Download Stratifying prostate cancer patients into phases of care in the UK

STratifying prostate
cAncer patients into
phases of caRe in the UK
H McConnell1, R Alonzi2, K Yip3, J Maher1&4.
1 Macmillan Cancer Support; 2 Senior Lecturer and Consultant in Clinical Oncology, Mount Vernon Cancer Centre; 3 Specialist Registrar in Clinical Oncology, Addenbrookes Hospital, Cambridge;
4 Consultant Clinical Oncologist, Mount Vernon Cancer Centre
End of life, 12,000 (2,000 year 1)
Progressive care
23,000
PC - Hormone
responsive 11,000
End of life, 11,000
(2,000 year 1)
PC - Hormone
non-responsive
21,000
Ongoing monitoring
10+yrs
235,000
Ongoing monitoring
10+yrs
29,000
Ongoing monitoring
5≥10yrs
62,000
Initial monitoring
63,000
Ongoing monitoring
5≥10yrs
127,000
AS 2+yrs, 9,000
AS 0-2yrs, 7,000
Watch & Wait 0-2yrs
18,000
Diagnosis & Treatment
29,000
Recovery &
Readjustment
27,000
Initial monitoring
103,000
Figure 1: People newly diagnosed, people living with prostate cancer by year since
diagnosis and deaths for people with a prostate cancer diagnosis, UK, 2010
Recovery &
Readjustment
47,000
Breast
Prostate cancer is the most commonly diagnosed malignancy in British men and accounts
for the second highest number of cancer related deaths.i Incidence and mortality have
been routinely collected for many years and prevalence data are now being reported
more frequently (Figure1). Better understanding of the demand on the health care system,
beyond incidence and prevalence, can be achieved through quantifying the cancer
survivors with respect to their phase of care.
Diagnosis & Treatment
50,000
Background
Prostate
Figure 3: Cancer care pathway – estimating the number of people in the UK,
by cancer type, 2010
Using routinely collected data to stratify prostate cancer patients
into phases of care in the UK: implications for resource allocation
and cancer survivorship
100
End of life, 35,000
(29,000 year 1)
255,000
Progressive care
(not estimated)
116,000
50
Ongoing
monitoring 10+yrs
21,000
106,000
Ongoing monitoring
5≥10yrs 6,000
60
Initial monitoring
9,000
Mortality
Recovery &
Readjustment
13,000
Prevalence
40
0–1yrs
1≥5yrs
>5yrs
Prevalence
end of 2010
Mortality
2010
End of life, 16,000
(11,000 year 1)
Incidence
2010
Progressive care
24,000
0
Ongoing monitoring
10+yrs
73,000
10
Ongoing monitoring
5≥10yrs
51,000
33,000
Initial monitoring
48,000
42,000
Recovery &
Readjustment
31,000
20
Diagnosis & Treatment
42,000
255,000
30
Colorectal
Percentage
70
Incidence
Diagnosis & Treatment
43,000
80
11,000
Lung
90
Prevalence by time since diagnosis
Method
Six main phases of care for prostate cancer have been identified in the study (Figure 2),
five of which have previously been defined for breast, colorectal & lung cancers.ii Active
surveillance and watchful waiting is an additional phase unique to prostate cancer. Using
incidence, survival, prevalence and mortality data, data from the British Association of
Urological Surgeons and clinical assumptions we make indicative estimates of the number
of people in phases of the care pathway. Full detail of calculations will be in a
forthcoming paper.
Figure 2: Assumptions used to estimate the cancer care pathway
How have we estimated the cancer care pathway?
Diagnosis &
Treatment
Recovery &
readjustment
Newly diagnosed:
assumed need of
acute sector care
(except AS/WW for
prostate only)
Surviving the first
year: assumed need
of rehabilitation
(except AS/WW
for prostate only)
Active
Surveillance /
Watch & Wait
(AS/WW)
Diagnosed but
receiving no anticancer treatment
(prostate only)
Initial
monitoring
Ongoing
monitoring
Progressive
care
End of life care
[Year 1 deaths]
Up to 5 years
Beyond 5 and
Incurable disease
End of life care:
from diagnosis:
10 years from
but not in last year of last year of life and
designated as ‘initial
diagnosis:
life: assumed need
subset of deaths
monitoring’
designated ‘ongoing more treatment and occurring in first year
monitoring’
support
of diagnosis
Results & Discussion
We present new 2010 estimates for prostate cancer and comparative figures for breast,
colorectal and lung cancer (Figure 3). The number of patients going through the care
pathway in a specific year with prostate cancer is estimated to be around 266,000 in 2010
(including flows in and out). Around a fifth are either receiving treatment or in the recovery
and readjustment phase. The majority (over half) are in the post treatment monitoring
phase. We estimate over 1 in 10 have not received any anti-cancer treatment, a further 1
in 10 have developed metastatic disease and around 1 in 25 are in the final stage of their
lives. The progressive disease phase accounts for a greater proportion of the total patient
population in prostate cancer compared to breast and colorectal cancers.
Even though the most expensive phases of prostate cancer care are immediately after
diagnosis and within the last year of life,iii the majority of prostate cancer patients, as
demonstrated in this study, are in the post treatment monitoring group. Maddams et al.
showed that prostate cancer survivors had the highest levels of health service utilisation five
or more years after diagnosis compared to other cancer patientsiv and more recent work
confirms that most costs are incurred the years after initial diagnosis.v
Conclusion
The current focus of cancer care is on initial diagnosis, primary treatment and the last year
of life, yet for most prostate cancer survivors, their health care service demands are likely
to resemble those of patients with chronic conditions. Greater involvement of general
practitioners, with appropriate support from hospital based specialists may potentially
provide relief to this pressure and improve the management of long-term chronic side
effects due to patients’ previous cancer and its treatment.
The balance between the post treatment monitoring and active surveillance/watch and
wait groups will be an important determinant in terms of resource allocation for prostate
cancer survivors in the future. We hope our estimates stimulate future work to collect
quantitative data related to the health care needs of patients at each stage of their cancer,
and be used to plan future services to meet the needs of these patients.
Data notes
Figure 1: Prostate cancer (ICD-10 C61). Incidence is the number of newly diagnosed cases and is a count of tumours in 2010. Prevalence is
a count of the number of people living with cancer at the end of 2010. Mortality is a count of deaths due to cancer only in 2010. In addition
a number of men living with prostate cancer will die from other causes Sources: Office for National Statistics; Information Services Division
(ISD) Scotland; Welsh Cancer Intelligence & Surveillance Unit; Northern Ireland Cancer Registry; Cancer Research UK. Cancer mortality - UK
statistics (Nov 2010); Maddams J, et al. Cancer prevalence in the United Kingdom: estimates for 2008. British Journal of Cancer. 2009. 101:
541-547.
Figure 3: For each cancer type, the size of the boxes reflects the approximate proportion of people in each phase (however, there is double
counting for people who are diagnosed and die in the same year). Female breast cancer (ICD-10 C50), Prostate cancer (ICD-10 C61);
Colorectal cancer which includes colon, rectum and anus (ICD-10 C18-C21), and Lung cancer which includes lung, bronchus and trachea
(ICD-10 C33-C34). Sources: Estimated based on Maddams, J, et al, Projections of cancer prevalence in the United Kingdom, 2010-2040.
Br J Cancer, 2012. 107(7): p. 1195-202; Maddams J, et al. (2009); Office for National Statistics and London School of Hygiene and Tropical
Medicine. 2012. Cancer Survival Rates - Cancer Survival in England: Patients Diagnosed, 2006–2010 and Followed up to 2011; Cancer
Research UK (2010) Cancer mortality – UK statistics; Personal Communication for incidence trends from Office for National Statistics,
Information Services Division (ISD) Scotland, Northern Ireland Cancer Registry, Welsh Cancer Intelligence and Surveillance Unit.
Acknowledgements
We acknowledge the use of data for this analysis collected by cancer registries across the UK.
References
i
ONS. Prostate Cancer: the most common cancer among men in England 2010. 2010
ii Maher, J. and H. McConnell, New pathways of care for cancer survivors: adding the numbers. Br J Cancer, 2011. 105 Suppl 1: p. S5-10.
iii Krahn, M.D., et al., Healthcare costs associated with prostate cancer: estimates from a population-based study. BJU Int, 2010. 105(3): p. 338-46.
iv Maddams, J. et al. A person-time analysis of hospital activity among cancer survivors in England. Br J Cancer, 2011. 105 Suppl 1: p. S38-45.
v Macmillan Cancer Support in partnership with Monitor-Deloitte and NCIN. 2014. Routes from Diagnosis: The most detailed map of cancer
survivorship yet.
For more information please contact Hannah McConnell, [email protected]
June 2014
Macmillan Cancer Support, registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604).