlier presentation. 3.1.2 Variation in Prostate Cancer Survival with Deprivation Figure 3.2 shows how one- and five-year relative survival rates for prostate cancer vary with deprivation. Although one-year relative survival rates were higher in males in the least deprived quintile, the differences in survival between deprivation quintiles were not significantly different. Five-year relative survival following a prostate cancer diagnosis is significantly higher in men in the least deprived quintile than in those in the most deprived quintile (93% compared to 8%). This may reflect higher levels of PSA testing uptake by more affluent men resulting in an earlier diagnosis. Author: TE/CB/GL Page 9 of 23 Last updated: 2/1/12

Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire Relative survival rate Least deprived Average Most deprived Least deprived Average Most deprived Relative survival rate Figure 3.2: Prostate cancer survival by ID21 deprivation quintile, West Midlands, 1-year diagnosed 26-21 and 5-year diagnosed 22-26 12% 1% 8% 6% 4% 2% % 1-year survival 5-year survival 3.2 Prostate Cancer Survival in the Top Tier Local Authorities Figure 3.3 shows one- and ten-year prostate cancer relative survival rates in each top tier Local Authority. One-year relative survival rates in Solihull are significantly higher than the West Midlands average, and one-year relative survival rates in Telford & Wrekin, Stoke-on-Trent and Walsall are significantly lower. Ten-year relative survival is significantly higher in Birmingham, compared to the West Midlands, but in Stoke-on-Trent, Herefordshire, Dudley and Wolverhampton ten-year relative survival is significantly lower. Figure 3.3: Prostate cancer survival by Top Tier Local Authority 1-year survival based on cases diagnosed 26-21, 1-year survival based on cases diagnosed 1997-21. Dotted lines indicate 95% confidence intervals for West Midlands 12% 1% 8% 6% 4% 2% % Top Tier Local Authority 1-year survival WM 1-year survival 1-year survival WM 1-year survival Author: TE/CB/GL Page 1 of 23 Last updated: 2/1/12

Trust first seen 4. REFERRAL PATTERNS 4.1 Referral Patterns to Acute Trusts In order to obtain the Trust first seen, with the exception of death certificate only registrations, all prostate cancer patients (n=11,221) in the cancer registration cohort were matched to Cancer Waiting Times (CWT) data. Where a match to CWT data was not possible a Trust first seen was assigned using the earliest record at an acute Trust or private hospital in the cancer registration data. Any information relating to a Trust first seen in CWT data that preceded the cancer registration data by more than 12 months was discarded. Date differences of more than 3 days were only accepted where a definitive ICD-1 code match was possible between both datasets. Where a patient had a single cancer diagnosis on the cancer registration database and a single occurrence in CWT data within 3 days of diagnosis, the rules for direct ICD-1 matching were relaxed. Of the 11,221 prostate cancers in the original cancer registration cohort, 3,856 (34%) could not be matched to CWT data. Of the 7,365 tumours that could be matched, 97% (n=7,145) shared the same Trust first seen in both data sources. This methodology may introduce some bias towards the tertiary Trusts where surgery was undertaken if imaging or other clinical data have not been not submitted to the WMCIU by the Trusts where the patients was first referred. However, the good agreement between datasets when matches were possible should be noted. Prostate cancer patients were referred to all of the main acute Trusts in the region, though the number of tumours diagnosed in each Trust varied widely. The Burton Hospitals NHS Foundation Trust (BH) diagnosed the smallest number of prostate cancers in West Midlands residents (although it also saw out of region patients), while the Heart of England NHS Foundation Trust (HEFT) diagnosed the largest number of prostate cancers (over 1,6 in 3 years). Figure 4.1: Referral patterns from TTLA of residence to Trust first seen, 28-21 GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH 2 4 6 8 1, 1,2 1,4 1,6 1,8 Number of tumours diagnosed Top Tier LA Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire The majority of patients were diagnosed in Trusts within the cancer network where they lived. The Trusts with the most diverse referral patterns were The Dudley Group of Hospitals NHS Foundation Trust (DGH), The Royal Wolverhampton Hospitals NHS Trust (RWH), the Heart of England NHS Foundation Trust (HEFT), the Sandwell & West Birmingham Hospitals NHS Trust Author: TE/CB/GL Page 11 of 23 Last updated: 2/1/12

Trust first seen (SWBH) and the University Hospital Birmingham NHS Foundation Trust (UHB). These Trusts each diagnosed cases from at least 7 TTLAs. 4.2 Referral Patterns of Trust First Seen to Trust of Radiotherapy Five Trusts within the West Midlands region have Linear Particle Accelerators (LINACs) and provide radiotherapy treatment. West Midlands patients who live close to the region s boundaries are also referred to the Derby Hospitals NHS Foundation Trust (DHFT) and the Gloucestershire Hospitals NHS Foundation Trust (GH) for radiotherapy treatment. The University Hospital Birmingham NHS Foundation Trust (UHB) had the most referrals from other Trusts for radiotherapy treatment (n=778). The majority of these were from Heart of England NHS Foundation Trust (HEFT) and the Sandwell & West Birmingham Hospitals NHS Trust (SWBH) due to the proximity of these Trusts to the UHB. The Worcester Acute Hospitals NHS Trust (WAH) refers patients to three different radiotherapy centres, reflecting the geographical area that the Trust covers, with hospitals in the Arden, 3 Counties and Greater Midlands Cancer Networks. The Gloucester Hospitals NHS Foundation Trust (GH) received referrals from the Wye Valley NHS Trust (WV) and the Worcester Acute Hospitals NHS Trust (WAH). Treatment at the Gloucester Hospitals NHS Foundation Trust (GH) is likely to be phased out for some patients from 213 when a new radiotherapy unit is opened at the Wye Valley NHS Trust (WV). Figure 4.2: Referral patterns from Trust first seen to Trust of radiotherapy, 28-21 GEH SW BH DGH MSH HEFT SWBH WH WV Trust of radiotherapy UHCW STH RWH UHNS UHB DHFT GH WAH 5 1 15 2 25 3 35 4 45 Number of tumours referred to Trust of radiotherapy 5. TREATMENT 5.1 Types of Treatment For many prostate cancers, no radical treatment is necessary as the growth of the disease is indolent. As a result, many patients will undergo a programme of watchful waiting, whereby the development of the disease is monitored to ensure it does not evolve into a fast-growing tumour. When prostate cancer treatment is applicable, the main aims are to either control or cure the disease, with specific reference to minimising the day-to-day side effects of the disease. The main treatments for prostate cancer include surgery, radiotherapy and hormone therapy. Author: TE/CB/GL Page 12 of 23 Last updated: 2/1/12

Age group 5.2 Prostate Cancer Treatment Patterns 5.2.1 Variation in Prostate Cancer Treatment with Age Figure 5.1 shows that the proportion of tumours treated with surgery decreases with age, while the proportion of patients receiving no treatment rises with age; 39% of patients aged 5-59 years received surgery compared with 25% of patients aged 6-69 years and only 6% of patients aged 7-79 years. Care should be taken in the interpretation of the data for the youngest age group as there are only 11 cases in the -49 year age group (see Figure 2.1). Hormone therapy as the only treatment increases with age and is likely to be palliative in intent. This treatment is most common in men aged 8 years and above (25% in men aged 7-79 years compared with 13% and 8% in men aged 6-69 years and 5-59 years respectively). These older patients may have co-morbid conditions and the side effects of surgery, which may be difficult for the patient to tolerate, may confer little additional benefit in terms of life-expectancy for the patient. Figure 5.1: Treatment patterns for all prostate cancer cases by age, diagnosed 28-21 -49 5-59 6-69 7-79 8+ All % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Percentage of tumours Surgery only Surgery & adjuvant therapy Hormone therapy only Radiotherapy only Radiotherapy & hormone therapy Adjuvant therapies No treatment - active monitoring No treatment -no active monitoring A large proportion (36%) of prostate cancers registered by the WMCIU had no record of having received treatment. Although this is in line with guidance suggesting that no active treatment is an option for many prostate cancer patients, it could mask poor data quality provision to the WMCIU since 53% of these cancers could not be verified via CWT data as being actively monitored. 5.2.2 Variation in Prostate Cancer Treatment with Deprivation Figure 5.2 shows how the combinations of treatment given to prostate cancer patients vary with deprivation. Treatment patterns are similar for all patients regardless of levels of deprivation, suggesting that the deprivation status of the patient is not influencing treatment decisions. Although a higher proportion of prostate cancers diagnosed in men in the least deprived quintile received surgery when compared to men in the most deprived quintile (17% compared with 13%), this difference was not statistically significant. Author: TE/CB/GL Page 13 of 23 Last updated: 2/1/12

Trust first seen Deprivation quintile Figure 5.2: Treatment patterns for all prostate cancer cases by ID27 deprivation quintile, diagnosed 28-21 Most Affluent More Affluent Average More Deprived Most Deprived West Midlands % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Percentage of tumours Surgery only Surgery & adjuvant therapy Hormone therapy only Radiotherapy only Radiotherapy & hormone therapy Adjuvant therapies No treatment - active monitoring No treatment -no active monitoring 5.2.3 Variation in Prostate Cancer Treatment with Trust First Seen Prostate cancer treatment varied with the Trust where the patient was first seen. Reasons for this are complex. There may be true variation in treatment provided, which may be clinically relevant due to variation in case-mix. There may also be variation in the quality of data sent to the WMCIU by different Trusts. Figure 5.3: Treatment patterns for prostate cancers in each Trust first seen, diagnosed 28-21 GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH Other WM % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Percentage of tumours Surgery only Surgery & adjuvant therapy Hormone therapy only Radiotherapy only Radiotherapy & hormone therapy Adjuvant therapies No treatment - active monitoring No treatment -no active monitoring In Figure 5.3 the proportion of patients receiving surgery is higher in patients first seen in the Heart of England NHS Foundation Trust (HEFT) (24% compared with 15% in the West Midlands as a whole). The proportion of patients receiving surgery in the Other category is also higher than the West Midlands average. The majority (67%) of the patients included in this category were treated Author: TE/CB/GL Page 14 of 23 Last updated: 2/1/12

Top tier local authority in private hospitals. The Burton Hospitals NHS Trust (BH) has a high proportion of prostate cancer patients who did not have any treatment recorded. This may be due to the incomplete provision of treatment information for patients who are referred on to out of region Trusts. The Shrewsbury & Telford NHS Trust (STH) provided surgery, hormone therapy and/or radiotherapy treatment to 81% of patients first seen there. This is the highest proportion in the region and substantially higher than the regional average of 64%. The proportion of patients receiving active monitoring alone in this Trust was substantially lower than the regional average (5% compared with 17%). 5.2.4 Treatment in Each Top Tier Local Authority Figure 5.4 shows that higher proportions of residents of the Shropshire, Telford & Wrekin and Walsall TTLAs received surgery, hormone therapy and/or radiotherapy treatment for their prostate cancer compared to the West Midlands average. These results are consistent with the relatively high proportions of treatment recorded at the Shrewsbury & Telford NHS Trust (STH) and the Walsall Healthcare NHS Trust (WH) (Figure 5.3). Figure 5.4: Treatment patterns for all prostate cancer cases by TTLA, diagnosed 28-21 Coventry Warwickshire Dudley Shropshire Staffordshire Stoke-on-Trent Telford & Wrekin Wolverhampton Birmingham Sandwell Solihull Walsall Herefordshire Worcestershire West Midlands % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Percentage of tumours Surgery only Surgery & adjuvant therapy Hormone therapy only Radiotherapy only Radiotherapy & hormone therapy Adjuvant therapies Active monitoring No active monitoring 6. SURGICAL CASELOAD 6.1 Trust Caseload In 21, 584 prostate cancer patients had a surgical resection (Table 6.1). 85% of these were known to be elective operations and 2 were known to be elective. The admission status for 86 patients was not recorded. However, as 53 (62%) of these operations took place in private hospitals, they can be assumed to have been elective which increases the regional average to 94%. The admission status of 28% of the resections undertaken at The Dudley Group of Hospitals NHS Foundation Trusts was unknown because the cancers could not be matched to HES. 24% of all prostate cancer patients in the West Midlands had their surgical resection at the Heart of England NHS Foundation Trust (HEFT). 91% of these operations were known to be elective. Author: TE/CB/GL Page 15 of 23 Last updated: 2/1/12

Table 6.1: Prostate cancer surgical caseload of Trusts during 21 by admission method and number of consultants operating within the Trust Trust as a Main Trust proportion of Emergency Elective % Elective Unknown % Unknown Total West Midlands 18 1% % 18 UHCW 8 1% % 8 5% 2 1% % 2 BH 5 1% % 5 1 1% % 1 1% MSH 1 1% % 1 % STH RWH 1 21 6 88% 85% 2 11 8% 15% 24 71 15 13 1% 1% % % 15 13 7% 14% 21 91% 2 9% 23 UHNS 9 1% % 9 1 1% % 1 6% 1 1% % 1 1 43 96% 1 2% 45 35 83% 7 17% 42 HEFT 28 97% 1 3% 29 25% 23 82% 5 18% 28 1 5% 1 5% 2 27 1% % 27 SWBH 4 1% % 4 6% 4 1% % 4 UHB 11 1% % 11 2% WV 9 1% % 9 2% 36 86% 6 14% 42 WAH 32 89% 4 11% 36 14% 1 1% % 1 Private 62 58% 44 42% 16 % 1 1% 1 18% 1 1% % 1 OR 1 1% % 1 1% 1 1% % 1 Other % 1 1% 1 1 1% % 1 % WM 2 496 85% 86 15% 584 1% 6.2 Consultant Surgical Caseload Prostate cancer operations Table 6.2 shows the urological cancer (defined as ICD-1 C6 - C68) and prostate cancer surgical caseload for consultant surgeons operating in 21 who undertook surgical resections on prostate cancer patients, broken down by method of admission and the Trust in which they performed the most procedures. These caseload data relate to surgical procedures for urological cancers for which the intent of the operation was thought to be curative. Trust level data in this table cannot be directly compared with those in Table 6.1 as some consultants operate in more than one Trust. Thirty four consultant surgeons were recorded by the WMCIU as having operated on 584 prostate cancer patients during 21. The total number of curative operations performed on patients with a urological cancer was 1,75. The average prostate cancer surgical caseload was 17 and the average overall urological cancer caseload was 32. Only 12 consultants carried out more than 17 procedures on prostate cancer patients, and 15 carried out more than 32 curative procedures on urological cancer patients. Eleven consultants were recorded as having undertaken only a single Author: TE/CB/GL Page 16 of 23 Last updated: 2/1/12

prostate cancer operation in 21. Of these, 7 undertook fewer than 1 curative operations on urological cancer patients. The outside region caseload of the three outside region surgeons in Table 6.2 is not known. Most Trusts had at least one consultant who carried out more than 17 prostate cancer operations; the exceptions being the Burton Hospitals NHS Foundation Trust (which is believed to refer patients to an outside region Trust for surgery) and the Wye Valley NHS Trust. In the Heart of England NHS Foundation Trust (HEFT) all four consultants operated on 28 or more prostate cancer patients in 21. The Worcestershire Acute NHS Trust (WAH) also had a high degree of surgical specialisation with two consultants carrying out 36 or more prostate cancer operations in 21. Table 6.2: Consultant caseload for urological cancer operations performed in 21: Admission method and main Trust of consultant Main Trust Operations Admission status for all urology operations Prostate Caseload Urology Caseload Emergency Elective Unknown 18 22 22 UHCW 8 16 16 2 14 14 BH MSH STH RWH 5 1 24 71 5 1 47 15 1 1 5 1 41 83 5 21 1 1 15 13 1 6 33 39 1 1 5 33 36 1 2 23 33 31 2 UHNS 9 63 61 2 1 11 11 1 5 4 1 45 61 4 53 4 HEFT 42 7 2 61 7 29 39 34 5 28 41 29 12 27 51 49 2 SWBH 4 1 8 2 4 7 7 WH 1 25 23 2 UHB 16 145 3 89 53 11 43 1 39 3 9 1 1 WV 1 5 5 1 3 3 42 53 46 7 WAH 36 57 47 1 1 28 1 22 5 2 9 2 7 OR 1 6 6 1 2 1 1 WM 584 1,75 15 97 153 Author: TE/CB/GL Page 17 of 23 Last updated: 2/1/12

Trust first seen 7. STAGE AT DIAGNOSIS The stage at which prostate cancer is diagnosed is inextricably linked to the treatment provided and to patient outcome; with early stage tumours having better outcomes than late stage tumours. 7.1 Histological Confirmation of Prostate Cancer The benefit of having histological confirmation for a cancer is that the tumour characteristics (such as grade, size, and stage) can be accurately verified. This enables a more accurate and targeted treatment plan for the patient to be developed. In the West Midlands, 89% of prostate cancers were histologically verified in 21. Four Trusts, (University Hospital of North Staffordshire NHS Trust (UHNS), Worcestershire Acute Hospitals NHS Trust (WAH), University Hospitals Coventry & Warwickshire NHS Trust (UHCW) and Royal Wolverhampton Hospitals NHS Trust (RWH)) had histological confirmation rates below the West Midlands average. Figure 7.1: Histological confirmation by Trust where first seen, cases diagnosed 21 Solid black line indicates West Midlands average histological confirmation for 21 GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH WM % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Histological confirmation Percentage of tumours 7.2 Variation in Stage Completeness with Trust First Seen No histological confirmation In order to make appropriate decisions on treatment, all cancers should be clinically staged at diagnosis. TNM stage for prostate cancer is incompletely recorded on the WMCIU s cancer registration database; with the stage at diagnosis being unknown for 45% of cases in 21. This is mainly due to the limited provision by Trusts of clinical TNM stage and imaging data to the WMCIU which means that only the T and N components of the TNM stage are known. Figure 7.2 shows the TNM Stage completeness for each Trust first seen. Four Trusts (University Hospitals Coventry & Warwickshire NHS Trust (UHCW), The Dudley Group NHS Foundation Trust (DGH), Walsall Healthcare NHS Trust (WH) and George Eliot Hospital NHS Trust (GEH)) had particularly low proportions of prostate cancers with a TNM stage. There were no Stage I cancers recorded in 21. Stage I cancers are often diagnosed incidentally during other procedures, for example investigation of the bladder. Diagnosis of prostate cancer is usually directly linked to a person presenting with symptoms or high PSA levels which are unlikely to occur in patients with Stage I tumours. Author: TE/CB/GL Page 18 of 23 Last updated: 2/1/12

Trust first seen Trust first seen Figure 7.2: TNM Stage by Trust where first seen, cases diagnosed 21 Solid black line indicates the West Midlands average of known stage for 21 GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH WM % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Percentage of tumours Stage I Stage II Stage III Stage IV Stage not known The TNM stage data in Figure 7.3 are derived using a combination of overall TNM stage provided by Trusts, and internal algorithms developed by the WMCIU which piece together all the information that is received in order to construct a TNM stage at diagnosis. Using these combined data, 55% of prostate cancers diagnosed in the West Midlands in 21 could be assigned an overall TNM stage and 29% a partial TNM stage. Approximately 16% of cases could not be assigned a partial or overall TNM stage. Figure 7.3: TNM Stage completion by Trust where first seen, cases diagnosed 21 Solid black line indicates the West Midlands average for 21 GEH SW UHCW BH DGH MSH STH RWH UHNS HEFT SWBH WH UHB WV WAH WM % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Percentage of tumours Given Derived Partial Missing The Trust with the highest proportion of cases (49%) with a TNM stage provided to the WMCIU was the Mid Staffordshire NHS Foundation Trust (MSH). This could be increased to 86% by Author: TE/CB/GL Page 19 of 23 Last updated: 2/1/12

Trust of surgery Number of surgical resections applying internal algorithms. The main reason for the good staging information received from this Trust is the standardised and simplified reporting format used which allows for easy transfer of data to the WMCIU. Much of the good prostate cancer staging data recorded for Trusts in 21 can be attributed to the efforts that WMCIU staff have made in undertaking visits to Trusts to obtain staging data from patient files and electronic patient records directly rather than being reliant upon the data being provided. 8. TRUST-BASED 3-DAY MORTALITY AND SURVIVAL 8.1 3-day Post Operative Mortality Thirty-day post operative mortality following surgical resection to the prostate for cases diagnosed between 28-21 in the West Midlands was very good. Only 7 patients died within 3-days of their elective surgical procedure. Approximately 3% of patients who underwent a surgical resection between 28-21 had subsequently died by 31/12/211. Figure 8.1 shows 3-day post-operative mortality rates following a surgical resection to the prostate in Trusts of the West Midlands that undertook surgical resections in the 3-year period 28 to 21, the total number of surgical resections undertaken for the treatment of prostate cancer in each Trust is given to the right of the Figure 8.1. Of the seven deaths to occur within 3- days of elective surgery, five were patients who underwent surgical treatment for bladder cancer and in each case a cystoprostatectomy was performed. Following the removal of both the bladder and the prostate, a prostate cancer was diagnosed incidentally in each of these patients. Figure 8.1: 3-day mortality following a surgical resection, cases diagnosed 28-21 GEH SW UHCW DGH MSH STH RWH UHNS HEFT SWBH WH UHB WAH Other WM 2 1 118 2 1 91 186 73 348 12 3 35 25 342 2,31 % 2% 4% 6% 8% 1% Percentage of Tumours Died within 3 days - Elective Died over 3 days - Emergency Died over 3 days - Elective Not dead Operation not in HES Private hospitals undertook the majority (278 out of 342) of the surgical resections in the Other group and this explains the low proportion (38%) of operations that were identified in HES data. Author: TE/CB/GL Page 2 of 23 Last updated: 2/1/12

UHCW STH RWH UHNS HEFT SWBH UHB WAH UHCW STH RWH UHNS HEFT SWBH UHB WAH UHCW STH RWH UHNS HEFT SWBH UHB WAH Relative survival rate 8.2 Variation in Prostate Cancer Survival with Trust of Surgery Patients who undergo surgical resection to treat prostate cancer have exceptionally good five-year relative survival. In many cases there are no differences in survival between these patients and the general population, matched by age, sex and calendar year; with 5-year relative survival often above 1% as shown in Figure 3.5 for the 8 Trusts which treated more than 1 prostate cancers during the two five-year periods studied. Figure 8.2: Prostate cancer survival in each Trust of surgery 1-year survival based on cases diagnosed 26-21, 2-year survival based on cases diagnosed 25-29 and 5-year survival based on cases diagnosed 22-26 12% 1% 8% 6% 4% 2% % 1-year survival 2-year survival 5-year survival Trust of surgery Author: TE/CB/GL Page 21 of 23 Last updated: 2/1/12

APPENDIX TABLE A.1 Trust Abbreviation BH DGH DHFT GEH GH HEFT MSH RWH STH SW SWBH UHB UHCW UHNS WAH WH WV OR Other abbreviations CI HES ICD1 ICD-O3 TNM TTLA WMCIU Definition Burton Hospitals NHS Foundation Trust The Dudley Group of Hospitals NHS Foundation Trust Derby Hospitals NHS Foundation Trust George Eliot Hospital NHS Trust Gloucester Hospitals NHS Foundation Trust Heart of England NHS Foundation Trust Mid Staffordshire NHS Foundation Trust The Royal Wolverhampton Hospitals NHS Trust The Shrewsbury & Telford Hospital NHS Trust South Warwickshire NHS Foundation Trust Sandwell & West Birmingham Hospitals NHS Trust University Hospital Birmingham NHS Foundation Trust University Hospitals Coventry & Warwickshire NHS Trust University Hospital of North Staffordshire NHS Trust Worcestershire Acute Hospitals NHS Trust Walsall Healthcare NHS Trust Wye Valley NHS Trust Outside Region Definition Confidence interval Hospital Episode Statistics International Classification of Diseases 1th Revision International Classification of Diseases for Oncology 3rd Edition TNM Classification of Malignant Tumours (Tumour, Nodes Metastasis) Top tier Local Authority West Midlands Cancer Intelligence Unit Author: TE/CB/GL Page 22 of 23 Last updated: 2/1/12

THE WEST MIDLANDS CANCER INTELLIGENCE UNIT The WMCIU houses a cancer registry serving the approximate 5.4 million residents in the West Midlands. The registry holds records dating back to 1936 and has been population based since 1957. All malignant neoplasms of invasive, in-situ, uncertain or unknown behaviour and a limited number of benign tumours of the brain and CNS are recorded on the WMCIU s central database. Over 37, new tumours were registered in 21 of which approximately 29, relate to invasive malignant neoplasms 9. The database now holds in excess of 1.2 million records. Data are acquired from a variety of sources, including hospitals, cancer centres, treatment centres, hospices, private hospitals, cancer screening programmes, other cancer registries, general practices, nursing homes and death certificates. The WMCIU aims to register each case from a range of data sources to ensure the most accurate information possible full coding of a cancer case may involve data from hospital patient information systems, pathology reports, medical records departments, radiotherapy systems and death certificates. The WMCIU has in recent years increased its activity of receiving electronic cancer registration data and utilising automated methods of processing this data. A preliminary registration is recorded on the WMCIU database within 3 months of receiving the data. Full clinical coding of the case takes place within 12 months of the preliminary registration, within which time the registry expects to have received all relevant information relating to the patient. The WMCIU collects a wide range of data items, including: Patient demographics Tumour details Treatment modality Death details The records are clinically coded by experienced registrars trained to UK Association of Cancer Registries (UKACR) standards, who use internationally recognised ICD1 topography, ICDM morphology and OPCS4 procedure codes. All data inputted to the database is subjected to a detailed quality assurance process, and the data are available for detailed analysis 14 months after the end of the calendar year to which they relate. The WMCIU aims to deliver timely, comparable and high quality cancer data to a range of stakeholders. The core information team undertakes a range of analyses to support this aim. These include: Monitoring trends in cancer incidence, mortality and survival Evaluating the quality and outcomes of cancer care Supporting the work of cancer genetic counselling services Providing data for and working with academic researchers Planning and monitoring the efficacy and cost effectiveness of the diagnostic and therapeutic services provided to cancer patients Monitoring performance against key standards. 9 Non melanoma skin cancers are excluded from the count of malignant invasive tumours as they are often treated in primary care; therefore case ascertainment is incomplete. Author: TE/CB/GL Page 23 of 23 Last updated: 2/1/12