NPCA Annual Report 2020
Source: data.gov.uk (2021-01-18)

NPCA Annual Report 2020. In the 2020 Annual Report, we present the results for patients diagnosed between 1st April 2018 and 31st March 2019 in England and Wales including:
1. The participation of NHS providers and the completeness and quality of the data submitted to the National Cancer Registration and Analysis Service (NCRAS), Public Health England and the Wales Cancer Network, Public Health Wales.
2. Patient demographic information, key aspects of the diagnostic and staging process they underwent and the treatments they received.
3. The variation in disease presentation and treatment allocation across NHS providers in England and Wales. For the first time, we report on the use of prostate plus pelvic lymph node irradiation men with high-risk localised/locally advanced disease in England.
In addition, we present:
4. Treatment outcomes (up to two years post-treatment) for men in England and Wales undergoing radical prostatectomy (RP) or radical external beam radiotherapy (EBRT) in 2017.
5. The functional outcomes reported by patients (urinary incontinence, sexual or bowel functioning) following radical treatment (RP or EBRT) for prostate cancer.

Individual provider results and reports are available enabling regional and national comparisons to support local QI. https://www.npca.org.uk/provider-results/

Annual Report 2020
Results of the NPCA Prospective Audit in England and
Wales for men diagnosed from 1 April 2018 to 31 March
2019 (published January 2021).

Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
National Prostate Cancer Audit
Seventh Year Annual Report – Results of the NPCA Prospective Audit
in England and Wales for men diagnosed 1 April 2018 – March 2019
London: The Royal College of Surgeons of England, 2021.
All rights reserved. Applications for the copyright owner’s written
permission to reproduce significant parts of this publication
(including photocopying or storing it in any medium by electronic
means and whether or not transiently or incidentally to some
other use of this publication) should be addressed to the publisher.
Brief extracts from this publication may be reproduced without
the written permission of the copyright owner, provided that the
source is fully acknowledged.
Copyright © 2021 Healthcare Quality Improvement Partnership
(HQIP)
Published January 2021 by the National Prostate Cancer Audit
The Royal College of Surgeons of England
35–43 Lincoln’s Inn Fields
London
WC2A 3PE
T xx-xxxx-xxxx
E xxx@xxx.xx
www.npca.org.uk
Designed @ www.superbirdcreative.co.uk
The Royal College of Surgeons of England (RCS) is an independent professional body
committed to enabling surgeons to achieve and maintain the highest standards of surgical
practice and patient care. As part of this it supports Audit and the evaluation of clinical
effectiveness for surgery.
The NPCA is based at the The Clinical Effectiveness Unit (CEU). The CEU is an academic
collaboration between The Royal College of Surgeons of England and the London School
of Hygiene and Tropical Medicine, and undertakes national clinical audits and research.
Since its inception in 1998, the CEU has become a national centre of expertise in methods,
organisation, and logistics of large-scale studies of the quality of surgical care. The CEU
managed the publication of the NPCA Annual Report, 2020.
In partnership with:
Commissioned by:
The British Association of Urological Surgeons (BAUS) was founded in 1945 and exists to
promote the highest standards of practice in urology, for the benefit of patients, by fostering
education, research and clinical excellence. BAUS is a registered charity and qualified
medical practitioners practising in the field of urological surgery are eligible to apply for
membership. It is intended that this website will be a resource for urologists, their patients,
other members of the healthcare team and the wider public.
The British Uro-oncology Group (BUG) was formed in 2004 to meet the needs of
clinical and medical oncologists specialising in the field of urology. As the only dedicated
professional association for uro-oncologists, its overriding aim is to provide a networking
and support forum for discussion and exchange of research and policy ideas.
The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the
Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices.
Its aim is to promote quality improvement in patient outcomes, and in particular, to
increase the impact that clinical audit, outcome review programmes and registries have
on healthcare quality in England and Wales. HQIP holds the contract to commission,
manage, and develop the National Clinical Audit and Patient Outcomes Programme
(NCAPOP), comprising around 40 projects covering care provided to people with a wide
range of medical, surgical and mental health conditions. The programme is funded by
NHS England, the Welsh Government and, with some individual projects, other devolved
administrations and crown dependencies www.hqip.org.uk/national-programmes
National Cancer Registration and Analysis Service (NCRAS), Public Health England
collects patient-level data from all NHS acute providers and from a range of national data
feeds. Data sources are collated using a single data processing system (’Encore’) and the
management structure is delivered through eight regional offices across England.
The NCRAS is the data collection partner for the NPCA.
Registered Charity No: 212808

Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Contents
Acronym list
2
Acknowledgements
3
Foreword
5
Executive Summary
6
Background
6
Data collection and analysis
6
NICE Quality Standards, 2015
7
How to use this report and the NPCA website
8
Key Messages
9
Recommendations, key findings and related national guidance
10
Annual Report 2020 Infographic
15
1. The National Prostate Cancer Audit (NPCA): Introduction
16
1.1
Background
16
1.2
Aim and objectives
16
1.3
Previous Annual Report
17
2. Methods
18
2.1
Inclusion criteria & prospective audit period
18
2.2
Routine data collection
18
2.3
NPCA dataset
18
2.4
Patient-reported outcome and experience measures (PROMs/PREMs)
18
2.5
Level of reporting
19
2.6
Patient inclusion and data quality
19
2.7
Definition of disease status and risk stratification
19
2.8
Treatment allocation
19
2.9
NPCA performance indicators
20
3. Results
22
3.1
Audit participation
22
3.2
Data completeness
23
3.3
Audit findings
23
3.4
NPCA performance indicators
27
4. Discussion
41
4.1
Participation and data completeness
41
4.2
Diagnostics
41
4.3
Performance indicators
41
4.4
Future Plans for the NPCA
43
Glossary
44
Appendix: Outlier Communications
48

2
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Androgen Deprivation Therapy (ADT)
British Association of Urological Surgeons (BAUS)
British Uro-Oncology Group (BUG)
Cancer Network Information System Cymru (CaNISC)
Cancer Outcomes and Services Dataset (COSD)
Clinical Effectiveness Unit (CEU)
Clinical Nurse Specialist (CNS)
Clinical Outcomes Programme (COP)
Clinical Reference Group (CRG)
Expanded Prostate Cancer Index Composite 26-item
(EPIC-26)
External Beam Radiation Therapy (EBRT)
Gastrointestinal (GI)
General Practitioner (GP)
Genitourinary (GU)
Healthcare Quality Improvement Partnership (HQIP)
Hospital Episode Statistics (HES)
Intensity Modulated Radiation Therapy (IMRT)
International Classification of Disease (ICD)
Kilovoltage Imaging (KV imaging)
Magnetic Resonance Imaging (MRI)
Minimum Data Set (MDS)
Multi-Disciplinary Team (MDT)
National Cancer Patient Experience Survey (NCPES)
National Cancer Registration and Analysis Service (NCRAS)
National Clinical Audit and Patient Outcomes Programme
(NCAPOP)
National Clinical Audit Benchmarking (NCAB)
National Health Service (NHS)
National Institute for Health and Care Excellence (NICE)
National Prostate Cancer Audit (NPCA)
National Radiotherapy Data Set (RTDS)
Office for National Statistics (ONS)
Office of Population Censuses and Surveys (OPCS)
Patient Episode Database for Wales (PEDW)
Patient-Reported Experience Measure (PREM)
Patient-Reported Outcome Measure (PROM)
Patient and Public Involvement (PPI)
Prostate Specific Antigen (PSA)
Public Health England (PHE)
Radical Prostatectomy (RP)
Royal College of Surgeons (RCS)
Specialist Multidisciplinary Team (SMDT)
The Index of Multiple Deprivation (IMD)
Tumour, Nodes, Metastases (TNM)
Wales Cancer Network (WCN)
Welsh Cancer Intelligence and Surveillance Unit (WCISU)
Acronym list

3
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Acknowledgements
The National Prostate Cancer Audit (NPCA) is commissioned
by the Healthcare Quality Improvement Partnership (HQIP)1
and funded by NHS England and the Welsh Government as
part of the National Clinical Audit and Patient Outcomes
Programme. The audit is a collaboration between the Clinical
Effectiveness Unit (CEU) at the Royal College of Surgeons of
England (RCS), the British Association of Urological Surgeons
(BAUS) and the British Uro-oncology Group (BUG).
The NPCA Project Team would like to thank all men in
England and Wales who have completed the NPCA Patient
Survey and for sharing their views on the quality of care and
the impact of radical treatment on their daily lives.
We would also like to thank all urologists, uro-oncologists
and their clinical and non-clinical teams at NHS Trusts in
England and Health Boards in Wales who collected and
submitted data for the audit. Your support is key to enabling
the NPCA to evaluate the care that men receive following a
diagnosis of prostate cancer in England and Wales and
whether this care reflects recommended guidelines and
quality standards. The NPCA compares NHS Providers in
England and Wales identifying any potential outlying
performance related to both short and medium-term
treatment outcomes following radical treatment.
We are grateful to the NPCA data collection partners
including the National Cancer Registration and Analysis
Service (NCRAS), Public Health England (PHE)2 and the
Wales Cancer Network, Public Health Wales for supporting
NPCA data submissions from Trusts and Health Boards and
for supplying data for this report. We particularly appreciate
the efforts of the cancer intelligence analysts and cancer
information specialists at NCRAS and the Wales Cancer
Network who supplied the data in the midst of the
COVID-19 pandemic.
We would like to thank BAUS and BUG for their continued
professional guidance and for raising awareness amongst
urological and uro-oncological colleagues. We would also like
to thank all members of the newly-formed NPCA Patient and
Public Involvement (PPI) Forum for providing advisory
support and ensuring the voice of patients is central to the
direction and delivery of the NPCA. A lay report
summarising the key results will be developed in consultation
with the NPCA PPI Forum and published in Spring 2021.
1
The NPCA is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). HQIP is led by a consortium
of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that
clinical audit, outcome review programmes and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage and develop the National Clinical Audit and Patient
Outcomes Programme (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS
England, the Welsh Government and, with some individual projects, other devolved administrations and crown dependencies https://www.hqip.org.uk/national-programmes/
2
This work uses data that has been provided by patients and collected by the NHS as part of their care and support. The data are collated, maintained and quality assured by the National Cancer Registration and
Analysis Service (NCRAS), which is part of Public Health England (PHE). Access to the data was facilitated by the PHE Office for Data Release. http://www.ndrs.nhs.uk/
This report was prepared by members of the
NPCA Project Team:
Clinical Effectiveness Unit, The Royal College of
Surgeons of England and LSHTM
Melanie Morris, NPCA Lead Epidemiologist
Julie Nossiter, NPCA Audit Lead
Matthew Parry, NPCA Clinical Research Fellow
Thomas Cowling, NPCA Data Analyst
Ajay Aggarwal, Clinical Audit Coordinator (Oncology)
Paul Cathcart, Clinical Audit Coordinator (Urology)
Jan van der Meulen, NPCA Chair and Methodological Lead
Arun Sujenthiran, NPCA Clinical Research Fellow
Brendan Berry, Academic Clinical Fellow
The British Association of Urological Surgeons
Noel Clarke, NPCA Urological Clinical Lead
The British Uro-Oncology Group
Heather Payne, NPCA Oncological Clinical Lead
With support from:
The National Cancer Registration and Analysis
Service (NCRAS), Public Health England (PHE)
Natasha Wood, NCRAS Audit Manager
Eleanor Fitzgerald, Cancer Intelligence Analyst
Jem Rashbass, Director for National Disease Registration
NCRAS Data Liaison and Registration teams
Wales Cancer Networks, Public Health Wales
(PHW)
Gareth Popham, Network Assistant Manager
Stephanie Price, Wales Information Specialist
Anne Lane, Wales Information Specialist

4
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
With review by:
The NPCA Clinical Reference Group:
Roger Kockelbergh (Chair), Consultant Urological Surgeon,
Urology Expert Advisory Group, NCRAS, PHE
Stephen Allen, Patient representative, Tackle Prostate Cancer
Pauline Bagnall, Uro-oncology nurse specialist, British
Association of Urological nurses (BAUN)
Victoria Coupland, Principal Cancer Intelligence Analyst,
NCRAS, PHE
Adam Glaser, Clinical Associate Professor, UK Cancer
Survival Initiative
Luke Hounsome, Analytical Programme Manager, NCRAS,
PHE
Michael Kirby, Visiting Professor, Royal College of General
Practitioners (RGCP)
Gokul KandaSwamy, Consultant Urological and Robotic
Surgeon, BAUS (Wales)
John McGrath, Consultant Urological Surgeon, NHS
England’s Specialised Cancer CRG
Krishna Narahari, Consultant Urological Surgeon, BAUS
Oncology
Raj Persad, Consultant Urological Surgeon and Andrologist,
BAUS
Janet Rimmer, Senior Implementation Lead, NHS Cancer
Screening Programmes
Simon Russell, Consultant Oncologist, BUG
Vijay Sangar, Consultant Urological Surgeon, Chair of of NHS
England Specialist Cancer Surgery CRG
Karen Stalbow, Head of Policy, Knowledge & Impact,
Prostate Cancer UK
Members of the NPCA Project Team
NPCA Project Board:
Tim Terry (Chair), Trustee of RCS Council
Heather Blake, Director of Support and Influencing, Prostate
Cancer UK
Roger Kockelbergh, University Hospitals of Leicester NHS
Trust
Gokul KandaSwamy, Consultant Urological and Robotic
Surgeon, BAUS (Wales)
Krishna Narahari, Consultant Urological Surgeon, BAUS
Oncology
Simon Russell, Consultant Oncologist, BUG
Caroline Rogers, Associate Director, HQIP
Sarah Walker, Project Manager, HQIP
Members of the NPCA Project Team

5
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Foreword
This 2020 NPCA report has been produced in exceptional
circumstances. There has been a 23% surge in prostate cancer
cases diagnosed as a consequence of the “Fry-Turnbull” effect.
Also, the COVID-19 crisis has brought special challenges for
local data-gathering and a combination of innovation,
resourcefulness and sheer hard work has ensured that future
NPCA reports can be produced. We would like to thank all
teams for their outstanding efforts, meeting and overcoming
the exceptional challenges engendered by these events.
This, the 7th NPCA Annual Report covering the diagnostic
period between April 1st 2018 and March 31st 2019, brings
clinicians and patients right up to date with the prostate cancer
landscape in 2020 in England and Wales. It is reassuring to see
that the overall quality of the diagnostic and treatment services
are good, and that patient reported satisfaction is high.
That said, there are areas of practice highlighted in the report
where there is significant variation between hospitals in
aspects of prostate cancer diagnosis and treatment, particularly
for those men with high-risk disease and those in the older
age groups. Consider the use of docetaxel in newly diagnosed
prostate cancer patients: although there has been a modest
increase in usage from 27 to 36%, the overall figure is still low.
The NPCA Quality Improvement (QI) Programme will
continue to address issues such as this, building on its successes
in 2019 and 2020, which include the addition of new quality
standards, the organisation of a highly effective QI workshop
and a designated QI section on the NPCA web site. This web
site has information about individual units. Please take a look
and use it when you can!
This year’s Annual Report includes the results of the second
survey of individual patient-reported outcomes. Detailed
questionnaires were sent to just under 11,000 men 18 months
after they were diagnosed with prostate cancer. We would like
to thank all the men who completed the survey enabling us to
achieve an excellent response rate (78%). These results build
on those of the highly successful first survey that were
reported in the 2018 Annual Report and will enable future
benchmarking. The first survey provided detailed comparative
outcome information, collecting patient-reported outcomes in
more than 45,000 men. It also led to numerous papers
demonstrating how prostate cancer care can be further
improved, published in journals such as the Lancet Oncology,
Journal of Clinical Oncology, BJUI and others.
In addition to the Annual Report, the NPCA team has
produced short reports, including one on ‘under-treatment’ of
men with high risk localised disease. All this demonstrates
that the NPCA has now created a unique prostate cancer data
resource of national and international importance. This is an
achievement that the UK prostate cancer community can
justifiably be proud of.
For 2021, the NPCA will continue to develop its activities
aimed at performance assessment and quality improvement
using data that we receive from our data collection partners in
England and Wales, the National Cancer Registration and
Analysis Service and the Wales Cancer Network. A further
organisational audit will be carried out, giving a ‘state-of-the-
nation’ overview of how prostate cancer services are being
organised and delivered in England and Wales, in particular
the provision of support services.
We will also strengthen our collaborations with existing
partners such as the British Association of Urological
Surgeons, the British Uro-oncology Group, and NHS
Improvement’s Getting It Right First Time programme in
England, whilst reaching out to other groups to use the power
of the NPCA prostate cancer data resource to monitor and
improve the quality of care. A programme to establish formal
collaborations will also be developed and instituted in the
next two years.
Finally, we would like to express our great thanks to the
members of the NPCA PPI Forum and patient
organisations, including Tackle Prostate Cancer and Prostate
Cancer UK, for their support. A very special thanks goes to
the hard-working local, regional and national teams for their
endeavours in making the NPCA such a success. Their work
has been a substantial and sustained effort over years which
has put prostate cancer and prostate cancer patients’ welfare
at the forefront of the national cancer agenda. Given the
incidence and importance of this disease, this is exactly
where it should be.
Noel Clarke
Urological Clinical Lead
representing the British
Association of Urological
Surgeons
Heather Payne
Oncological Clinical Lead
representing the British
Uro-oncology Group

6
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Background
The aim of the NPCA is to assess the process of care and its
outcomes in men diagnosed with prostate cancer in England
and Wales. The NPCA determines whether their prostate
cancer care is consistent with current recommended
practice and it provides information to support healthcare
providers, commissioners, regulators, patient groups and
patients in helping improve prostate cancer diagnosis and
treatment. In this report we continue our work as the first
national audit which is able to report on process and
outcome measures from all aspects of the care pathway for
men with prostate cancer.
Data collection and analysis
This report presents results from the prospective audit for
men diagnosed with, or treated for, prostate cancer between
1st April 2018 and 31st March 2019 in England and Wales.3
The basis of the audit are routine data sources which include:
Cancer Registry data, Cancer Outcomes and Services Dataset
(COSD), Hospital Episode Statistics (HES), the Office for
National Statistics (ONS), the Radiotherapy Data Set (RTDS)
and the Systemic Anti-Cancer Therapy (SACT) database in
England, and CaNISC, Patient Episode Database for Wales
(PEDW) and ONS in Wales.
We report on specific information relating to diagnosis,
staging and treatment, as well as core performance
indicators, in order to compare diagnostic specialist MDTs
and/or treatment centres. We also report the results from
the latest round of the NPCA patient survey including
patients’ views of their experience of care and their
functional outcomes after radical treatment. The NPCA
patient survey includes key questions from the National
Cancer Patient Experience Survey (NCPES) and the
Expanded Prostate Cancer Index Composite 26-item version
(EPIC-26) and is collected at least 18 months after diagnosis
for men diagnosed between 1st April 2018 and 30th
September 2018.
We report on 14 performance indicators:
1.
Proportion of men diagnosed with metastatic disease at
first presentation.
2. Proportion of men with low-risk localised prostate cancer
undergoing radical prostate cancer therapy.
3.
Proportion of men with high-risk localised/locally
advanced disease receiving radical prostate cancer
therapy.
4. Proportion of men with newly diagnosed metastatic
disease who received docetaxel in combination with
androgen deprivation therapy (ADT).
5.
Proportion of men with high-risk localised/locally
advanced disease receiving both prostate and pelvic
lymph node irradiation, as opposed to prostate-only
irradiation.
6. Proportion of patients who were given the name of a
clinical nurse specialist.
7.
Proportion of patients rating their overall care as at least
8 out of 10.
8. Proportion of patients who had an emergency
readmission within 90 days of radical prostatectomy.
9. Proportion of patients experiencing at least one
genitourinary (GU) complication requiring a procedural/
surgical intervention within 2 years of radical
prostatectomy.
10. Proportion of patients receiving a procedure of the
large bowel and a diagnosis indicating radiation toxicity
(gastrointestinal [GI] complication) up to 2 years
following radical prostate radiotherapy.
11. Mean urinary incontinence score after radical
prostatectomy
12. Mean sexual function score after radical prostatectomy
13. Mean bowel function score after radical radiotherapy
14. Mean sexual function score after radical radiotherapy.
Executive Summary
3
Medium-term indicators require longer follow-up (up to two years’ post-treatment) so the reporting time period for GU or GI complications is 1st January to 31st December 2017.

7
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Although the NPCA started prior to the publication of the
NICE Quality Standards, the Audit provides results that can
be used to evaluate to what extent prostate cancer care
providers meet most of these standards.
This year we present results from the second NPCA patient
survey, which provides information on how men were
informed about their treatment options, how treatment
decisions were made and to what extent they had access to a
named clinical nurse specialist (CNS) (QS1). We also present
results for indicators of possible over-treatment in men with
low-risk disease and potential under-treatment in men with
high-risk localised/locally advanced disease (see section 3.4,
QS2 and QS3).
Previous results from our annual organisational survey5
indicate whether providers of cancer services have specialist
services on-site (QS4). These will be updated early next year
as the planned implementation of this survey has been
delayed due to the COVID-19 pandemic.
Currently data with respect to hormone-relapse and
recurrence are not available from routine national datasets
and so an assessment of treatment options for these men is
not possible (QS5).
In addition to the results linked directly to the NICE Quality
Standards, the NPCA reports on aspects of care that capture
ongoing developments in the way men with prostate cancer
are being assessed and treated. The Audit also provides
evidence on the adoption of newer technologies (e.g. the
type of biopsy used) and treatments (robotic-assisted
prostatectomy and intensity-modulated radiotherapy), as
well as the impact on patient outcomes.
Further to the publication of updated NICE guidelines in May
20196 we report, for the second time, the uptake of docetaxel
in men with newly presenting metastatic disease, and the
extent of the use of prostate plus pelvic lymph node
irradiation for men with high-risk localised or locally
advanced disease.
4
Prostate Cancer. NICE Quality Standard [QS91], 2015 (Updated May 2019).
5
https://www.npca.org.uk/reports/npca-organisational-audit-2019/
6
Prostate cancer: diagnosis and management. NICE Guideline [NG131], 2019.
NICE Quality Standards, 20154
1.
QS1: men with prostate cancer have a discussion about treatment options and adverse effects with a named nurse
specialist.
2. QS2: men with low-risk localised prostate cancer for whom radical treatment is suitable are offered a choice between
active surveillance, radical prostatectomy or radical radiotherapy.
3.
QS3: men with intermediate- or high-risk localised/locally advanced localised prostate cancer who are offered non-
surgical radical treatment are offered radical radiotherapy and ADT in combination.
4. QS4: men with adverse effects of prostate cancer treatment are referred to specialist services.
5.
QS5: men with hormone-relapsed metastatic prostate cancer have their treatment options discussed by the urological
cancer MDT.

8
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
How to use this report and the NPCA
website
The information presented here compares prostate cancer
services locally and nationally. We recommend that this be a
starting point for reflection on the reasons behind variation
in practice and outcomes, and that this report be used to
identify areas for potential quality improvement. It also
provides an impetus to maintain and improve data collection
for the most accurate reflection of prostate cancer care in
England and Wales.
A breakdown of results at the level of each Trust/Health
Board and specialist MDT are provided on our website.7
Users of this report should take time to identify areas for
improvement in data completeness, service availability and
patient outcomes. We also encourage clinical leads to attend
our next Quality Improvement workshop in April 2021.
These results will be the basis for discussion and
improvement planning. We welcome feedback on how the
audit outputs can be improved.
It is also important to highlight that treatment outcome
results are published as part of the Clinical Outcomes
Programme (COP) and the National Clinical Audit
Benchmarking (NCAB) to enable dissemination of our
findings to clinicians, stakeholders, patients and the wider
public. We also encourage users of this report to access these
resources to facilitate quality improvement.
Patients can use these results to start conversations with
their care providers and a lay summary of the report will be
published in early 2021. Previous lay summaries of our Annual
Reports and patient-friendly slide sets for use by support
groups can be found on our website at: www.npca.org.uk
7
https://www.npca.org.uk/provider-results/

9
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Key Messages
Data quality
1.
Completeness of key variables remains low in England
(e.g. performance status 52% – no change from 2019).
New data items for multiparametric MRI have been
introduced into COSD and we encourage all prostate
MDTs in England to submit these data items so that
they can provide reliable results about key parts of the
diagnostic pathway.
Prospective audit
2. The number of men diagnosed with prostate cancer has
increased by 23% (52,580 compared to 42,668 in 2019),
which might be explained by increased public awareness
following media reporting of the diagnosis of two high-
profile celebrities in February/March 2018 .
3.
The proportion of men presenting with metastatic disease
at diagnosis has reduced (13% compared to 16% in 2019).
4. The potential ‘over-treatment’ of men with low-risk
disease has remained low at a national average of 5%
(compared to 4% in 2019) although some centres have a
persistently higher level.
5.
The potential ‘under-treatment’ of men with high-risk
localised/locally advanced disease has decreased slightly
(29% compared to 32% in 2019).
6. The use of primary docetaxel in metastatic disease has
increased in this second year of reporting (36% compared
to 27% in 2019).
7.
The proportion of men with intermediate-risk disease
receiving a hypofractionated radiotherapy regimen has
increased (96% compared to 91% in 2019).
8. Brachytherapy boost combined with EBRT was given
to 5% of men with high-risk localised/locally advanced
disease who received radical radiotherapy, as was found
last year (5% in 2019).
9. We report a national average (England only) of 18%
of these men having prostate and pelvic lymph node
irradiation with substantial national variation (a new
indicator).
10. Emergency readmission within 90 days of radical prostate
cancer surgery remains the same as in 2019 at 14%.
11. Genitourinary complications following radical
prostatectomy have remained stable with 9% of men
experiencing at least one genitourinary complication
within two years of their prostatectomy (compared to 9%
in 2019).
12. Gastrointestinal complications following radical
radiotherapy are stable at 11% of men experiencing a
gastrointestinal complication within two years of their
radiotherapy (compared to 10% in 2019).
Patient-reported outcomes

13. The majority of men (87%) were given the name of
a clinical nurse specialist, an increase from the last
reporting of this measure in the 2018 annual report (83%).
A high proportion of men (91%) rate their care at least 8
of out 10 (compared to 89% in 2018).
14. Following radical prostatectomy, the mean sexual
function score was generally poor at 24 on a scale of
0-100, an improvement of 1 point compared with the
previous round of reporting in 2018.
15. The urinary incontinence score was an average of 73
on a scale of 0-100 following radical prostatectomy, an
increase in 2 points.
16. Following radical radiotherapy, the average sexual
function score was generally poor at 18 on a scale of
0-100, an improvement in 1 point compared with 2018.
17. The mean bowel function score after radical radiotherapy
was 85 on a scale of 0-100. This is unchanged from the
previous round of reporting.

10
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Table 1. Recommendations, key findings and related national guidance
These recommendations are based on results from data collected in the audit period of 1st April 2018 to 31st March 2019 which therefore do not cover the period of the COVID-19
pandemic. This should be borne in mind if implementing a recommendation below in a time when services are impacted by the pandemic situation.
No.
Recommendation
Audience
Annual Report 2020 findings underlying
recommendation
Previous results
National guidance
R1
Where appropriate increase the use of
transperineal biopsy methods when targeting
lesions in the anterior region of the prostate,
whilst balancing against resource constraints
and the risk of side effects.
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
21% of men in England and 6% of men in Wales had a
trans-perineal prostate biopsy.
(Results 3.3, Table 3).
Increase: 17% of men in England and 7% in
Wales in NPCA Annual Report 2019
National guidance currently unavailable. This
recommendation is based on the views of the
NPCA Clinical Reference Group (CRG).
R2
NHS Organisations in England should aim to
achieve high completeness of key data items,
capturing performance status and NEW
Cancer Outcomes Services Dataset (COSD)
data items related to mpMRI and prostate
biopsy type available from July 2020.
A clinician responsible for reviewing and
checking their team’s data returns should be
identified, mirroring the approach in Wales
where data completeness remains high.
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
with support from the
National Cancer Team
Data completeness in England:
Performance status (52%)
Data completeness in Wales:
Performance status (100%)
(Results 3.3, Table 2).
No change:
England - Performance status (52%)
Wales - Performance status (100%)
in NPCA Annual Report 2019
NICE Guideline [NG131], 2019
1.2.2 Offer multiparametric MRI as the first-
line investigation for people with suspected
clinically localised prostate cancer.
The Cancer Outcome and Services Data
set (COSD) has been the national standard
for reporting cancer in the NHS in England
since January 2013. Feedback reports for the
data submitted are available through the
CancerStats website.
R3
NHS Organisations in Wales should aim to
improve their case ascertainment working with
data specialists in the Wales Cancer Network.
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
Case ascertainment in Wales: 89%
(Results 3.3, first paragraph).
Small increase: 85% in NPCA Annual Report
2019
The Welsh Cancer Intelligence and
Surveillance Unit collects, analyses and
releases information about cancer in Wales.
R4
Continue to advocate active surveillance in the
first instance for men with low-risk prostate
cancer.
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
5% of men diagnosed with low-risk localised cancer in
England and Wales underwent radical prostate cancer
therapy within 12 months of diagnosis.
There were two specialist MDTs with significantly higher
levels of ‘potential over-treatment’ compared with the
national average after case-mix adjustment.
(Results 3.4, Performance indicator 2,
Figure 3).
Small increase : 4% of men in England and
Wales in NPCA Annual Report 2019
NICE Quality Standard [QS91], 2015
QS2: men with low-risk prostate cancer for
whom radical treatment is suitable are also
offered the option of active surveillance.
NICE Guideline [NG131], 2019
1.3.7 Offer a choice between active
surveillance, radical prostatectomy or radical
radiotherapy to people with low-risk localised
prostate cancer for whom radical treatment
is suitable.

11
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2020 findings underlying
recommendation
Previous results
National guidance
R5
Prostate cancer teams should investigate why
men with high-risk/locally advanced disease
are not considered for radical treatment.
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
71% of men diagnosed with locally-advanced prostate
cancer underwent radical treatment within 12 months of
diagnosis in England and Wales equating to 29% of men
being ‘potentially under-treated’.
‘Potential under-treatment’ by NHS provider varied (18%
to 61%) and there were five specialist-MDTs which had
significantly higher levels of ‘under-treatment’ compared
with the national average following adjustment for case-
mix.
(Results 3.4, Performance indicator 3,
Figure 4).
Reduction: 32% of men in England and
Wales were ‘potentially undertreated’ in
NPCA Annual Report 2019
NICE Guideline [NG131], 2019
1.3.13 Do not offer active surveillance to people
with high-risk localised prostate cancer.
NICE Guideline [NG131], 2019
1.3.14 Offer radical prostatectomy or radical
radiotherapy to people with high-risk localised
prostate cancer when it is likely the person’s
cancer can be controlled in the long term.
R6
Where appropriate, offer combined systemic
therapy, either with docetaxel or novel anti-
androgenic therapy, to people with newly
diagnosed metastatic disease
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
36% of men received primary docetaxel in combination
with standard ADT (ranging from 0% to 47% by NHS
provider in England).*
(Results 3.4, Performance indicator 4, Figure 5).
Increase: 27% of men received primary
docetaxel in combination with standard
ADT in NPCA Annual Report 2019
NICE Guideline [NG131], 2019
1.5.6 Offer docetaxel chemotherapy to
people with newly diagnosed metastatic
prostate cancer who do not have significant
comorbidities
NICE Guideline [NG161], 2020. NHS
England interim treatment changes during
the COVID-19 pandemic
Option to give enzalutamide with androgen
deprivation therapy for patients with newly
diagnosed metastatic disease instead of
docetaxel to reduce toxicity and potential for
admission. For patients who are intolerant
of enzalutamide, give the option of switching
treatment to abiraterone
R7
Develop a national working group to provide
consensus guidelines to support decision
making around the routine use of pelvic lymph
node irradiation for high risk localised/locally
advanced disease
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
with support from the
National Cancer Team
18% of men with high-risk localised /locally advanced
prostate cancer received prostate plus pelvic lymph nodes
irradiation, with wide variation by provider (ranging
from 0% to 68% by RT centre in England).*
(Results 3.4, Performance indicator 5, Figure 6).
N/A*
National guidance currently unavailable.
*Information currently unavailable for Wales
/Table 1 continued

12
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2020 findings underlying
recommendation
Previous results
National guidance
R8
Consider establishing radiotherapy centre
specialist gastrointestinal services to offer
advice to people with bowel-related side effects
of radiotherapy.
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
11% of men experienced at least one bowel complication
(defined as receiving a procedure of the large bowel and
confirmed diagnosis of radiation toxicity) within two
years after radical radiotherapy. Following adjustment,
two centres had significantly worse rates of severe bowel
toxicity compared with other NHS providers in England
and Wales.
(Results 3.4, Performance indicator 10, Figure 11).
Small increase : 10% of men in England and
Wales in NPCA Annual Report 2019
NICE Guideline [NG131], 2019
1.3.39 Offer people with signs or symptoms
of radiation-induced enteropathy care from
a team of professionals with expertise in
radiation-induced enteropathy (who may
include oncologists, gastroenterologists, bowel
surgeons, dietitians and specialist nurses).
R9
Consider high dose rate brachytherapy in
combination with external beam radiotherapy
for patients with intermediate- or high-risk
prostate cancer.
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
5% of men receiving radical radiotherapy for high-risk/
locally advanced disease received a brachytherapy boost
in England.*
(Table 4).
No change: 5% of men in England in NPCA
Annual Report 2019
NICE Guideline [NG131], 2019
1.3.22 Consider brachytherapy in combination
with external beam radiotherapy for people
with intermediate- and high-risk localised
prostate cancer.
R10
Ensure access to nurse specialists and their
services for patients with prostate cancer.
Prostate cancer teams
(local and specialist
MDTs) within NHS
Trusts/Health Boards
87% of men reported that they were ‘given the name of a
CNS’, which varied from 73% - 100% by provider.
(Results 3.4, Figure 7),
Increase: 83% of men in NPCA Annual
Report 2018
NICE Quality Standard [QS91], 2015
QS 1 Men with prostate cancer should have
a discussion about treatment options and
adverse effects with a named nurse specialist.
R11
Seek advice from a doctor if you experience
any of the following new symptoms: urinary
symptoms, erectile problems, blood in your
urine or unexplained back pain.
Patients
Overall 13% of men in England and Wales were diagnosed
with metastatic disease at presentation (ranging from 7%
to 22% by specialist MDT).
(Results 3.4, Performance indicator 1, Figure 2).
Reduction: 16% of men in England and
Wales in NPCA Annual Report 2019
NHS Long Term Plan for Cancer 2019
‘..build on work to raise greater awareness
of symptoms of cancer, lower the threshold
for referral by GPs, accelerate diagnosis and
treatment..’
Cancer delivery plan for Wales 2016 - 2020
‘…develop a programme of awareness
campaigns for cancer’
R12
Men with a family history of prostate, breast or
ovarian cancer should ensure this is reported
to their healthcare provider with a view to a
possible genetic counselling referral.
Patients
Overall 13% of men in England and Wales were diagnosed
with metastatic disease at presentation (ranging from 7%
to 22% by specialist MDT).
(Results 3.4, Performance indicator 1, Figure 2).
Reduction: 16% of men in England and
Wales in NPCA Annual Report 2019
NHS Long Term Plan for Cancer 2019
‘..build on work to raise greater awareness
of symptoms of cancer, lower the threshold
for referral by GPs, accelerate diagnosis and
treatment..’
‘routinely offer genomic testing to all people
with cancer for whom it would be of clinical
benefit’
Cancer delivery plan for Wales 2016 - 2020
‘… develop a programme of awareness
campaigns for cancer’
*Information currently unavailable for Wales
/Table 1 continued

13
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2020 findings underlying
recommendation
Previous results
National guidance
R13
Men with low-risk prostate cancer should
discuss with their specialist the option of
disease monitoring with active surveillance in
the first instance.
Patients
5% of men diagnosed with low-risk localised cancer in
England and Wales underwent radical prostate cancer
therapy within 12 months of diagnosis.
There were two specialist MDTs with significantly higher
levels of ‘potential over-treatment’ compared with the
national average after case-mix adjustment.
(Results 3.4, Performance indicator 2, Figure 3).
Small increase: 4% of men in England and
Wales in NPCA Annual Report 2019
NICE Quality Standard [QS91], 2015
QS2: men with low-risk prostate cancer for
whom radical treatment is suitable are also
offered the option of active surveillance.
NICE Guideline [NG131], 2019
1.3.7 Offer a choice between active
surveillance, radical prostatectomy or radical
radiotherapy to people with low-risk localised
prostate cancer for whom radical treatment
is suitable.
R14
Men who are offered prostate cancer treatment
should be aware of the side effects including:
loss of libido, problems getting or keeping
erections, loss of ejaculatory function, a
worsening of sexual experience, urinary
incontinence and/or bowel side effects.
Patients and prostate
cancer teams
Radical prostatectomy – urinary complications and sexual
function
9% of men experienced at least one genitourinary
complication requiring a procedural/surgical intervention
within two years after radical prostatectomy. Following
adjustment, three surgical centres had significantly worse
rates of severe urinary toxicity compared with other NHS
providers in England and Wales.
(Results 3.4, Performance indicator 9, Figure 10).
Overall, the mean urinary incontinence score was 73
and the mean sexual function score was 24 (with higher
scores representing improved function).
(Results 3.4, Performance indicators 11 [Figure 12] and 12
[Figure 13]).
Radical radiotherapy – bowel complications and sexual
function
11% of men experienced at least one bowel complication
within two years after radical radiotherapy. Following
adjustment, one centre had significantly worse rates
of severe bowel toxicity compared with other NHS
providers in England and Wales.
(Results 3.4, Performance indicator 10, Figure 11).
Overall, the mean bowel function score was 85 and mean
sexual function was 18 on a scale of 1 to 100.
(Results 3.4, Performance indicators 11 [Figure 14] and 12
[Figure 15]).
No change in urinary complications
compared with previous report – 9% of men
in England and Wales in NPCA Annual
Report 2019
Small increase compared with the previous
reporting period (urinary incontinence - a
score of 71 and sexual function – a score of
23) in NPCA Annual Report 2018
Bowel complications are consistent with
previous report – 10% of men in England
and Wales in NPCA Annual Report 2019
No change in reported bowel function (a
score of 85) and a small increase in sexual
function score (a score of 17) in NPCA
Annual Report 2018
NICE Guideline [NG131], 2019
1.1.12 Tell people with prostate cancer and
their partners or carers about the effects of
prostate cancer and the treatment options on
their: sexual function, physical appearance
continence, other aspects of masculinity.
Support people and their partners or carers
in making treatment decisions, taking into
account the effects on quality of life as well as
survival.
NICE Quality Standard [QS91], 2015
QS4: men with adverse effects of prostate
cancer treatment are referred to specialist
services.
/Table 1 continued
/Table 1 continued

14
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2020 findings underlying
recommendation
Previous results
National guidance
R15
Men experiencing physical or psychological
side effects during or following prostate cancer
treatment should be referred to specialist
support services. These should be offered
early and on an ongoing basis, in keeping with
national recommendations.
Patients and prostate
cancer teams
Recommendation in light of R14.
87% of men reported that they were ‘given the name of a
CNS’, which varied from 73% - 100% by provider.
(Results 3.4, Figure 7).
Increase compared with previous reporting
year – 83% of men in NPCA Annual Report
2018
NICE Guideline [NG131], 2019
1.1.11 Ensure that mechanisms are in place so
people with prostate cancer and their primary
care providers have access to specialist services
throughout the course of their disease.
R16
Sources of further information and support
should be available for men with prostate
cancer and carers. These are accessible
via GP services and from prostate cancer
charities including Prostate Cancer UK (www.
prostatecanceruk.org) and Tackle Prostate
Cancer (www.tackleprostate.org). Both of
these charities operate nationwide support
networks
Patients and prostate
cancer teams
Recommendation in light of R14 and R15.
N/A
NICE Guideline [NG131], 2019
1.1.3 Offer people with prostate cancer advice
on how to get information and support
from websites, local and national cancer
information services, and from cancer support
groups.
1.1.4 Choose or recommend information
resources for people with prostate cancer that
are clear, reliable and up to date. Ask for
feedback from people with prostate cancer
and their carers to identify the highest quality
information resources.
R17
Review and identify regional performance
indicators for prostate cancer. Pay particular
attention to variations in service provision
(diagnostics, treatment and support services)
and treatment outcomes. Where variation is
apparent, agree quality improvement action
plans and present these to the Trust Board
and/or CCG. Trust Boards and CCGs should
follow-up implementation progress.
Commissioners and
health care regulators
Recommendation in light of R1 – R16.
N/A
This recommendation is based on the views of
the NPCA CRG.
R18
Local commissioners should ensure that
radiotherapy centres are able to deliver a full
range of radiotherapy techniques and support
services for patients
Commissioners and
health care regulators
Recommendation in light of R7 – 9, R14 and R15.
N/A
This recommendation is based on the views of
the NPCA CRG.
*Information currently unavailable for Wales
/Table 1 continued

15
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
DIAGNOSIS AND STAGING
TREATMENT ALLOCATION
TREATMENT OUTCOMES
PATIENT EXPERIENCE OF CARE
for men diagnosed 18/19
men were diagnosed with prostate cancer in England
and Wales between 1st April 2018 and 31st March 2019
of men were 70 years or older
- 56% of men in 17/18
13%
54%
87%
Low-risk, localised disease
of men had radical treatments
and were potentially ‘over-treated’
– 4% in 17/18
Metastatic disease
of men had primary docetaxel
chemotherapy in England
– 27% of men in 17/18*
**mean scores on a scale of 1-100 with higher scores with higher scores representing better function
* data currently unavailable in Wales
of men said they were
‘given the name of a
clinical nurse specialist’ -
83% of men in the previous
survey in 2018
of men rated their care as
– 89% of men in 2018
of men undergoing surgery 18/19
were readmitted within 3 months
following surgery
This short-term outcome is stable
compared with 17/18
After surgery, men reported their
sexual function to be 24 and
urinary continence to be 73**
After external beam radiation, men
reported their sexual function to be
18 and bowel function to be 85**
Annual Report 2020
of men presented with
metastatic disease –
16% of men in 17/18
Medium term outcomes are stable for men
undergoing treatment in 2017 compared with 2016
Within 2 years of treatment
1 in 10 men experienced a severe
genitourinary complication
after surgery or a severe
gastrointestinal complication
after radical radiotherapy
the use of transperineal biopsy
is increasing in England
England
2017-18
2018-19
Wales
2017-18
7%
2018-19
6%
increase compared
with 42,668 men
in 17/18
This may be explained by the diagnosis
of two high-profile celebrities during the
period, which was publicised by the media
17%
21%
High-risk/locally advanced disease
of men did no have radical treatments
and were potentially ‘under-treated’ –
32% of men in 17/18
of men received radiation to their
prostate plus lymph nodes**
In England
for men diagnosed 18/19

16
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
8
Parry MG, Cowling TE, Sujenthiran A, et al. Risk stratification for prostate cancer management:
value of the Cambridge Prognostic Group classification for assessing treatment allocation. BMC
Med. 2020;18(1):114.
9
Sujenthiran A, Charman S et al. Quantifying severe urinary complications after radical
prostatectomy: the development and validation of a surgical performance indicator using hospital
administrative data. BJU int (2017); 120:219-225
10 Sujenthiran A, Nossiter J et al. National population-based study comparing treatment-related
toxicity in men who received Intensity-modulated versus 3D-Conformal Radical Radiotherapy for
prostate cancer. Int J Radiat Oncol Biol Phys.(2017); 99: 1253 -1260
11 Prostate Cancer: diagnosis and management. NICE Guideline [NG131], 2019.
12 NICE Guideline [NG161], 2020. NHS England interim treatment changes during the COVID-19
pandemic
13 Outcome measures of survival are not used in this year’s Annual Report but will be used in future
reports when the NPCA data has sufficient follow-up
1.1 Background
The National Prostate Cancer Audit has been reporting
annually for seven years, developing and adding indicators
year-on-year. The NPCA reports on the whole patient care
pathway from diagnosis through to treatment and
treatment-related outcomes. The key indicators with regard
to potential ‘over-treatment’ of low-risk disease and
potential ‘under-treatment’ of high-risk localised/locally
advanced disease have shown improving trends over the
first years of the Audit and they remain a priority area for
the NPCA. Future audits will use an updated, widely-
accepted risk stratification score (Cambridge Prognostic
Grouping8) which will give more detail about treatment
allocation for different risk groups, in particular whether
men with low risk disease are potentially receiving
treatment unnecessarily.
Limiting the impact of the adverse events of radical
treatments is another priority area. We use our previously
developed and validated performance indicators to identify
men experiencing moderate genitourinary (GU)
complications following surgery (radical prostatectomy) and
moderate GI toxicity following radiotherapy (external beam
radiation [EBRT]).9,10 Comparisons of surgical and
radiotherapy providers across the country by these
indicators also feed into the Clinical Outcomes Programme
(COP) and the National Clinical Audit Benchmarking
(NCAB). We hope that these processes can drive quality
improvement in sites across the country so that they can
reach the highest standards possible.
This is the second year that we report on the use of
docetaxel in addition to androgen deprivation therapy for
metastatic prostate cancer in keeping with the NICE 2019
recommendation for patients who are fit and willing to
receive chemotherapy.11 However, we note that this guidance
has been updated during the COVID-19 pandemic in 2020
to include the use of enzalutamide/abiraterone.12
We have started this year to report on the proportion of
men with high-risk localised/locally advanced disease given
prostate plus pelvic lymph node irradiation. We have not
reported on this aspect of radiotherapy treatment before but
it will be important to monitor the use of this approach
currently and in subsequent Annual Reports.
1. The National Prostate Cancer Audit (NPCA): Introduction
1.2 Aim and objectives
The aim of the NPCA is to assess the process of care and its
outcomes in men diagnosed with prostate cancer in England
and Wales.
The key objectives of the Audit are to investigate:
• service delivery and organisation of prostate cancer care in
England and Wales.
• the characteristics of men newly diagnosed with prostate
cancer.
• the diagnostic and staging process and planning of initial
treatment.
• the initial treatments that men received.
• the experiences of men receiving care and their health
outcomes 18 months after diagnosis.
• overall and disease-free survival with further follow-up.13
The NPCA determines whether the care received by men
diagnosed with prostate cancer in England and Wales is
consistent with current recommended practice and provides
information to support healthcare providers, commissioners
and regulators in helping improve care for patients. With its
full suite of performance indicators, including those from
patient-reported outcomes, the NPCA is the first national
audit which is able to report on process and outcome
measures from all aspects of the care pathway for men with
prostate cancer.

17
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
1.3 Previous Annual Report
The 2019 Annual Report14 reported on prostate cancer services provided by individual NHS providers to men diagnosed
between 1st April 2017 to 31st March 2018 in England and Wales. Key findings included:
• Increases in the use of multiparametric MRI and of trans-perineal biopsy.
• The proportion of men diagnosed with metastatic disease remained stable.
• The potential ‘over-treatment’ of men with low-risk disease remained low.
• The potential ‘under-treatment’ of men with high-risk/locally advanced disease decreased slightly.
• The use of hypofractionated radiotherapy was reported for 91% in intermediate-risk cases
• Brachytherapy boost for high-risk/locally advanced cases was reported at 5%
• Genitourinary complications at 2 years following radical prostatectomy improved with 1 in 10 men experiencing such a
complication
• 1 in 10 men experienced bowel dysfunction following radical radiotherapy, which was consistent with previous years.
From the 2019 organisational audit:15
• The service organisation survey showed that the majority of radiotherapy centres use rotational IMRT (96%) with cone
beam CT (80%) (with few using fiducial markers (9%) and none using kilovoltage (KV) imaging).
• The majority of oncology centres support the use of docetaxel in high volume (100%) and low volume (84%) M1
disease.
• There was little agreement across centres in the duration of neo-adjuvant and adjuvant ADT treatment duration for low-
risk and high-risk disease.
14 NPCA Annual Report 2019. Download from: http://www.npca.org.uk/reports/
15 NPCA Organisational Audit 2019. Download from: https://www.npca.org.uk/reports/npca-organisational-audit-2019/

18
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
2.1 Inclusion criteria & prospective
audit period
Patients are eligible for inclusion in the prospective audit if
they have newly diagnosed prostate cancer using the ICD-10
diagnostic code of “C61” (malignant neoplasm of the
prostate). The data collection period reported here includes
men diagnosed between 1st April 2018 and the 31st March
2019 in England and Wales. This duration of follow-up allows
an assessment of all short-term indicators.
Medium-term indicators require longer follow-up (up to two
years’ post-treatment) so the diagnostic period is earlier. The
reporting time period is therefore over a whole calendar year
(1st January 2017 to 31st December 2017).
2.2 Routine data collection
In England, the NPCA works with the National Cancer
Registration and Analysis Service (NCRAS), Public Health
England, as a data collection partner. NCRAS collects
patient-level data from all NHS acute providers using a range
of national data-feeds. This includes the Cancer Outcomes
and Services Dataset (COSD), which specifies the data items
that need to be submitted. Data is submitted to the National
Cancer Data Repository (NCDR) on a monthly basis via
MDT electronic data collection systems. Clinical sign-off of
data submitted to NCRAS is not mandated in England.
The NPCA’s data collection partner in Wales is the Wales
Cancer Network (WCN), Public Health Wales. The NPCA
dataset (section 2.3) is captured through a national system,
Cancer Information System for Wales (CaNISC), after
identification by hospital cancer services and uploaded via
electronic MDT data collection systems. Prior to submission
of NPCA data to the WCN, each patient record is validated
(frequently by an MDT coordinator) and signed off by a
designated clinician. Patient records are signed off when all
key data items have been completed.
2.3 NPCA dataset
The audit collects data on the diagnosis, management and
treatment of every patient newly diagnosed with prostate
cancer in England and Wales. Only COSD data items are
collected for men newly diagnosed with prostate cancer from
1st April 2019 in England in the following categories of the
NPCA dataset:
1.
NPCA Minimum data set 1 (MDS-1): The first category of
data items is collected for all men newly diagnosed with
prostate cancer during the initial phase of management.
2. NPCA Minimum data set 2 (MDS-2): The second
category of data items are collected for all patients who
have undergone radical prostatectomy.
A summary of the COSD data items in the NPCA dataset
collected for patients diagnosed between 1st April 2018 and
31st March 2019 can be found on the website.16 These data are
linked to other national datasets to provide extra information.
In England, these supplementary datasets are Cancer Registry
data, Hospital Episode Statistics (HES) data, the Office for
National Statistics (ONS) dataset, the National Radiotherapy
Dataset (RTDS) and the Systemic Anti-Cancer Dataset
(SACT).
In Wales, RTDS data are currently unavailable so the following
additional category in the NPCA dataset is collected:
3.
NPCA Minimum data set 3 (MDS-3): The third category
of data items are collected for all men for whom external
beam radiation therapy or brachytherapy is planned,
with or without androgen deprivation therapy.
NPCA Minimum dataset items 1-3 in Wales are linked to
additional data items from the Patient Episode Database for
Wales (PEDW), ONS and CaNISC. The NPCA dataset is
captured through CaNISC, which also provides information
regarding radiotherapy intent, site and dosing. The
radiotherapy centres are currently implementing the
collection of the RTDS, which will be available to the NPCA
in the near future.
We urge centres to work with their data collection leads to
ensure prostate cancer data is collected as completely as
possible as the audit is only as accurate as the data we receive.
2.4 Patient-reported outcome and
experience measures (PROMs/PREMs)
The NPCA Patient Survey was designed by the NPCA Project
Team following review of current literature/guidelines and in
consultation with clinical and patient representatives in the
Audit’s Clinical Reference Group. The questionnaire includes
PROMs and PREMs including:
• Selected questions from the National Cancer Patient
Experience Survey (NCPES) – a national survey
commissioned by NHS England to determine patients’
views of their experience of care.
• The Expanded Prostate Cancer Index Composite 26-
item version (EPIC-26) –a validated instrument to
measure prostate cancer related quality of life after radical
treatments for prostate cancer including urinary, bowel and
sexual functioning17
2. Methods
16 https://www.npca.org.uk/resources/npca-minimum-dataset/
17 The EPIC-26 produces a validated summary score for each domain that ranges from 0 to 100,
with higher scores representing better function. The urinary incontinence domain, includes
questions related to urinary frequency and leakage, the bowel function domain assesses bowel
frequency,urgency, bleeding and pain and the sexual function domain asks questions related to the
quality and frequency of erections. Szymanski K, Wei, J et al. Development and validation of an
abbreviated version of the expanded prostate cancer index composite instrument for measuring
health-related quality of life among prostate cancer survivors. Urology (2010), 76, 1245-50.
18 NPCA Annual Report 2016. Download from: https://www.npca.org.uk/reports/npca-annual-
report-2016/
19 Nossiter J, Sujenthiran A et al. Robot-assisted radical prostatectomy vs laparoscopic and open
retropubic radical prostatectomy: functional outcomes 18 months after diagnosis from a national
cohort study in England. Br J Cancer (2018); 118: 489-494

19
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
The survey cohort included men diagnosed between 1st April
and 30th September 2018 who subsequently underwent radical
prostatectomy or EBRT. The mechanism for data collection
has been described previously.18,19 In summary, further to
identification of the patient cohort by the NPCA team, the
NPCA data collection partners in England (NCRAS, PHE)
and Wales (WCN, PHW) securely transferred the relevant
identifiable patient data (name, address, date of birth, NHS
number and NPCA identifier) to Quality Health, the NPCA’s
survey provider. Before sending out the surveys, Quality
Health access NHS Digital’s automated National Data Opt-out
service and automated PDS/DBS service to remove men who
had raised a type-II objection, to determine a current address
and whether a patient had died. Questionnaires were mailed
to the homes of all identified men ≥18 months after diagnosis.
Two reminders were sent to non-responders with the final
reminder ≤ 8 weeks after the first mail out.
De-identified survey response data was securely transferred to
the NPCA team for linkage to de-identified patient-level
clinical data and analyses.
2.5 Level of reporting
It is recommended that the care of patients eligible for radical
prostate cancer treatments should be coordinated by specialist
MDTs.20 These hubs are made up of one or more specialist
cancer centres coordinating services for referring local Trusts
or Health Boards.21
Results are presented at the level of the specialist MDT except
for treatment specific outcomes which are reported at the
level of the surgery or radiotherapy centre. The arrangement
of NHS providers, both local and specialist MDTs, and the
range of services they provide for the staging and
management of prostate cancer was determined by the NPCA
Organisational Audit 201922 but could not be updated in time
for this report due to the pandemic. Updated information will
be reported in 2021.
2.6 Patient inclusion and data quality
A patient is included in the prospective audit in England if he
has a record of newly diagnosed prostate cancer in the English
Cancer Registry. Patients newly diagnosed with prostate
cancer are identified through the Cancer Registry and so ‘per
definition’ we report case ascertainment at 100%.
A patient is included in the prospective audit in Wales if a
completed NPCA record was submitted and the Wales
Cancer Network (WCN) can assign that record to a
diagnosing Health Board. The total expected number of
cases was determined from the number of men newly
diagnosed with prostate cancer in the Welsh Cancer
Intelligence and Surveillance Unit (WCISU) in 2017. WCISU
were not able to provide exact numbers for the time frame
of NPCA data collection and so figures from 2017 were used
as the closest approximation. As only data for men with an
NPCA record is available for analysis, case ascertainment
for the Health Boards in Wales is presented and defined as
the proportion of the expected number of newly diagnosed
men present in the WCISU dataset for whom an NPCA
record was submitted which contained at least one NPCA
tumour staging data item.
The completeness of four key data items (PSA, Gleason score,
TNM and performance status) in England and Wales
provided a marker of data quality.
2.7 Definition of disease status and
risk stratification
In England, men were assigned to a prostate cancer risk
according to a modified D’Amico classification, which is a
three-tiered disease status category, assigned according to
their TNM stage, Gleason score and PSA, using an algorithm
previously developed by the NPCA.23 TNM and Gleason score
are received from the Cancer Registry. PSA is collected from
the COSD dataset as is not routinely collected within the
Cancer Registry.
In Wales, cancer stage was defined using “T category (pre-
treatment)”, “N category (pre-treatment)” and “M category
(pre- treatment)”. Where pre-treatment information was
missing for T or N, the corresponding pathological staging
items were used if available. All men were assigned to a disease
status category in the same way as the English men. All data
items were collected as part of the NPCA dataset in Wales.
2.8 Treatment allocation
A patient was considered to have undergone radical prostate
cancer therapy if he was identified as having received a
radical prostatectomy, radical external beam radiotherapy or
brachytherapy within 12 months of his diagnosis date.
HES and PEDW records, for England and Wales respectively,
were used to identify patients who had undergone a radical
prostatectomy using the OPCS-4 procedure code “M61”.
Where information on radical prostatectomy was missing in
the PEDW data for Wales, this information was added from
the NPCA dataset.
For England, the RTDS data-item “treatment modality” was
used to identify men who received external beam radiotherapy
and/or brachytherapy. Men receiving radiotherapy for
metastases or radiotherapy with palliative intent were
excluded. Men were assigned to a standard fractionated or
hypofractionated regimen (with or without a brachytherapy
boost – both low dose rate and high dose rate) based on the
doses documented in the RTDS. HES and PEDW records were
also used to identify brachytherapy patients using OPCS-4
20 NICE 2002. Improving outcomes in urological cancer.
21 Aggarwal A, Nossiter et al. Organisation of Prostate Cancer Services in the English National Health
Service. Clin Oncol (R Coll Radiol) 2016; 28:482-9.
22 NPCA Organisational Audit 2019. Download from: https://www.npca.org.uk/reports/npca-
organisational-audit-2019/
23 NPCA Annual Report 2016. Download from: https://www.npca.org.uk/reports/npca-annual-
report-2016/

20
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
24 NICE Guideline [NG161], 2020. NHS England interim treatment changes during the COVID-19 pandemic
procedure codes (“M706” + “X653” + “Y363 / M706” + “X653
/ M712” +“X653”). In England, the data-item “radiotherapy
treatment region” was used to determine whether men had
irradiation of their prostate plus pelvic lymph nodes or just to
the prostate and seminal vesicles.
For Wales, CaNISC was used in a similar way to the RTDS to
identify men receiving curative radiotherapy and to exclude
those receiving palliative radiotherapy. Comparable data were
not available with regard to radiotherapy dosing or treatment
region in Wales and so no reporting was possible for the
actual receipt of prostate plus pelvic lymph node irradiation,
hypofractionation or use of a brachytherapy boost.
SACT was used to identify the men receiving docetaxel and
was only available for English men
2.9 NPCA performance indicators
2.9.1 Definition
In this Annual Report the NPCA report on 14 performance
indicators which are summarised here:
Disease presentation
• Performance indicator 1: Proportion of men diagnosed
with metastatic disease (presented at the level of the
SMDT).
• This process indicator provides information on the potential
late diagnosis of prostate cancer.
Treatment allocation
• Performance indicator 2: Proportion of men with low-
risk localised prostate cancer undergoing radical prostate
cancer therapy (presented at the level of the SMDT).
• This process indicator provides information about the
potential ‘over-treatment’ of men with low-risk prostate
cancer.
• Performance indicator 3: Proportion of men with high-
risk/locally advanced disease receiving radical prostate
cancer therapy (presented at the level of the SMDT).
• This process indicator provides information about potential
‘under-treatment’ of men with high-risk/locally advanced
disease.
• Performance indicator 4: Proportion of men with
metastatic disease receiving docetaxel in combination
with standard ADT (presented at the level of the SMDT).24
• This process indicator provides information about the use
of docetaxel as primary treatment for metastatic disease.
Docetaxel is a chemotherapeutic treatment new to the
NICE 2019 prostate cancer guidelines and should be
‘discussed’ with men with high-risk non-metastatic disease
and ‘offered’ to men with metastatic disease. As the data
collection period was prior to the publication period of the
new NICE guidelines only metastatic patients were included
for this indicator.
Radiotherapy regimen allocation
• Performance indicator 5: Proportion of men with high-
risk/locally advanced disease receiving prostate and pelvic
lymph node irradiation (presented at the level of the
radiotherapy centre).
• This process indicator provides information about the extent
of irradiation used for patients with high-risk or locally
advanced disease using data from the RTDS.
Patient experience of care
• Performance indicator 6: Proportion of patients who were
given the name of a clinical nurse specialist (presented at
the level of the SMDT).
• Performance indicator 7: Proportion of patients rating
their overall care as at least 8 out of 10 (presented at the
level of the SMDT).
• These process indicators provide information on key aspects
of a man’s experience of care following a prostate cancer
diagnosis and were derived from selected NCPES questions
in the NPCA patient survey
Outcomes of treatment: short-term
• Performance indicator 8: Proportion of patients who
had an emergency readmission within 90 days of radical
prostate cancer surgery (presented at the level of the
surgery centre).
• This outcome indicator was derived from linkage with HES/
PEDW admissions. Emergency readmission may reflect
that patients experienced a complication related to radical
prostate cancer surgery after discharge from hospital.

21
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
25 More detail of the genitourinary procedure codes can be found here: Sujenthiran A, Charman
S, Parry M et al. Quantifying severe urinary complications after radical prostatectomy: the
development and validation of a surgical performance indicator using hospital administrative data.
BJU int (2017); 120:219-225
26 More detail of the gastrointestinal procedure codes and diagnostic codes indicating radiation
toxicity can be found here: Sujenthiran A, Nossiter J, Charman S et al. National population-based
study comparing treatment-related toxicity in men who received Intensity-modulated versus
3D-Conformal Radical Radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys.(2017); 99: 1253
-1260
27 Armitage JN and van der Meulen J. Identifying co-morbidity in surgical patients using
administrative data with the Royal College of Surgeons Charlson Score. Br J Surg 2010; 97:772-81..
28 https://www.npca.org.uk/resources/npca-outlier-policy-2020/
Outcomes of treatment: medium-term
• Performance indicator 9: Proportion of patients
experiencing at least one genitourinary (GU)
complication requiring a procedural/surgical intervention
within 2 years of radical prostatectomy (presented at the
level of the surgical centre).
• We used a coding-framework based on OPCS-4 procedure
codes to capture genitourinary complications that
required an intervention.25 These included complications
of the urinary tract as opposed to those related to sexual
dysfunction. Men with an associated diagnosis of bladder
cancer (ICD-10 “C67” code) or who received post-operative
radiotherapy were excluded.
• Performance indicator 10: Proportion of patients
receiving a procedure of the large bowel and a diagnosis
indicating radiation toxicity (gastrointestinal (GI)
complication) up to 2 years following radical prostate
radiotherapy (presented at the level of the radiotherapy
centre).
• We used a coding-framework based on OPCS-4
procedure codes to capture interventions required to treat
gastrointestinal (GI) toxicity.26 This indicator also required
the presence of specific ICD-10 diagnosis codes relating
to GI toxicity. This combination approach allowed us to
exclude the men who had GI interventions for reasons
unrelated to radiotherapy, such as part of a screening
programme. Men with an associated diagnosis of bladder
cancer, those who received additional brachytherapy and
those who had received a radical prostatectomy prior to
radiotherapy were excluded.
Outcomes of treatment: patient-reported
These performance indicators present the validated summary
score for each EPIC-26 domain, which ranges from 0 to 100
with higher scores representing better function.
• Performance indicator 11: Mean urinary incontinence
score after radical prostatectomy (presented at the level of
the surgery centre).
• Performance indicator 12: Mean sexual function score
after radical prostatectomy (presented at the level of the
surgery centre).
• Performance indicator 13: Mean bowel function score
after radical radiotherapy (presented at the level of the
radiotherapy centre).
• Performance indicator 14: Mean sexual function score
after radical radiotherapy (presented at the level of the
radiotherapy centre).
2.9.2 Outlier identification
Multivariable logistic regression was carried out for
performance indicators 2 and 3 and 5-10, and multivariable
linear regression for performance indicators 11-14. Centres
which performed less than 10 procedures per year were
excluded.
The analyses for indicators 2 and 3 were adjusted for patient
age and comorbidity, and additionally for socio-economic
status for indicators 5-7. Risk group was also included in the
adjustment model for all treatment and patient-reported
outcomes (performance indicators 8-14).
Comorbidity was captured using the Royal College of
Surgeons (RCS) Charlson comorbidity score27 based on
ICD-10 diagnosis codes in HES/PEDW. The Index of Multiple
Deprivation (IMD) was used to categorise patients into five
socioeconomic groups (1=least deprived; 5=most deprived)
based on the areas in which they lived. The five categories
were fifths of the national IMD ranking of these areas.
Funnel plots were generated for the performance indicators
using control limits defining differences corresponding to
two standard deviations (inner limits) and three standard
deviations (outer limits) from the national average
population. Funnel plots are able to graphically display
variation across specialist MDTs/Trusts/Health Boards for
our performance indicators according to patient volume.
These are shown for process measures and patient-reported
measures across the country (performance indicators 1-7
and 11-14).
For the adjusted treatment-related outcomes (performance
indictors 8-10), surgical and radiotherapy treatment centres
outside the inner or outer funnel limits (alerts and alarms,
respectively) were considered as potential outliers and were
contacted, where necessary, according to the NPCA Outlier
Policy.28

22
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
3. Results
3.1 Audit participation
49,804 men were identified with prostate cancer in England
from 1st April 2018 to 31st March 2019, of whom 49,509 were
confirmed as diagnosed within the NHS and 49,492 could be
assigned a valid NHS provider in England. Prostate cancer
diagnostic services are provided at 132 NHS Trusts across 47
specialist MDTs in England and 6 Health Boards across 4
specialist MDTs in Wales.29 Surgical services were provided
by 54 centres and radiotherapy services by 54 centres during
this time period.
In Wales we received a total of 2,776 NPCA records of newly
diagnosed men and all could be assigned to a valid NHS
provider. In the most recent case ascertainment data available,
for calendar year 2017, the number of prostate cancer
diagnoses appearing in WCISU was 2,705 compared to 2,396
found in NPCA data, resulting in approximate case
ascertainment of 89%.
The number of men diagnosed with prostate cancer has risen
quite significantly in the diagnosis period of 1st April 2018 to
31st March 2019 compared to the previous year: by 23% in
both England (40,429 to 49,804) and Wales (2,239 to 2,776).
This is a larger year-on-year increase than we have seen
previously and might be explained by the diagnosis of two
high-profile celebrities with prostate cancer in February/
March 2018 which were publicised in the media. Indeed, we
do see a rise in diagnoses made in the period just after this,
peaking in May 2018 (Figure 1). These diagnoses appear to be
predominantly for men with intermediate risk and locally
advanced disease, with little change evident in the numbers of
men diagnosed in that period with low risk or metastatic
disease. Further exploration of this phenomenon will be
undertaken to determine if there were differences in the
distribution of socio-demographic characteristics of the men
diagnosed, and in the subsequent diagnostic investigations
and treatments received in that period. For this report, the
surge in numbers may give context to some of the changes
seen from the previous reporting period.
29 https://www.npca.org.uk/reports/npca-organisational-audit-2019/
Figure 1. Number of men diagnosed with prostate cancer in England and Wales each month and their
assigned risk group*
0
1000
2000
3000
4000
5000
Jan-18
Feb
Mar
Apr
May
June
Jul
Aug
Sept
Oct
Nov
Dec
Jan-19
Feb
Mar
Metastatic
Locally advanced
Intermediate
Low
Total
* 52,580 men were diagnosed with prostate cancer during reporting period 1st April 2018 to 31st March 2019. Of these, 4,598 men could not be assigned to a risk group due to insufficient or missing staging
information.

23
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
3.2 Data completeness
Completeness of pre-treatment data items
Data completeness is high for Wales, and remains consistent
with previous year’s results, with performance status reaching
100% completeness. 95% of Welsh men could be assigned to a
risk category due to the high completeness of PSA, Gleason
score and TNM variables (89%, 89% and 80%, respectively).
Data completeness in England is lower than in Wales.
Performance status is 52% complete, however, the
completeness of the diagnostic information is substantially
better with completeness for PSA, Gleason score and TNM
reported at 68%, 84% and 79%, respectively. It is possible to
place 91% of English men into a risk category showing that the
quality of the cancer data items is very good.
Overall data completeness can be seen in Table 2 and
completeness of all data items by diagnosing Trust/Health
Board and specialist MDT can be found on our website (www.
npca.org.uk).
Table 2. Data completeness for selected data items for men newly diagnosed with prostate cancer in
England and Wales over the period of 1 April 2018 and 31 March 2019.
Data variable
England
Wales
N
%
N
%
Diagnostic and staging variables
No. of men with new diagnosis of prostate cancer
49,804
[CR]
2,776
[NPCA]
Performance status completed
25,857
[COSD]
52%
2,776
[NPCA]
100%
Biopsy performed
21,815
[NPCA]
44%
2,775
[NPCA]
100%
PSA completed
33,671
[COSD]
68%
2,472
[NPCA]
89%
Gleason score completed
41,858
[CR]
84%
2,472
[NPCA]
89%
TNM completed
39,434
[CR]
79%
2,212
[NPCA]
80%
Acronyms: COSD = Cancer Outcome and Services Dataset; CR = Cancer Registry dataset; NPCA = National Prostate Cancer Audit dataset; PSA = Prostate Specific Antigen; TNM = Tumour, Nodes, Metastases
Classification of Malignant Tumours
3.3 Audit findings
Patient and diagnostic characteristics are summarised in
Table 3.
Patient characteristics
Over one third of men are aged between 70 and 80 (39%
and 42% for England and Wales, respectively) and another
third are aged between 60 and 70. Prostate cancer is a
disease of the older man as is shown by the significant
proportion being diagnosed above 80 years old (15% and
12% in England and Wales, respectively). This is consistent
with last year’s report. In England, 72% of the men who had
a performance status had one of 0 (fully active) versus 65%
for Wales, a little higher for Wales compared to last year’s
report. Data completeness was again better for the Welsh,
compared to English, data (100% versus 52%).
Diagnostic investigations
Although the trans-rectal ultrasound guided method remains
the most common biopsy technique there has been a reduction
in the use of this approach in England (70% this year compared
with 83% in 2017/18) and Wales (79% compared with 93%),
with 21% and 6% of men undergoing a trans-perineal biopsy
(in England and Wales respectively), although incomplete data
makes these figures difficult to compare across the years.
Disease status at presentation
The distribution of PSA, Gleason score and TNM staging is
shown in Table 3 and has remained consistent with last
year’s results. Stage at diagnosis has remained stable
compared to last year: 42%, 39% and 6% of men were
assigned to high-risk/locally advanced, intermediate-risk and
low-risk disease in England. The respective figures for Wales
were 33%, 46% and 8%. Slightly fewer men were diagnosed
with metastatic disease in England compared to last year
(13% compared to 16%, which may be due to the higher
numbers in other risk groups this year) but the proportion
in Wales remained similar to last year at 14%.

24
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Table 3. Patient and diagnostic characteristics for men newly diagnosed with prostate cancer in England
and Wales over the period of 1 April 2018 and 31 March 2019.
Data variable
England
Wales
N
%
N
%
No. of men with new diagnosis of prostate cancer
49,804
2,776
Age
<60
6,665
13%
311
11%
60-70
16,075
32%
965
35%
70-80
19,417
39%
1,162
42%
≥80
7,647
15%
338
12%
Total
49,804
100%
2,776
100%
Missing
0
0
Performance status
0
18,660
72%
1,807
65%
1-2
6,805
26%
922
33%
≥3
392
2%
47
2%
Total
25,857
100%
2,776
100%
Missing
23,947
0
Charlson score
0
37,892
76%
2,172
78%
1
8,014
16%
320
12%
≥2
3,898
8%
284
10%
Total
49,804
100%
2,776
100%
Missing
0
0
Biopsy performed
Transrectal sampling
14,438
66%
2,201
79%
Transrectal saturation
934
4%
13
0%
Perineal sampling
2,469
11%
2
0%
Perineal template
2,182
10%
178
6%
Other
866
4%
84
3%
None
926
4%
297
11%
Total
21,815
100%
2,775
100%
Missing
27,989
1
Prostate Specific Antigen (PSA)
<10
16,705
50%
1,285
52%
10-20
7,585
23%
579
23%
>20
9,381
28%
608
25%
Total
33,671
100%
2,472
100%
Missing
16,133
304
Gleason score
≤6
8,317
20%
820
33%
7
21,788
52%
1,177
48%
≥8
11,753
28%
475
19%
Total
41,858
100%
2,472
100%
Missing
7,946
304

25
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
/Table 3 continued
Data variable
England
Wales
N
%
N
%
T stage
T1
6,765
15%
439
16%
T2
19,420
44%
1,352
50%
T3
15,710
36%
731
27%
T4
2,047
5%
158
6%
Total
43,942
100%
2,680
100%
Missing
5,862
96
N stage
N0
37,177
89%
2,346
91%
N1
4,430
11%
222
9%
Total
41,607
100%
2,568
100%
Missing
8,197
208
M stage
M0
37,537
86%
2,020
86%
M1
6,153
14%
335
14%
Total
43,690
100%
2,355
100%
Missing
6,114
421
Risk group
Metastatic
6,153
14%
335
13%
High risk/Locally advanced
18,816
42%
887
33%
Intermediate
17,481
39%
1,225
46%
Low risk
2,882
6%
203
8%
Total
45,332
100%
2,650
100%
Insufficient
4,472
126
Acronyms: PSA = Prostate Specific Antigen; TNM = Tumour, Nodes, Metastases Classification of Malignant Tumours.
*unadjusted values.
Treatment Information
Treatment characteristics are summarised in Table 4.
8,957 men were identified as undergoing a radical
prostatectomy in England; most were robotically assisted
(89%), with the remainder being performed laparoscopically
(5%) or through open surgery (6%). There has been a
continued adoption of the robotic-assisted approach with
previous proportions being 85% (2017/2018), 81% (2016/2017)
and 74% (2015/2016). Robotic prostatectomies were performed
less frequently in Wales (76%) but this is steadily increasing
from 68% last year and 63% the year before. Just under one
third of the prostatectomies were performed with a
lymphadenectomy in England (28%) but more so in Wales
(50%).
17,121 men underwent radical radiotherapy in England; the
vast majority were performed with IMRT (Table 4) for first
line therapy, which is consistent with the figure reported last
year, but 9% still had 3D conformal radiotherapy. Of all men
receiving radiotherapy, 15% received radiotherapy to the pelvic
lymph nodes as well as the prostate, with the remainder of
men receiving radiotherapy to the prostate +/- seminal
vesicles only. Wales used IMRT routinely and 18% of Welsh
men appear to be having “regional” vs “prostate only”
radiotherapy, although these figures rely on data on ‘planned
region of treatment’. Wales is transitioning to using the same
radiotherapy dataset (RTDS) system as England, after which a
better comparison between countries will be possible.
The proportion of men receiving a brachytherapy boost for
high-risk or locally advanced disease has stayed low at 5%,
while the proportion of men with intermediate-risk disease
receiving a hypofractionated regimen increased from 91% last
year to 96%.

26
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Table 4. Treatment characteristics for men receiving radical radiotherapy or prostatectomy in England
and Wales over the period of 1 April 2018 and 31 March 2019.
Data variable
England
Wales
N
%
N
%
Radical prostatectomy information
No. of men undergoing radical prostatectomy
8,957
319
Prostatectomy type
Robotic
7,950
89%
232
76%
Open
466
5%
46
15%
Laparoscopic
541
6%
29
9%
Total
8,957
100%
307
100%
Missing
0
12
Lymphadenectomy performed
No
6,463
72%
160
50%
Yes
2,494
28%
159
50%
Total
8,957
100%
319
100%
Missing
0
0
Radical radiotherapy information
No. of men undergoing radical radiotherapy
17,121
951
Radiotherapy modality
Intensity Modulated Radiation Therapy
15,538
91%
920
100%
3D conformal
1,583
9%
2
0%
Total
17,121
100%
922
100%
Missing
0
29
Planned radiotherapy region
Prostate and/or seminal vesicles
14,011
85%
760
82%
Whole pelvis including lymph nodes
2,505
15%
166
18%
Total
16,516
100%
926
100%
Missing
605
25
No. of men with locally advanced disease undergoing radical radiotherapy
8,791
Brachytherapy boost*
No
8,389
95%
Yes
402
5%
Total
8,791
100%
Missing
0
No. of men with intermediate risk disease undergoing radical radiotherapy
4,419
Hypofractionated regimen*
No
171
4%
Yes
4,248
96%
Total
4,419
100%
Missing
0
*comparable data not available for Wales

27
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
3.4 NPCA performance indicators
We were able to determine disease status and allocate a
provider to 45,174 patients in England (91%) and 2,650 in
Wales (95%).
Disease presentation
Performance indicator 1: Proportion of men diagnosed with
metastatic disease
Overall 13% of men were diagnosed with metastatic disease at
presentation which is a small reduction compared to last
year’s figure of 16%. An unadjusted funnel plot (Figure 2)
demonstrates the variation in the proportion of men
diagnosed with metastatic disease across 49 specialist MDTs
(ranging from 7% - 22%).
Figure 2. Unadjusted funnel plot for the proportion of patients with metastatic disease at diagnosis
across the specialist MDTs in England and Wales.
0
10
20
30
40
50
60
70
80
90
100
Patients with metastatic disease (%)
0
250
500
750
1000
1250
1500
1750
2000
2250
2500
Number of Patients
English Specialist MDT
Welsh Specialist MDT
99.8% limit
National percentage
95% limit

28
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Treatment allocation
Performance indicator 2: Proportion of men with low-
risk localised cancer undergoing radical prostate cancer
treatment
5% of men diagnosed with low-risk localised cancer
underwent radical prostate cancer therapy within 12 months
of diagnosis (range: 0% - 27%). The average has not changed
substantively since last year, but the range and variation
across providers has increased. An adjusted funnel plot
demonstrates that some specialist MDTs still have unusually
high levels of over-treatment (Figure 3) with two
significantly higher than the average.
Figure 3. Adjusted funnel plot for the proportion of patients with low-risk prostate cancer undergoing
radical treatment by specialist MDTs in England and Wales.
0
10
20
30
40
50
60
70
80
90
100
Patients undergoing radical treatment (%)
0
25
50
75
100
125
150
175
Number of Patients
English Specialist MDT
Welsh Specialist MDT
99.8% limit
National percentage
95% limit

29
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Performance indicator 3: Proportion of men with high-risk/
locally advanced disease undergoing radical prostate
cancer treatment
71% of men diagnosed with high-risk/locally advanced
prostate cancer were found to have undergone some form of
radical local therapy within 12 months of diagnosis (range:
39% - 82%). An adjusted funnel plot demonstrates that of 49
specialist MDTs there were five which had significantly worse
levels of ‘under-treatment’ compared to the others (negative
outliers), and two which had significantly better rates of
‘under-treatment’ (positive outliers) (Figure 4).
Figure 4. Adjusted funnel plot for the proportion of patients with high-risk/locally advanced prostate
cancer undergoing radical treatment by specialist MDTs in England and Wales.
0
10
20
30
40
50
60
70
80
90
100
Patients undergoing radical treatment (%)
0
100
200
300
400
500
600
700
800
900
1000
Number of Patients
English Specialist MDT
Welsh Specialist MDT
99.8% limit
National percentage
95% limit

30
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Performance indicator 4: Proportion of men with
metastatic disease receiving docetaxel in combination with
standard ADT
36% of men with metastatic disease (range: 0% - 47%)
received primary docetaxel in combination with standard
ADT, which is an increase from last year. The adjusted funnel
plot (Figure 5) demonstrates the variation in its use across 46
specialist MDTs in England. This information is currently not
available for Wales.
Figure 5. Adjusted funnel plot for the proportion of men with newly diagnosed metastatic disease
receiving primary docetaxel by specialist MDTs in England.
0
10
20
30
40
50
60
70
80
90
100
Patients receiving docetaxel (%)
0
50
100
150
200
250
300
Number of Patients
English Specialist MDT
99.8% limit
95% limit
Note: Data was not available for Wales and so Welsh providers were not included.

31
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Radiotherapy regimen allocation
Performance indicator 5: Proportion of men with high-risk
localised /locally advanced disease receiving prostate and
pelvic lymph node irradiation
18% of the men receiving radical radiotherapy for high-risk/
locally advanced prostate cancer received prostate plus pelvic
lymph nodes irradiation (range: 0% - 68%). The adjusted
funnel plot (Figure 6) demonstrate the wide variation in the
use of this method across 51 radiotherapy centres in England.
This information is currently not available for Wales.
Figure 6. Adjusted funnel plot for the proportion of men with high-risk/locally advanced disease receiving
prostate and pelvic lymph node irradiation by RT centre in England.
0
10
20
30
40
50
60
70
80
90
100
Patients receiving whole pelvis irradiation (%)
0
50
100
150
200
250
300
350
400
Number of Patients
English Radiotherapy Centre
99.8% limit
95% limit
Note: Data were unavailable for Wales and so Welsh providers were not included.

32
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Figure 7. Unadjusted funnel plot for the proportion of men who were given the name of a clinical nurse
specialist by specialist MDTs in England and Wales.
0
10
20
30
40
50
60
70
80
90
100
Patients given the name of a CNS (%)
0
50
100
150
200
250
300
350
400
450
500
550
600
Number of Patients
English Specialist MDT
Welsh Specialist MDT
99.8% limit
National percentage
95% limit
Patient experience of care

The NPCA Patient Survey was sent to 10,756 men who were
diagnosed with prostate cancer from 1st April 2018 to 30th
September 2018 in England and Wales and who subsequently
underwent radical prostatectomy or radical radiotherapy.
8,356 men responded resulting in a response rate of 78%.
Performance indicator 6: Proportion of patients who were
given the name of a clinical nurse specialist (presented at the
level of the SMDT).
87% of men (range 73-100%) were given the name of a clinical
nurse specialist. An adjusted funnel plot (Figure 7)
demonstrates the variation across 49 specialist MDTs in
England and Wales with some SMDTs providing the name of
a CNS to a surprisingly low proportion of men receiving
radical treatment.

33
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Performance indicator 7: Proportion of patients rating their
overall care as at least 8 out of 10 (presented at the level of
the SMDT).
91% of men (range 81–100%) rated their care very highly.
An adjusted funnel plot (Figure 8) demonstrates low variation
across 49 specialist MDTs in England and Wales.
Figure 8. Unadjusted funnel plot for the proportion of men rating their overall care as at least 8 out of 10
by specialist MDTs in England and Wales.
0
10
20
30
40
50
60
70
80
90
100
Patients overall rating of care >=8 (%)
0
50
100
150
200
250
300
350
400
450
500
550
600
Number of Patients
English Specialist MDT
Welsh Specialist MDT
99.8% limit
National percentage
95% limit

34
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Outcomes of treatment: short-term

Performance indicator 8: Proportion of patients who had an
emergency readmission within 90 days of radical prostate
cancer surgery (presented at the level of the surgery centre).
9,276 men underwent a radical prostatectomy at 54 surgical
centres between 1st April 2018 and 31st March 2019. The
90-day emergency readmission rate following radical
prostatectomy was 14% (range 0 – 34%), consistent with last
year. Following adjustment, four surgical centres had a
significantly worse readmission rate than the others (negative
outlier), and two centres had a significantly better rate
(positive outlier) (Figure 9). This outcome measure is also
used for the NPCA outlier process and the outlier Trust
responses to notification of their outlier status can be found in
the Appendix.
Figure 9. Adjusted funnel plot for the proportion of patients readmitted as an emergency within 90 days
of radical prostatectomy by surgical centres in England and Wales.
0
10
20
30
40
50
60
70
80
90
100
Readmissions within 90 days of surgery (%)
0
100
200
300
400
500
600
700
Number of Patients
English Surgical Centre
Welsh Surgical Centre
99.8% limit
National percentage
95% limit

35
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Figure 10. Adjusted funnel plot for the proportion of patients experiencing at least one genitourinary
complication requiring a procedural/surgical intervention within 2 years of radical prostatectomy by
surgical centres in England and Wales.
0
10
20
30
40
50
60
70
80
90
100
Genitourinary complication (%)
0
50
100
150
200
250
300
350
400
450
Number of Patients
English Surgical Centre
Welsh Surgical Centre
99.8% limit
National percentage
95% limit
Outcomes of treatment: medium-term

Performance indicator 9: Proportion of patients
experiencing at least one genitourinary (GU) complication
requiring a procedural/surgical intervention within 2 years
of radical prostatectomy (presented at the level of the
surgical centre).
5,842 men underwent a radical prostatectomy at 54 surgical
centres during 2017. Overall 9% of men experienced at least
one treatment-related GU complication within two years
following surgery, with a range of 0 – 26%. Following
adjustment, there were three surgical centres which had
significantly worse rates of GU complications than the others
(negative outliers), and three centres with significantly better
rates of complications (positive outliers) (Figure 10). This
outcome measure is also used for the NPCA outlier process
and the outlier Trust responses to notification of their outlier
status can be found in the Appendix.

36
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Performance indicator 10: Proportion of patients receiving a
procedure of the large bowel and a diagnosis indicating
radiation toxicity (gastrointestinal [GI] complication) up to
2 years following radical prostate radiotherapy (presented at
the level of the radiotherapy centre).
11,683 men received EBRT at 54 radiotherapy centres during
2017. Overall 11% (range 2 – 26%) experienced at least one
bowel complication within two years of radiotherapy.
Following adjustment, there were two centres with
significantly worse rates of GI toxicity than the others
(negative outlier). Three centres had significantly better rates
of complications (positive outliers) (Figure 11). This outcome
measure is also used for the NPCA outlier process and the
outlier Trust responses to notification of their outlier status
can be found in the Appendix.
Figure 11. Adjusted funnel plot for the proportion of patients receiving a procedure of the large bowel and
a diagnosis indicating radiation toxicity up to 2 years following radical prostate radiotherapy.
0
10
20
30
40
50
60
70
80
90
100
Gastrointestinal complication (%)
0
100
200
300
400
500
Number of Patients
English Radiotherapy Centre
Welsh Radiotherapy Centre
99.8% limit
National percentage
95% limit

37
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Outcomes of treatment: patient-reported
Of the 8,356 men diagnosed with prostate cancer from 1st
April 2018 to 30th September 2018 in England and Wales
who responded to the NPCA Patient Survey, 2,790 (33%)
had a radical prostatectomy at 49 surgical centres and 5,569
(67%) had EBRT at 53 radiotherapy centres. The following
performance indicators use results from the EPIC-26
questionnaire which ranks patient function on a scale of 0 to
100 representing bad (low score) to good (high score) function.
Performance indicator 11: Mean urinary incontinence score
after radical prostatectomy (presented at the level of the
surgery centre).
2,667 men (96%) who had radical surgery completed
sufficient information to be assigned an EPIC-26 urinary
incontinence score. Overall, the mean urinary incontinence
score after a radical prostatectomy was 72.8 (range: 54.9 –
84.6). An adjusted funnel plot demonstrates that out of 49
surgical centres, only one had a significantly worse score
(negative outlier) than the national average (Figure 12).
Figure 12. Adjusted funnel plot for the mean EPIC 26 urinary incontinence score after radical
prostatectomy by surgical centres in England and Wales (on a scale of 0-100).
Adjusted mean EPIC 26 urinary incontinence score
0
25
50
75
100
125
150
Number of Patients
English Surgical Centre
Welsh Surgical Centre
99.8% limit
National mean score
95% limit
0
10
20
30
40
50
60
70
80
90
100

38
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Performance indicator 12: Mean sexual function score after
radical prostatectomy (presented at the level of the surgery
centre).
2,701 men (98%) completed sufficient information to be
assigned an EPIC-26 sexual function score. Sexual function is
generally low following radical prostatectomy across 49
surgical centres in England and Wales. Overall, the mean
sexual function score after a radical prostatectomy was 23.8
(range: 9.3 – 34.6). An adjusted funnel plot demonstrates that
out of 49 surgical centres, three had significantly worse scores
(negative outliers), and two had significantly better scores
than the national average for this domain (positive outliers)
(Figure 13).
Figure 13. Adjusted funnel plot for the mean EPIC 26 sexual function score after radical prostatectomy by
surgical centres in England and Wales (on a scale of 0-100).
Adjusted mean EPIC 26 sexual function score
0
25
50
75
100
125
150
175
Number of Patients
English Surgical Centre
Welsh Surgical Centre
99.8% limit
National mean score
95% limit
0
10
20
30
40
50
60
70
80
90
100

39
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Performance indicator 13: Mean bowel function score after
radical radiotherapy (presented at the level of the
radiotherapy centre).
4,875 men who had EBRT (88%) completed sufficient
information to be assigned an EPIC-26 bowel function score.
Overall, the mean bowel function score after radical
radiotherapy was 85.2 (range: 79.1 - 90.4). The adjusted funnel
plot demonstrates limited variation across 53 radiotherapy
centres. However, two had significantly worse scores (negative
outliers) and one had a significantly better score than the
national average (positive outliers) (Figure 14).
Figure 14. Adjusted funnel plot for the mean EPIC 26 bowel function score after radical radiotherapy by
radiotherapy centres in England and Wales (on a scale of 0-100).
Adjusted mean EPIC 26 bowel function score
0
50
100
150
200
250
Number of Patients
English Radiotherapy Centre
Welsh Radiotherapy Centre
99.8% limit
National mean score
95% limit
0
10
20
30
40
50
60
70
80
90
100

40
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Performance indicator 14: Mean sexual function score after
radical radiotherapy (presented at the level of the
radiotherapy centre).
5,070 men (92%) who had EBRT completed sufficient
information to be assigned an EPIC-26 sexual function
score. Overall, the mean sexual function score after radical
radiotherapy was 18.2 (range: 10.9 – 26.1). An adjusted
funnel plot demonstrates that out of 53 radiotherapy centres,
one had significantly worse scores (negative outliers), and
one had significantly better scores than the national average
for this domain (positive outliers; Figure 15).
Figure 15. Adjusted funnel plot for the mean EPIC 26 sexual function score after radical radiotherapy by
radiotherapy centres in England and Wales (on a scale of 0-100).
Adjusted mean EPIC 26 sexual function score
0
50
100
150
200
250
Number of Patients
0
10
20
30
40
50
60
70
80
90
100
English Radiotherapy Centre
Welsh Radiotherapy Centre
99.8% limit
National mean score
95% limit

41
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
4.1 Participation and data
completeness
Data completeness for staging items is high and allows for
more than 90% of men to be assigned a risk status. In future
reports we will move to using a validated five-tiered risk
stratification metric which will allow for even finer-grained
reporting of outcomes (Cambridge Prognostic Grouping30).
Other key variables, however, are not so comprehensive and
data completion varies between Trusts. For instance, the use
of multiparametric MRI was not included in this report due
to poor data completeness. However, data from our
organisational audits provide an alternative source of its use at
a Trust-level. The NPCA are targeting the completeness of this
variable as a priority for subsequent reports. From April 2019,
the NPCA has moved to using routine databases for all our
data analyses in England. This has therefore replaced the
bespoke data items collected through the NPCA minimum
datasets so as to avoid replication of information and to
ensure an easier data collection process. From July 2020 there
were new data items added to COSD including pre-biopsy
multiparametric MRI. We encourage all Trusts carrying out
diagnostic procedures to ensure that these variables are
completed fully.
Performance status is a measure of how well a person is able to
carry on ordinary daily activities and provides an indication
of what treatments a person may tolerate, thereby helping
to guide decisions about the appropriateness of certain
treatments. Although completeness of performance status
is high in Wales (100%), this remains low in England (52%).
Improving the completeness of this key clinical data item is a
key quality improvement goal for clinical teams in England.
4. Discussion
New data items in the Urology/ Prostate Cancer section of COSD V9.0.1 to capture information on
diagnostic procedures
Data item No.
Data Item Name
Data Item Description
National code definition
UR15440
BIOPSY
ANAESTHETIC
Record the type of anaesthetic used
during the biopsy
Local
Sedation
General
Not Known
UR15500
mpMRI PRE-
BIOPSY
Was a multiparametric mpMRI
performed on the patient before the
biopsy?
Yes
No
Not Known
UR15510
MRI/FUSION
BIOPSY
Was a MRI/Fusion Biopsy performed
on the patient?
Yes
No
Not Known
4.2 Diagnostics
The use of trans-perineal biopsies has increased compared to
last year and this procedure was being performed in three-
quarters of the Trusts/Health Boards in England and Wales in
the period of this audit (2018/19). However, trans-rectal
ultrasound guided biopsy was still the most common biopsy
technique being used, although trans-perineal biopsy is
accepted as the best way to diagnose anterior lesions.31
Further questions in this area, around the type of trans-
perineal biopsy (targeted or systematic) and if it is performed
under local anaesthetic or sedation, will be explored in the
upcoming organisational survey.
4.3 Performance indicators
Diagnosis and treatment selection
The proportion of men diagnosed with metastatic disease at
first presentation has reduced slightly from last year to 13%
and there is minimal variation across specialist MDTs in
England and Wales. The reduction may be due to the higher
numbers in other risk groups this year which may be due to
the impact of high-profile celebrities encouraging men to be
checked for prostate cancer. This has led to a rise primarily in
the intermediate risk and locally advanced categories, and
with little change evident in the numbers of men diagnosed in
that period with low risk or metastatic disease, the relative
proportions for these may appear lower.
30 Parry MG, Cowling TE, Sujenthiran A, et al. Risk stratification for prostate cancer management:
value of the Cambridge Prognostic Group classification for assessing treatment allocation. BMC
Med. 2020;18(1):114.
31 Berry B, Parry MG, Sujenthiran A, et al. Comparison of complications after transrectal and
transperineal prostate biopsy: a national population‐based study. BJU Int. 2020; 126:97-103

42
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
The figures for potential ‘over-treatment’32 in low-risk men
and potential ‘under-treatment’ in high-risk/locally advanced
men has remained stable compared to last year at 5% (17/18:
4%) and 29% (17/18: 32%), respectively.
The recently added process measure of the receipt of
primary docetaxel by newly-presenting hormone-naive
metastatic patients has shown an increase from 27% last
year to 36% this year. However, given that this was added to
the NICE guidelines in 2019 as a standard of care and was
established as effective in the Stampede Trial in 2015,33 this
still seems low. We do expect this to keep increasing year
on year although there may be an upper limit as docetaxel
is less suitable for treating older men, who make up a
significant proportion of patients with metastatic disease.
We will continue to monitor this trend going forward.
We continue to follow changes in radiotherapy
fractionation. Hypofractionated radiotherapy is now the
most common radiotherapy regimen used for intermediate-
risk (96%) prostate cancer in the primary setting.34,35
Nationally, very few men with high-risk/locally advanced
disease who received radical radiotherapy also received a
brachytherapy boost, still at 5%. We have added an indicator
to capture the use of irradiation for the prostate plus pelvic
lymph nodes vs prostate-only radiation in the primary
setting. This was found to be at a national average of 18% in
England but the variation seen was concerning and will
need further evaluation. It seems there is little consistency
in the use of radiotherapy delivered to both the prostate and
the pelvic lymph nodes, although it has been found to be
well-tolerated.36 More work needs to be done to understand
why some centres do not adopt this method of treatment:
we propose the development of a national working group to
provide consensus guidelines to support decision making in
this area of prostate cancer treatment.
Patient-reported experience measures
Only men diagnosed in a 6-month period (April 2018 –
September 2018) and who subsequently underwent radical
prostatectomy or EBRT, were sent a survey in this current
round of data collection. An excellent high response rate
(78%) was achieved (an increase compared with 73% of all
non-metastatic men diagnosed April 2014 to September 2016
in the previous round of data collection) demonstrating that
patients in England and Wales have continued to engage
successfully with the NPCA Patient Survey.
The results of the PREMs demonstrate that the majority of men
rate their overall care very highly. Most (91%) rated their care
at least eight out of ten (where ten represents ‘very good’ care).
There was only limited variation across SMDTs. Reflecting the
key NICE Quality Standard ‘men with prostate cancer should
have a discussion about treatment options and adverse effects
with a named nurse specialist’, the majority of men who had
radical treatment stated they were given the name of a CNS
(87%). However, this varied by provider and was low for a
number of SMDTs. Furthermore, we have no indication as to
whether this translated into use of specific nurse-led services.
SMDTs should ensure the involvement of a CNS for every new
diagnosis of prostate cancer. The NPCA will explore further
the availability of specific nurse-led services in the 2020
organisational audit.
Treatment-related outcome measures
The national average for 90-day readmissions after RP is
stable at 14% with four centres being identified as potential
negative outliers. The proportion of men experiencing a
treatment-related GU complication within two years of
surgery has remained stable since last year’s report at 10%
with five centres being identified as potential outliers, which is
up from two centres being outside the expected range last
year. It is important to note that 89% of the RPs were carried
out robotically and a recent study carried out by the NPCA
indicates that there is no evidence that GU outcomes would
be better if this percentage would increase further.37
The proportion of men experiencing a treatment-related GI
complication within two years of radiotherapy remained
consistent with last year at 11%, and although three centres
were outliers last year, only two centres were identified as a
potential outlier this year. One of the centres was previously
an outlier and has since made changes to their processes
which would not be captured as yet by the data period
analysed here. Their negative outlier status is therefore a
reflection of outcome in patients treated at that centre using
different methods. This is expected to improve with the
changes facilitated by the NPCA outlier process.
Although patient-reported sexual function scores have
increased by one-point at a national level since the previous
round of the NPCA Patient Survey, these scores remain low
following radical surgery or radiotherapy at 24 and 18 (out of
100), respectively. There was also significant variation between
providers with three surgical centres and one radiotherapy
centre having significantly worse outcomes for sexual
function compared with the national average. Patients should
be counselled appropriately and honestly regarding their
likelihood of experiencing urinary and/or sexual dysfunction
following radical surgery or radiotherapy.
Centres should review their survivorship programmes to
ensure they are equipped to provide support to patients
experiencing post-treatment problems which may need
physical or pastoral help.
32 The recently published NPCA Short Report 2020 examines geographical variation in the
management of high-risk/locally advanced prostate cancer in England and explores determinants
of potential ‘under-treatment’ of men https://www.npca.org.uk/content/uploads/2020/10/NPCA-
Short-Report-2020_Undertreatment_Final-08.10.20.pdf
33 James ND, Sydes MR, Clarke NW, et al. Addition of docetaxel, zoledronic acid, or both to first-line
long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive,
multiarm, multistage, platform randomised controlled trial. The Lancet; 2015; 387(10024):1163-1177
34 Nossiter J, Sujenthiran A, Cowling TE et al. Patient-Reported Functional Outcomes After
Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort
Study in England. J Clin Oncol. 2020; 38(7):744-752.
35 Sujenthiran A, Parry MG, Nossiter J, et al. Comparison of Treatment-Related Toxicity With
Hypofractionated or Conventionally Fractionated Radiation Therapy for Prostate Cancer: A
National Population-Based Study. Clin Oncol. 2020; 32(8):501-508
36 Parry MG, Sujenthiran A, Cowling TE, et al. Treatment-Related Toxicity Using Prostate-Only
Versus Prostate and Pelvic Lymph Node Intensity-Modulated Radiation Therapy: A National
Population-Based Study. J Clin Oncol. 2019; 37(21):1828-1835
37 Nossiter J, Sujenthiran A, Charman SC et al. Robot-assisted radical prostatectomy vs laparoscopic
and open retropubic radical prostatectomy: functional outcomes 18 months after diagnosis from a
national cohort study in England. Br J Cancer. 2018; 118(4):489-494.

43
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Centres with performance that lies outside the expected
range for the outcome measures should review their
treatment pathway and engage with other providers to
understand any differences in care. The next NPCA Quality
Improvement workshop will take place in Q2 2021 and we
encourage all clinical leads to attend. It will be a perfect
opportunity to learn about the processes of the NPCA and
ways to improve care.
4.4 Future Plans for the NPCA
The NPCA in England no longer collects any bespoke data
items within the NPCA minimum dataset. For men
diagnosed from the 1st April 2019 COSD data items only have
been collected in keeping with the monthly routine
submission of data to the NCRAS, PHE. We encourage Trusts
to review their data quality and to ensure the following COSD
data items are uploaded to the cancer registry for every newly
diagnosed patient with prostate cancer: performance status,
CNS availability, PSA, Gleason score, TNM and the two new
COSD data items regarding use of pre biopsy multiparametric
MRI and prostate biopsy type.
The NPCA are working with our data collection partners to
access available data more rapidly. This will enable the NPCA
to determine the impact of COVID-19 on the diagnosis and
treatment of men with prostate cancer, including treatment
delay and potential receipt of sub-optimal treatment, and how
this varies by region and individual hospitals. With further
follow-up, the NPCA will determine the impact of changes in
diagnostic and treatment pathways during the COVID-19
pandemic on the outcomes of men with prostate cancer.
We plan to continue our annual organisational survey,
although it has been delayed this year, in order to provide up
to date information about service availability across the
country. Data was gathered in the latter part of 2020 and will
be published early in 2021.
We shall continue to publish data in England as part of the
Clinical Outcomes Programme (COP) and the National
Clinical Audit Benchmarking (NCAB) to enable
dissemination of our findings to clinicians, stakeholders,
patients and the wider public. The indicators we use for this
are those used for our own outlier policy and focus on
treatment-related outcomes (90-day readmissions following
surgery, 2 year genitourinary complications following surgery
and 2 year gastrointestinal complications following
radiotherapy).
The success of the NPCA relies heavily on the quality of the
data received from Trusts and Health Boards across England
and Wales. Our data collection partners (NCRAS and WCN)
will continue to work directly with individual care providers
to help improve data quality. This will ensure the reliability of
all the results we present and the reporting of outliers. The
NPCA will continue to use our outlier policy to notify
outlying providers for which we publish the Trust responses
in each Annual Report. This will enable the data to be checked
and changes implemented to improve patient outcomes.

44
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Active Surveillance
The initial monitoring of prostate cancer with low risk clinical
characteristics.
Adjuvant
Treatment that is given following the primary treatment. Neo-
adjuvant treatment is treatment before the definitive therapy.
Androgen Deprivation Therapy (ADT)
Androgen deprivation therapy is a hormone therapy used to
control prostate cancer and delay or manage any symptoms
arising from it. Testosterone makes prostate cancer cells grow
faster and this therapy works by either stopping the body
from making the hormone testosterone, or by stopping
testosterone reaching the prostate cancer cells. By doing this
the cancer will usually shrink, wherever it is in the body.
Androgen deprivation therapy can be used when prostate
cancer cells have already spread to distant sites but it can also
be used with other treatments, such as radiotherapy, to make
them more effective.
ASA score
The American Society of Anaesthesiologists (ASA)
classification is a scoring system based on the perioperative
health and co-morbidities of a surgical patient. A high ASA
score denotes a higher risk of perioperative complications in
the short and long term. For the NPCA, an ASA score is
assigned to all patients regardless of treatment.
Brachytherapy
A treatment for prostate cancer using either the
implantation of permanent radioactive seeds into the
prostate (termed low dose rate brachytherapy) or the
temporary insertion of a source of radiation into the
prostate (termed high dose rate brachytherapy).
Brachytherapy can deliver a high radiation dose to the
prostate gland whilst reducing radiation to the surrounding
healthy tissue. This treatment can be used in isolation or in
combination with radiotherapy in higher risk disease.
British Association of Urological Nurses (BAUN)
The British Association of Urological Nurses is a registered
charity which aims to promote and maintain the highest
standards in the practice and development of urological
nursing and urological patient care. Registered charity no:
1140616.
British Association of Urological Surgeons
(BAUS)
Professional association for urological surgeons. Registered
charity no: 1127044.
British Uro-oncology Group (BUG)
Professional association for clinical and medical oncologists
specialising in the field of urology. Registered charity no:
1116828.
Glossary
Cancer Network Information System Cymru
(CaNISC)
An online computer system that provides information for
health professionals on cancer patients across Wales.
Cancer Outcomes and Services Dataset (COSD)
The national standard for reporting on cancer in the NHS in
England. Trusts submit a data file to the National Cancer
Registration and Analysis Service (NCRAS) every month.
Care Quality Commission (CQC)
Independent regulator of health and adult social care in
England. The CQC makes sure that health and social care
services provide people with safe, effective, compassionate
and high-quality care.
Case-mix
Refers to different characteristics of patients seen in different
hospitals (for example age, sex, disease stage, social
deprivation and general health). Knowledge of differing
case-mix enables a more accurate method of comparing
quality of care (case-mix adjustment).
Case-mix adjustment
A statistical method of comparing quality of care between
organisations that takes into account other important and
measurable characteristics which might affect outcome (also
see risk-adjustment).
Castrate Resistant Prostate Cancer
Prostate cancer that keeps growing even when the amount
of circulating testosterone in the body is reduced to very
low levels.
Charlson Co-morbidity Score
A scoring system used commonly to quantify the co-existence
of other medical conditions (medical co-morbidities: see
below) that patients may have in addition to their prostate
cancer. The score is calculated based on the absence and
presence of specific medical problems in the Hospital Episode
Statistics (HES) database.
Clinical Effectiveness Unit (CEU)
An academic collaboration between the RCS and the
London School of Hygiene and Tropical Medicine
(LSHTM). The CEU carries out national surgical audits,
develops audit methodologies and produces evidence on
clinical and cost effectiveness.
Clinical Nurse Specialist (CNS)
Experienced senior nurses who have undergone specialist
training and play an essential role in improving
communication and coordinating treatment in cancer
patients. They act as the first point of contact for the patient,
coordinating and facilitating the patient’s treatment.
Clinical Outcomes Publication (COP)
An NHS initiative to promote data transparency and support
wider engagement with national clinical audit data via
publication of a directory of audits on myNHS.

45
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Co-morbidity
Medical condition(s) or disease process(es) that are
additional to the disease under investigation (in this case,
prostate cancer).
Cone Beam Computed Tomography
A medical imaging technique consisting of X-ray computed
tomography (CT). These are focussed in a specific way to
enable the computer assisted generation of three
dimensional images.
Cyberknife®
Cyberknife® is an advanced radiation therapy device which
has X-ray linked cameras that monitor the position of a
tumour and sensors that monitor the patient’s breathing. This
enables the robot to reposition the radiotherapy beam during
treatment in order to deliver X Ray treatment precisely and
minimise damage to healthy tissue close to the cancer.
Expanded Prostate Cancer Index Composite 26-
item version (EPIC-26)
A validated survey comprising questions for patients to
measure prostate cancer related quality of life after radical
treatments including urinary, bowel and sexual functioning.
External Beam Radiotherapy (EBRT)
The use of high energy X-ray beams directed at the prostate to
kill cancer cells. It is used as a standard method to treat
localised or locally advanced prostate cancer.
Fiducial Markers
Tiny metal objects used during radiotherapy which allows
greater precision in directing radiation enabling radiation
therapy to be delivered to the same area of the cancer each
time it is given.
Gleason Score
The Gleason score is a microscopic measure assigned by a
pathologist to determine how aggressive an individual’s
prostate cancer is. It is made up of two separate scores which
are then added together to make a final score graded between
6 and ten. Along with PSA and TNM, the Gleason score can
be used to predict how a prostate cancer might behave in the
future. This process is known as risk stratification.
Health Board
A local health organisation that is responsible for delivering
all healthcare services within a regional area in Wales.
Currently, there are seven Health Boards in Wales and six of
these provide prostate cancer services
Healthcare Quality Improvement Partnership
(HQIP)
The Healthcare Quality Improvement Partnership (HQIP)
aims to promote quality improvement in patient outcomes
and in particular, to increase the impact that clinical audit,
outcome review programmes and registries have on
healthcare quality in England and Wales. HQIP is led by a
consortium of the Academy of Medical Royal Colleges, the
Royal College of Nursing and National Voices.
Hospital Episode Statistics (HES)
A database that contains data on all patients treated within
NHS trusts in England. This includes details of admissions,
diagnoses and treatments.
Intensity-modulated Radiotherapy (IMRT)
A type of conformal radiotherapy enabling higher doses of
radiotherapy to be given to specific higher risk areas within
the prostate gland. Conformal radiotherapy shapes the
radiation beam to closely fit the area of the cancer in order to
avoid healthy tissue. The benefit over 3-dimentional
conformal radiotherapy is that a higher dose can be given to
specific areas of the prostate while limiting the radiation dose
to the surrounding tissues.
International Classification of Diseases, Tenth
Revision (ICD-10)
The World Health Organisation international standard
diagnostic classification. It is used to code diagnoses and
complications within the Hospital Episode Statistics database
of the English NHS.
KV Imaging
A high-resolution, low-dose digital imaging system that
makes image-guided radiation therapy more efficient and
convenient.
Localised Disease
When cancer is confined within the anatomical boundaries of
the prostate.
Locally Advanced Disease
When cancer has spread outside the anatomical boundaries of
the prostate (T3 or T4) but is still contained within the
prostate gland’s pelvic location. This may be associated with
spread to lymph nodes within the pelvis (N+).
Lymphadenectomy
The surgical removal of one or more groups of lymph nodes
(usually in the pelvis) in prostate cancer.
Magnetic Resonance Imaging (MRI)
A type of scan that uses strong magnetic fields and radio
waves to produce detailed images of the inside of the body.
The term “multi-parametric” (mpMRI) refers to variation in
the types of MR image obtained during a scan. This adds to
the ability of the clinical team to determine the presence of a
cancer and its chance of being a more aggressive type of
cancer growth.
Margin Status
Once the prostate has been removed during surgery, the
margin status indicates whether the edge of the specimen
contains cancer cells or not. A positive margin status does not
always indicate that residual prostate cancer cells may have
been left behind.
/Glossary continued

46
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Metastatic Disease
When cancer has spread from its initial site of development in
the prostate (the primary site) to distant sites of the body (the
metastatic site(s)). These sites are mainly in the bones and
lymph nodes in the first instance.
Multidisciplinary Team (MDT)
A team of specialist health care professionals from various
backgrounds (e.g. doctors, nurses, administrative staff) who
collaborate to assess diagnosis and treatment and organise
and deliver care for patients with conditions such as prostate
cancer. The specialist MDT enables local cancer units to
access specialist prostate cancer services which may not be
locally available (see Specialist Multidisciplinary Team).
Multimodal Therapies
The use of multiple treatments used in combination against
prostate cancer. These combinations may include
radiotherapy, hormone therapy, surgery and/or systemic
chemotherapy.
National Cancer Data Repository (NCDR)
The NCDR comprises a merged dataset of English cancer
registration data, linked to further national datasets including
Hospital Episode Statistics (HES), the radiotherapy dataset
(RTDS) and Office of National Statistics data (ONS).
National Cancer Patient Experience Survey
(NCPES)
A national survey commissioned by NHS England to
determine patients’ views of their experience of care.
National Cancer Registration and Analytical
Service (NCRAS)
A national body which collects, analyses and reports on
cancer data for the NHS population in England.
Neo-adjuvant
Treatment that is given as a first step before the primary
treatment.
Nerve-sparing Surgery
Preservation of the nerves surrounding the prostate during
prostatectomy in order to preserve erectile function after the
operation. This is not always possible if the cancer is extensive
within the prostate or has spread outside the anatomical
boundaries of the prostate.
NHS Digital
The provider of professional IT services to the NHS. Their
goal is to improve health and social care in England by
making better use of technology, data and information.
NHS Hospital Trust
An NHS organisation that provides acute care services in
England. A trust can include one or more hospitals.
National Institute for Health and Care
Excellence (NICE)
An organisation responsible for providing national guidance
on the promotion of good health, and the prevention and
treatment of ill health.
Office for National Statistics (ONS)
Government department responsible for collecting and
publishing official statistics about the UK’s society and
economy. This includes cancer registration data.
Patient Episode Database for Wales (PEDW)
A database that contains all inpatient and day case activity
undertaken in NHS hospitals in Wales. This includes details of
admissions, diagnoses and the treatments.
Performance Status (WHO/ECOG)
The World Health Organisation (WHO)/Eastern Cooperative
Oncology Group (ECOG) performance status indicator is a
measure of how disease(s) impacts a patient’s ability to
manage on a daily basis. It was initially developed in the
research setting to standardise the reporting of chemotherapy
toxicity and the response of cancer patients in clinical trials.
However, it is now in the public domain and is routinely used
in other research and clinical settings.
Prostate Specific Antigen (PSA)
A protein produced by the cells of the prostate gland. A high
PSA may indicate prostate cancer or prostate cancer
recurrence but it also may indicate benign conditions such as
an enlarged prostate or infection.
Radical Prostatectomy
The surgical removal of all the prostate gland and the
associated seminal vesicles. The latter are structures integrally
associated with the prostate. Their function is to produce and
store fluid which sustains the viability of sperm when it leaves
the prostate.
Radical treatment
Treatment aimed at curing prostate cancer (removing cancer
tissue or filling all cancer cells in their primary location). These
treatments include radical prostatectomy and radiotherapy.
Radiotherapy
The use of radiation to destroy cancer cells. There are different
types of radiotherapy, including external beam radiotherapy
(radiotherapy delivered from a radiation source outside the
body) and brachytherapy (radiotherapy delivered directly by
implanting a radiation source within the tumour itself).
Radiotherapy Data Set (RTDS)
A database that contains standardised data from all NHS
Trust providers of radiotherapy services in England.
/Glossary continued

47
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Rectal Spacer
Rectal spacers are used prior to radiotherapy and their
effectiveness is currently under evaluation. They are placed
between the prostate and rectum in order to move the
rectum away from the prostate. The belief is that this may
protect the rectum from radiation and reduce side effects of
radiation therapy. Results from further trials of this
technique are awaited.
Risk Stratification
Classification of prostate cancer according to individual risk
profile. This is done by taking into account how aggressive the
cancer is and how far it has spread (see Gleason score).
Risk-adjustment
A statistical method that takes into account important and
measurable characteristics (also see case-mix adjustment).
Roach Score
A formula which uses PSA and Gleason score to predict the
risk of pelvic node involvement in prostate cancer patients.
Robotic-assisted Prostatectomy
A “key-hole” laparoscopic operation that uses a robot
controlled from a separate console by a surgeon to carry out
removal of the prostate. The robot allows for more controlled
and precise movements during the operation. Advantages
over traditional open surgery include less blood loss, less
post-operative pain, a shorter hospital stay, smaller scars and
a greater likelihood of sparing the nerves which run within
the outer margin of the prostate.
Royal College of Surgeons of England (RCS)
An independent professional body committed to enabling
surgeons to achieve and maintain the highest standards of
surgical practice and patient care. As part of this it supports
audit and the evaluation of clinical effectiveness of surgery.
Specialist Multidisciplinary Team (SMDT)
A team of specialists who coordinates the specialist treatment
of men with prostate cancer. The SMDT enables local cancer
units to access specialist prostate cancer services which may
not be locally available. Specialist services include
prostatectomy and radiotherapy (see Multidisciplinary Team).
Staging/stage
The anatomical extent of a cancer. This determines whether
a cancer is confined within its primary site (localised
disease) or whether it has spread to other areas of the body
(metastatic spread). It is usually denoted by the TNM
staging process where “T” represents the local stage, “N” the
presence of cancer spread to lymph nodes and “M” spread
to metastatic sites.
Stereotactic Body Radiation Therapy (SBRT)
SBRT is a type of radiotherapy which delivers precise,
intense doses of radiation to cancer cells using image
guidance and in doing so minimises the damage to the
surrounding healthy tissue.
Systemic Anti-Cancer Therapy (SACT)
The SACT database collects data on the use of systemic
anti-cancer therapy from all NHS England providers. This
database has been used to identify the men receiving
docetaxel chemotherapy for their prostate cancer.
Tomotherapy
Tomotherapy is a form of radiotherapy which combines a
personalised treatment plan with intensity modulation and
image guidance to treat cancer efficiently.
Trans-perineal biopsy
Biopsy of the prostate using a fine needle through the
perineum (the area of skin between the back of the scrotum
and the front of the anus) guided using an ultrasound probe
placed in the rectum (back passage). This is performed
under general or local anaesthetic. The needle placement
can be more precise than trans-rectal ultrasound biopsies if
the prostate cancer sits in the forward portion of the
prostate gland.
Trans-rectal Ultrasound (TRUS) Biopsy
The use of thin needles to takes tissue samples from the
prostate after numbing the area with local anaesthetic. The
biopsy is done through the rectum (back passage). The
placement of these needles is enabled by use of an ultrasound
scanner in the rectum to guide the biopsy.
Treatment-related Toxicity
Complications following radical treatment. Genitourinary
and gastrointestinal complications can be expected following
radiotherapy or prostatectomy.
Wales Cancer Network (WCN)
A new organisation that has evolved from the merger of the
two Cancer Networks in Wales and the Cancer National
Specialist Advisory Group (NSAG) and is designed to collect
cancer-specific information in Wales.
Welsh Cancer Intelligence and Surveillance Unit
(WCISU)
WCISU is the National Cancer Registry for Wales. Its primary
role is to record, store and report on all incidences of cancer
for the resident population of Wales.
/Glossary continued

48
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Appendix: Outlier Communications
Introduction to the NPCA Outlier
Process
Surgical and radiotherapy treatment centres outside the inner
or outer funnel limits (‘alerts’ and ‘alarms’, respectively) for
the adjusted treatment-related outcomes listed below were
considered as potential outliers and were contacted, where
necessary, according to the NPCA Outlier Policy.
Performance indicator 8: The proportion of patients who had
an emergency readmission within 90 days of radical
prostatectomy.
Performance indicator 9: The proportion of patients
experiencing at least one genitourinary (GU) complication
requiring a procedural/surgical intervention within 2 years
of radical prostatectomy.
Performance indicator 10: The proportion of patients
receiving a procedure of the large bowel and a diagnosis
indicating radiation toxicity (gastrointestinal [GI]
complication) up to 2 years following radical prostate
radiotherapy.
The NPCA team reviews the individual patient data returned
by the treatment centres after they have carried out case
reviews, to determine whether any patients need to be
excluded from the analysis. This only happens if coding errors
or misclassification of a patient’s outcomes can be shown.
Data not provided to the NPCA and limitations of case mix
adjustment are not considered as these have been applied
consistently across all providers.
A final determination of outlier status is made and if the
‘alarm’ outlier status is confirmed, the NPCA informs the
CQC of their ‘alarm’ status. The responsible NHS Hospital
Trust or Health Board is asked for a formal response to the
findings, outlining the steps they will take for quality
improvement.
If a treatment centre is confirmed to be an ‘alert’ outlier two
years in a row, in keeping with the ‘Detection and
Management of Outliers for National Clinical Audit’
guidance, the NPCA informs the CQC of their ‘alert’ status.
Several instances of coding inaccuracies within treatment
centres have led to the misclassification of patients in the first
analysis. Following NPCA review and discussion of data with
the individual centre these misclassifications have been
accepted as a reason for excluding these patients from the
indicator analyses. The treatment centres with this type of
erroneous classification had their data re-analysed and were
each found not to be an ‘alarm’ outlier following correction.
This was the case, this year, for treatment centres in the
following Hospital Trusts or Boards:
Emergency Readmissions –
• Aneurin Bevan University Health Board
• Oxford University Hospitals NHS Foundation Trust
• University Hospitals of North Midlands NHS Trust
GU Complications –
• Worcestershire Acute Hospitals NHS Trust
These data quality issues are important to address as they are
likely to be widespread, not just in those treatment centres
that initially fell outside the limits this year. We urge all
Hospital Trusts and Health Boards to examine their coding
practices to ensure that admissions are coded appropriately
and that follow-up episodes are accurately captured so that
true improvement of the quality of care for men with prostate
cancer can be pursued.
Noel Clarke Urological Clinical Lead
representing the British Association of Urological Surgeons
Heather Payne Oncological Clinical Lead
representing the British Uro-oncology Group

49
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Responses from Trusts with a confirmed ‘case to answer’ during the NPCA
Outlier Policy1
Following identification as a true outlier each Trust was contacted by means of a letter to the MDT lead and Medical Director.
The following trusts were contacted in relation to the following specific performance indicators:
Surgical centres
Performance indicator 8: Proportion of patients who had an emergency readmission within 90 days of radical prostate cancer
surgery.
Bradford Teaching Hospitals NHS Foundation Trust
Performance indicator 9: Proportion of patients experiencing at least one genitourinary (GU) complication requiring a procedural/
surgical intervention within 2 years of radical prostatectomy.
East Lancashire Hospitals NHS Trust
Gloucestershire Hospitals NHS Foundation Trust
Radiotherapy centres
Performance indicator 10: Proportion of patients experiencing at least one severe gastrointestinal (GI) complication within 2 years
of radical external beam radiotherapy (presented at the level of the radiotherapy centre).
Norfolk & Norwich University Hospitals NHS Foundation Trust
1
https://www.npca.org.uk/resources/npca-outlier-policy-2020/

50
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Response from Bradford Teaching Hospitals NHS Foundation Trust
Performance indicator 8: Proportion of patients who had an emergency readmission within 90 days of radical prostate cancer
surgery.
Response 1
Thank you for your letter dated the 28th of September 2020 regarding our potential outlier position in terms of 90 day re-admission rates
for men undergoing radical prostatectomy between 1 April 2018 and 31 March 2019. As advised I contacted M/s Karen Graham, National
Cancer Registration and Analysis Data Improvement Lead who kindly provided us the NHS numbers for our patients who were re-
admitted to BTHFT. We have since had the opportunity to assess our patient records for this period, in particular, we have looked at the
causes of re-admission in the 54 patients noted by the NPCA.
BTHFT (Bradford Teaching Hospitals NHS Foundation Trust) started the Robotic prostatectomy programme in late 2012 and we have
since performed over 1200 cases. Our trust has been actively engaging with NPCA and have not previously been noted to be an outlier.
In the period between 1 April 2018 and 31 March 2019 we had performed 223 Radical prostatectomies higher than the denominator of 196
noted by the NPCA. All of these were robotically assisted (RALP). During this period the majority of cases were performed by 3 surgeons
Mr R Chahal, Mr R Singh and Mr C Molokwu. The first two of these surgeons have experience with over 500 radical prostatectomies each
and Mr Molokwu with 100 case experience. Mr S Addla, a previous colleague, was the 4th surgeon who performed 5 cases in a locum
capacity to cover a gap in service.
54 patients were noted to have been admitted in 90days post prostatectomy. I have grouped the reasons for re-admissions to understand
any patterns and suggested actions undertaken and plans going forward.
Presumed UTI: (12) The largest group of patients who re-attended were patients who had UTI (or possible UTI). They had presented after
variable intervals after RALP. Six patients presented with urosepsis and required admission for intravenous antibiotics, of these, 2 were after
trial without catheter (TWOC) and one after a cystogram. Four patients complained of testicular pain with no evidence of epididymitis
and were empirically started on antibiotics without admission, another patient had peri-catheter ooze. A further patient had retention one
day after his TWOC which was relieved by an in and out catheter and once again treated with antibiotics empirically.
Plan:
-We have changed our antibiotic prophylaxis from gentamycin (2mg/kg) and metronidazole to gentamycin and co-amoxiclav following
discussion with the Microbiologist. This was implemented a year ago
-We have reinforced the need for and improved the strict pre-operative culturing of urine and now review those cultures prior to
admission.
Pelvic Haematoma: (6) Six patients were admitted with abdominopelvic pain and CTs demonstrated pelvic haematomas. All these were
managed with percutaneous drainage. In review of the operating notes it was noted that all these had descriptions of difficult surgery with
high BMIs. I noted that none of these patients had “Rocco” stitches.
Action: “Rocco” stitches are now routinely performed by all 3 surgeons for all cases for over a year now. We expect the haematoma risks to
decrease and an audit of this is planned and we would be happy to share the results.
Following notification of outlier status each trust was given
the opportunity to review their individual data and check this
against the NPCA data gathered from their hospital. The trust
was then invited to respond by letter to the NPCA executive.
The responses from individual outlier trusts in relation to
their highlighted status are as follows:

51
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Response from Bradford Teaching Hospitals NHS Foundation Trust
Performance indicator 8: Proportion of patients who had an emergency readmission within 90 days of radical prostate cancer
surgery.
Lymphocoele (5) Five patients were admitted with abdominopelvic pain and or fever and CTs demonstrated collections in relation to the
areas of lymph node dissection. All these were managed with percutaneous drainage with or without antibiotics.
Action: Following discussions noted at the ERUS meeting last year on lymph node dissection we have modified our template for prostate
cancer lymph node dissections to exclude the dissection lateral to the external Iliac. The symptomatic lymphocoele rates will also be
audited and again we would be happy to share the results when available.
Urinoma: (1) One patient developed significant pain and sepsis and was noted to have a urinoma which was drained. Catheter was kept in
situ for several weeks until a cystogram showed no leak
Plan: No action as routine testing for water-tightness is assessed intra-operatively in all cases and we do not believe this is a recurring issue.
Abdominal and pelvic discomfort (7) Six patients were reviewed for complaints of excessive pain. Clinical evaluation and CT scans failed
to identify any adequate explanation. Patients were managed with anti-inflammatories and on subsequent follow up no issues have been
noted.
In a seventh patient CT suggested a small suspected leak of urine although no pelvic collection was noted. The patient was re-catheterised
with a cystogram showing no further leak at 1 week.
Bowel complications (4)
-Patient 1: A patient who had previous gastro-jejunostomy required significant adhesiolysis to gain access at the time of RALP. He
presented a week after discharge with high intestinal obstruction. He had a CT and surgical review. At laparotomy he was found to have
dense adhesions at the site of the previous gastroenterostomy which were causing a kink in the efferent loop of the gastroenterostomy. The
release of these adhesions relieved the obstruction. No bowel resection was necessary.

-Patient 2: During the prostatectomy he was noted to have adhesions of the sigmoid, possibly from a previous appendicetomy. These
adhesions were released and the surgery was otherwise uneventful. 6 days post operatively the patient presented with signs of peritonitis.
The CT scan and subsequent laparotomy by the surgical team confirmed a diverticular abscess and perforation. The surgeon noted that this
was unrelated to the recent RALP and was consistent with diverticular perforation which was distant from the area of adhesionolysis.
- Patient 3: The Urologist noted significant adhesions of the sigmoid to the bladder which were likely due to severe diverticulitis. No
fistulous connection was demonstrated with the bladder but the sigmoid was repaired in 2 layers where a small hole had been noted
while taking it off the bladder. The patient was discharged but subsequently re-admitted 5 days post-operatively with abdominal pain and
distension. He had a laparotomy which did not reveal any peritoneal contamination and the sigmoid stitches were noted to be intact. Due
to significant inflammatory changes around the sigmoid on the CT scan the surgeon performed a loop colostomy.
Patient 4: He was admitted with diarrhoea post RALP and was found to have C difficile. He was treated with oral Vancomycin as per our
Trust protocols.
Ureteric complication (1) The patient was undergoing a RALP with a posterior approach to the seminal vesicles. A “Hemolock” was
applied which the urologist had thought would be the tip of the seminal vesical. Post op it was apparent on CT scan that the left lower
ureter had a “Hemolock” across it. The patient had a nephrostomy placed and 6 weeks later had a left ureteric re-implantation performed.
Action: Team reflection on this complication: particular care to be taken in posterior dissections to not dissect laterally beyond the seminal
vesicle and apply clips on the surface of the tip rather than laterally
N.B: for the last 2.5 years all 3 surgeons perform an initial posterior dissection to release the seminal vesicles prior to dropping the bladder.
No other case of ureteric injury has been noted
Suspected Thrombosis/Thromboembolism (2) One patient presented with shortness of breath after RALP. A CTPA ruled out Pulmonary
embolism. A second patient complained of calf pain and had a Doppler which ruled out a DVT
Catheter problems (2) Two patients were assessed in the Surgical Assessment Unit (SAU) for blocked catheters. In the first the blockage
had already relieved at time of review. In the second patient the blockage was relieved with a simple washout of a small clot in the catheter.
Please note that the only area for urgent clinical review of patients at our Trust is the Surgical Assessment Unit; this sometimes leads to
patients coming for acute review being counted as “admitted”.
/continued

52
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Response from Bradford Teaching Hospitals NHS Foundation Trust
Performance indicator 8: Proportion of patients who had an emergency readmission within 90 days of radical prostate cancer
surgery.
Drain review (5) and lost drain (1) Following lymph node dissection an increased drain output is often noted. The ward staff routinely
send drain fluid for chemical analysis on the first post-operative day and if this is consistent with lymph the instructions are to remove the
drains. On weekends there were occasions where this process did not work. Patients were discharged with drains and brought in a few days
later for removal – this was consistent with historic practice that persisted on occasion. These 5 have all been recorded as re-admissions
when they returned for drain removal.
In one patient the staff whilst removing the drain inadvertently cut the drain itself which retracted into the abdomen. Patient required a
laparoscopic removal of the cut end of drain
Action: Staff education
Wound complications (2) One patient was worried about a slight ooze noted from a port site, this had settled without any action. A
second patient had wound infection and was treated with antibiotics.
We do not feel this is a significant problem our case series.
Scrotal oedema and pain (2) One patient was reviewed for scrotal oedema and was reassured. A second patient complained of scrotal pain
but no abnormality was noted and he was also re assured.
Action: We have improved education of our patients about the possibility of scrotal oedema after discharge and what signs or symptoms
might warrant review.
Symphisitis (1) Patient complained of significant pain and tenderness in the area of the symphysis. CT showed significant inflammation
around symphysis with no collection. He was managed with ant-inflammatory drugs.
No Action
Cystogram (1) No re-admission record. There were several other patients with cystograms but none had been recorded as a re-admission.
No readmission recorded for patients (2) Of 2 patient details provided by NPCA we have not found any record of re-admission.
Summary:
Of the 54 readmissions noted by NPCA we did not find any evidence of readmission in 3 patients. Of the remaining 51, 5 were patients who
attended our ward for review of the drain outputs. We do not believe these should be regarded as re-admissions for complications. We have
reinforced the current protocols for fluid analysis and drain removal prior to discharge.
A further 12 patients were assessed in the SAU by the team for minor complaints related to catheters, wound issues, scrotal issues and
suspected UTIs. These patients were reviewed and reassured and a small number given oral antibiotics. All these 12 patients were sent
home the same day after review without requiring admission.
A further 6 patients required an overnight stay often awaiting a senior review or imaging to confirm absence of any serious complications.
Discussion:
We are grateful that this issue has been raised and the review has given us an opportunity to scrutinise our practise.
We examined the records for all patients who were seemingly re-admitted within 90 days of their surgery. It was apparent that there
were patterns for the reasons for re-admission. As noted above the largest group were patients who attended for urinary tract infections.
Our protocol requires that patients have MSUs performed routinely at pre-assessment and the results are checked by the operating
surgeon. Unfortunately this was not strictly implemented at the time, with reliance on patient symptoms and a urine dipstick in the
morning of surgery.
Now the team are aware that pre-operative MSUs should be performed in every case. Our peri-operative antibiotic prophylaxis has also
since been modified following discussion with the microbiologist to replace gentamycin and metronidazole with gentamycin and co-
amoxiclav as a single dose. The ward staff are asked to give gentamycin at TWOC. In most patients a clear cystogram results in TWOC on
the same day but occasionally due to the late timing of the cystogram these may be on different days. We have informed the TWOC team
that antibiotic cover should be routinely prescribed to prevent any sepsis.
/continued

53
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Response from Bradford Teaching Hospitals NHS Foundation Trust
Performance indicator 8: Proportion of patients who had an emergency readmission within 90 days of radical prostate cancer
surgery.
The serious bowel complications were due to pre-existing conditions and it is not entirely clear if these were a direct consequence of
the radical prostatectomy itself. Severe diverticulitis in one case and an incidental diverticular perforation resulted in laparotomy and
colostomy in both these cases. The colorectal surgeon specifically noted that these were not related to any direct injury inflicted during
the prostatectomy. A third patient developed high intestinal obstruction due to efferent loop obstruction of a gastro-jejunostomy due
to adhesions and a kinking. Although not directly due to a surgical injury in all 3 cases the time-line suggests that these were possibly
precipitated by the recent surgery. None of these patients had symptoms or signs on pre-operative imaging to suggest these issues were
manifest at the time or were likely to occur.
The next group of complications relates to pelvic haematomas post prostatectomy. The surgery is performed at Intra-abdominal pressures
of 10-12mm. All 3 surgeons routinely lower the intra-abdominal pressure to 6mm towards the end of the surgery to ensure no oozing.
Operative notes for all these cases suggested difficult dissections, high BMIs and no “Rocco” stitches were placed. All 3 surgeons now
routinely perform “Rocco” stitches and this practise will hopefully decrease the risk of this complication.
Five patients developed symptomatic lymphocoeles necessitating drainage. Our templates for lymph-node dissection were similar for
bladder and prostate cancer in this period. There is some suggestion that dissection lateral to the iliac vessels may not be beneficial in
prostate cancer dissections and results in a higher incidence of lymphocoeles. We have now altered our templates and will be auditing our
practise to assess a decrease.
One patient had a Hemolock placed across the lower end on the left ureter whilst performing a posterior approach for the release of
seminal vesicles. The surgeon clearly applied the Hemolock more laterally than intended assuming it was being placed at the tip of the
vesicle. Particular care is taken to avoid a similar complication by staying close to the surface of the tip of the vesicle.
In our practise we encourage patients to have a low threshold for seeking advice and attending for a review by the urology team. This is to
avoid review by less experienced staff in primary care or district nursing teams which are often considered the first port of call by patients.
This has resulted in rapid experienced reviews and often simple reassurances which can allay anxiety for patients - particularly concerns
about wounds or catheters.
The prompt review does sometimes result in the event being registered as an admission but we do not regard these as complications. If we
exclude these 20 cases where either no admission was recorded (3), drain reviews were performed (5) or review and reassurance provided
without overnight admission (12) our 90 day re-admission rates are 34 of 223 (15.2%) cases that we have recorded for this period. This is
very similar to the average of 14% 90-days re-admission rates recorded nationally and this is despite having an 8% higher rate of locally
advanced prostate cancers (56% v 48% nationally) in our patient population.
In conclusion we appreciate the NPCA providing us an opportunity to clarify the reasons for a higher 90d re-admission rate reported. We
have identified several issues for which remedial actions have been initiated to mitigate these risks. We also feel that if account is taken of
the day reviews for patients the risks are in keeping with the national average.
We are happy to provide any further clarifications and will continue to engage constructively with the NPCA.
Response 2
Thank you for your letter highlighting our potential outlier status for re-admissions after radical prostatectomy. We welcome the review
and the opportunity to re-examine our outcomes after robotic prostatectomy.
We acknowledge and accept the results of the audit. We feel many of the reported re-admissions are a result of recording errors, with
patients presenting (often as a planned attendance) for clinical review. We are working with our data teams to address this
Our Urology department has also made some changes to reduce the incidence of some complications that have led to some ‘real’ re-
admissions, including a change in our peri-operative antibiotic prophylaxis and the use of reinforcing sutures (‘Rocco’ stitch). We are
continuing to monitor the outcomes to confirm this is reducing post-operative infections and haematomas.
/continued

54
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Response from East Lancashire Hospitals NHS Trust
Performance indicator 9: Proportion of patients experiencing at least one genitourinary (GU) complication requiring a
procedural/surgical intervention within 2 years of radical prostatectomy.
Thank you for informing us that ELHT is an outlier in the NPCA with respect to patients experiencing at least one severe genitourinary
tract complication within 2 years of radical prostatectomy.
This was clearly very disappointing for us to discover as a Trust and consequently we have looked in detail into our data. We were aware
of some complications as a result of our ongoing internal audit process. Changes to practice have already been made in terms of use and
positioning of clips and bladder neck anastomosis.
Having reviewed our internal audit data with that of the NPCA there were 83 cases recorded locally, compared to, 64 with the NPCA.
We assume this is down to a coding / data issue with HES and we are in the process of looking into this internally. Incorporating these
extra cases into the total number of procedures will make a difference when calculating complication rates.
On reviewing all the cases that were recorded as having a complication we felt that some of these should be excluded from the analysis.
We have commented the reason for exclusion against each case number.
Patient A2 – From our information this patient was admitted with constipation and bladder spasm but did not have any significant
intervention.
Patient B – From our information this patient was diagnosed with an overactive bladder and was treated with Botox.
Patient C – This patient had difficulty with catheter removal. This fell out shortly after attempted removal with no intervention required.
Patient D – This patient had complex pre-existing urological problems associated with previous stricture and urethroplasty, he therefore
should not be included as a post op complication.
Patient E – This patient had an episode of epididymo orchitis following surgery and does not fit the criteria of a major complication.
When we look at the additional patient data and take into account the above suggested exclusions we feel our complication rate is much
lower at 14 percent. We did not have access to HES data to double check for admission but did view our hospital admissions and cross
checked with our neighbouring hospitals that we provide the radical prostatectomy service for. Local agreement is that any complications
occurring post-surgery are referred back to ELHT to manage so we would expect to have picked up most of the significant complications.
We accept that our bladder neck stenosis rate is slightly higher than we would like and as mentioned above have already picked this up with
our internal audit process and have changed our practice. An audit of 2018 patient has started which has demonstrated 171 patients treated
with a complication rate of 9%, suggesting that there has been a successful change in practice. We are in the process of going through this
data and validating it further.
2 Patient ID numbers have been replaced

55
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Response from Gloucestershire Hospitals NHS Foundation Trust
Performance indicator 9: Proportion of patients experiencing at least one genitourinary (GU) complication requiring a
procedural/surgical intervention within 2 years of radical prostatectomy.
I am writing in response to your letter written on 1st December 2020. You highlighted that our Trust was an outlier for the following
performance indicator:-
The proportion of patients experiencing at least one genitourinary (GU) complication requiring a procedural/surgical intervention
within 2 years of radical prostatectomy (men undergoing RP between 1st January 2017 and 31st December 2017).
The raw data suggests 36 out of 112 patients that were affected. The Trust was an outlier in the same performance indicator in last year’s
report (1st January 2016 to 31st December 2016). As a department, we identified that during this time period we experienced an increased
rate of development of urethral stricture post-operatively. This increase resulted in the complication rate highlighted. This was highlighted
to you last year.
The strictures occurred across all 4 surgeons performing the operation. We reviewed the entire process of surgery to try and identify any
causative factors. Discussion with other departments highlighted similar problems in the units. Following our review we have changed the
skin prep used at surgery, we have also shortened the time a catheter may be put on gentle traction during surgery.
The actions described were put in place in 2018/19 and therefore would not have been in place to support the patients captured in this
reports timeframe. I am pleased to inform you that the clinical team have completed an audit on patients treated from January 2018 to
April 2019 and the review included all patients who had a follow up to December 2020. The scope of the audit includes 172 procedures, of
this cohort only 2 patients (1.16%) experienced genitourinary complications requiring a procedure/surgical intervention. One patient was
diagnosed with urine leak requiring drain insertion post op whilst an inpatient, whilst the other patient was diagnosed with bladder neck
stricture requiring readmitting and dilatation.

56
Copyright © 2021 Healthcare Quality Improvement Partnership (HQIP)
Response from Norfolk & Norwich University Hospitals NHS Foundation Trust
Performance indicator 10: Proportion of patients experiencing at least one severe gastrointestinal (GI) complication within 2
years of radical external beam radiotherapy.
Thank you for informing us that we remain a significant outlier for radiation proctitis for the 2017 patient cohort. We would like to
thank you for recognising our engagement in improving our outcomes and willingness to share our experience to date. We expect this
relationship to continue until we see significant improvements in our outcomes.
We have reviewed the patient dataset and agree that we remain a significant outlier triggering your alarm limits with a radiation proctitis
rate of 25%.
We would like to summarise all of the changes that we have made over the last two years since the last report and our presentation to the
NPCA. The following is a timeline of all of those changes.
Feb 2018
Moved from Bony matching to Soft tissue matching
May 2018
Reduced prostate margin from 1cm (0.5cm) sv margin 1cm
Aug 2018
Weekly Prostate Peer review meeting initiated
Oct 2018
First identified as outlier Radiation Proctitis 2015 Cohort
Dec 2018
Seminal vesicle dose dropped to 52.5Gy (60Gy prostates) and 60Gy (74Gy Prostates)
June 2019
Imaging study for IGRT showed with bony matching dose to rectum higher than planned
Oct 2019
Alarm Outlier for Radiation Proctitis 2016 Cohort
Dec 2019
Presentation of our proctitis rates at NPCA study day Guys Hospital Outside review Prostate protocols
Jan 2020
Dropped seminal vesicle dose to 48Gy for 60Gy prostates. GTV delineated Undertook Proknow national prostate

planning benchmark study national prostate planning benchmark study
July 2020
Adopted CHHIP planning for P and SV patients
It is a significant frustration that as it takes two years for radiation proctitis to develop it takes a long time to know whether the changes
we have made have been successful. We have prospectively looked at our outcome data for 2018 and for 2019. We will remain a significant
outlier for 2018 but are confident that from 2019 we will start to see significant improvements in our radiation proctitis rate as all of the
changes we have made to our processes kick in. The numbers for 2019 look significantly lower so far but it is still early.
The most significant changes performed over the last year were to ask a radiation oncology centre with a much lower radiation proctitis
rate to review our process after the 2019 round. We adopted all of the suggested planning changes. The changes suggested were as outlined
above ie dropping SV dose to 48Gy in 20 fractions, outlining a tumour volume and optimising our plans to achieve the best rectal dose
level we can achieve rather than stopping when mandatory constraints were met.
We have also, since the last report, taken part in the Proknow benchmarking study. We found that although our earlier changes put us on a
par dosimetrically with other centres, the adoption of the CHHIP planning technique improved our rectal dosimetry significantly. We now
plan all of our Prostate and seminal vesicle patients using the CHHIP protocol.