NPCA State of the Nation Report 2023
Source: data.gov.uk (2024-02-05)

NPCA State of the Nation Report 2023. The aim of the National Prostate Cancer Audit (NPCA) is to evaluate the patterns of care and outcomes for patients with prostate cancer in England and Wales, and to support services to improve the quality of care. National guidelines underpin the management of patients with prostate cancer and the NPCA evaluates current patterns of care against these standards including guidance and quality standards from the National Institute for Health and Care Excellence (NICE).

The information presented here reports on prostate cancer services in England and Wales, showing variation across providers.

For the first time since the NPCA Annual Report 2020, we report results from all six of our performance indicators for both England and Wales, using the most recently available data to the audit. Four performance indicators:

• proportion of men with low-risk localised cancer undergoing radical prostate cancer treatment

• proportion of men with high-risk/locally advanced disease undergoing radical prostate cancer treatment

• proportion of patients experiencing at least one genitourinary (GU) complication requiring a procedural/surgical intervention within 2 years of radical prostatectomy

• proportion of patients receiving a procedure of the large bowel and a diagnosis indicating radiation toxicity up to 2 years following radical prostate radiotherapy (RT)

require risk stratification using the Gleason score, which is not currently available in the Rapid Cancer Registration Dataset (RCRD) used by the NPCA for recent Annual Reports (2021 and 2022). Therefore, to include these, we have used the National Cancer Registration Dataset (NCRD) in England. The most recently available data to the audit from the NCRD in England is between 1st April 2020 and 31st March 2021.

In Wales, the data we receive includes the Gleason score, and the most recently available data to the audit covers patients newly diagnosed with prostate cancer between 1st April 2021 and 31st March 2022.

Previous analysis has shown that RCRD underestimated the proportion of men diagnosed with metastatic disease when compared to the NCRD, therefore we have used the NCRD in England to report this indicator. This means we report on different time frames for England and Wales. The proportion of patients who had an emergency readmission within 90 days of radical prostate cancer surgery however can be accurately calculated using the RCRD. Therefore, to compare rates between England and Wales, we selected the same timeframe for this indicator.

To report on the impact of and recovery from Covid-19 for prostate cancer services, we use the most recently available data in England from the RCRD between 1st January 2022 and 31st January 2023, and in Wales between 1st April 2021 and 31st March 2022.

Individual provider results and reports are available enabling regional and national comparisons to support local QI.

NPCA State of the Nation Report
An audit of the care received by people with prostate cancer in England and 
Wales from 01/01/2019 to 31/01/2023
 
Published January 2024

This report was prepared by members of the NPCA Project Team
Noel Clarke, Urological Oncology Clinical Lead
Ajay Aggarwal, Oncology Clinical Lead $May 20236Present)
Heather Payne, Oncology Clinical Lead (to May 2023%
Team members in NATCAN, based in the Clinical Effectiveness Unit, RCS England:
Adrian Cook, NPCA Senior Statistician
Thomas Cowling, NPCA Senior Methodologist
Joanna Dodkins, NPCA Clinical Fellow
Emily Mayne, NPCA Data Scientist
Jan van der Meulen, NPCA Methodological Lead
Julie Nossiter, Director of Operations, NATCAN
Marina Parry, NPCA Project Manager
 
 
Citation for this document: 
National Prostate Cancer Audit: State of the Nation Report. London: Royal College of Surgeons of England, 2024.
 
© 2024 Healthcare Quality Improvement Partnership $HQIP% 
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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 
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The British Association of Urological Surgeons $BAUS% was founded in 1945 and exists to 
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Cancer Registration in England and Wales 
This work uses data that has been provided by patients and collected by the NHS as part of their care and support.
For patients diagnosed in England, the data is collated, maintained and quality assured by the National Disease Registration Service $NDRS%, which is part of NHS 
England. Access to the data was facilitated by the NHS England Data Access Request Service.
 
For patients diagnosed in Wales, the NPCA dataset is captured through a national system, Cancer Network Information System Cymru $CaNISC%, after identification 
by hospital cancer services and uploaded via electronic MDT data collection systems to the Wales Cancer Network $WCN%, Public Health Wales.
 
The National Cancer Audit Collaborating Centre $NATCAN% is commissioned by the 
Healthcare Quality Improvement Partnership HQIP as part of the National Clinical Audit and 
Patient Outcomes Programme NCAPOP. NATCAN delivers national cancer audits in non-
Hodgkin lymphoma, bowel, breast (primary and metastatic), oesophago-gastric, ovarian, 
kidney, lung, pancreatic and prostate cancers. 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

1. Introduction
 
The aim of the National Prostate Cancer Audit $NPCA% is to evaluate the patterns of care and outcomes for patients with prostate 
cancer in England and Wales, and to support services to improve the quality of care. National guidelines underpin the management of 
patients with prostate cancer and the NPCA evaluates current patterns of care against these standards including guidance and 
quality standards from the National Institute for Health and Care Excellence $NICE%.
 
The information presented here reports on prostate cancer services in England and Wales, showing variation across providers. We 
recommend that these data provide a starting point for all for reflection on the reasons behind variation in practice and outcome, and 
that this report be used to identify such areas. There are additional supplementary materials that accompany this document available 
on the NPCA website at: www.npca.org.uk. These include individual NHS provider results (data completeness and performance 
indicator results at the provider/Specialist Multi Disciplinary Team &SMDT]-level), a description of the audit methods and resources to 
support local quality improvement initiatives, such as an action plan template.
 
For the first time since the NPCA Annual Report 2020, we report results from all six of our performance indicators for both England 
and Wales, using the most recently available data to the audit $Table 1%. Four performance indicators:
 
proportion of men with low-risk localised cancer undergoing radical prostate cancer treatment
proportion of men with high-risk/locally advanced disease undergoing radical prostate cancer treatment
proportion of patients experiencing at least one genitourinary $GU% complication requiring a procedural/surgical intervention 
within 2 years of radical prostatectomy $RP%
proportion of patients receiving a procedure of the large bowel and a diagnosis indicating radiation toxicity up to 2 years 
following radical prostate radiotherapy $RT%
require risk stratification using the Gleason score, which is not currently available in the Rapid Cancer Registration Dataset $RCRD% 
used by the NPCA for recent Annual Reports $2021 and 2022%. Therefore, to include these, we have used the National Cancer 
Registration Dataset $NCRD% in England. The most recently available data to the audit from the NCRD in England is between 1st April 
2020 and 31st March 2021.
 
In Wales, the data we receive includes the Gleason score, and the most recently available data to the audit covers patients newly 
diagnosed with prostate cancer between 1st April 2021 and 31st March 2022.
 
Previous analysis has shown that RCRD underestimated the proportion of men diagnosed with metastatic disease when compared to 
the NCRD, therefore we have used the NCRD in England to report this indicator. This means we report on different time frames for 
England and Wales. The proportion of patients who had an emergency readmission within 90 days of radical prostate cancer surgery 
however can be accurately calculated using the RCRD. Therefore, to compare rates between England and Wales, we selected the 
same timeframe for this indicator.
 
To report on the impact of and recovery from Covid-19 for prostate cancer services, we use the most recently available data in 
England from the RCRD between 1st January 2022 and 31st January 2023, and in Wales between 1st April 2021 and 31st March 2022.
3

 ¹ Due to the unavailability of one third of data from Cardiff and Vale UHB, a large provider of services in Wales, comparisons to previous years would be inaccurate.
Table 1: Cohorts reported on and datasets used for each section by country
4
        
England
Wales
 
Per formance Indicator (PI)
 
Disease presentation:
 
Treatment allocation:
NCRD*
Patients diagnosed between:
01.04.20-31.03.21
CaNISC**
Patients diagnosed between:
01.04.21-31.03.22
Outcomes of treatment: shor t-term,
 
RCRD***
Patients who underwent a radical 
prostatectomy between:
01.04.21-31.03.22
CaNISC
Patients who underwent a radical 
prostatectomy between:
01.04.21-31.03.22
Outcomes of treatment: medium-
term,
 
NCRD
Patients who received radical 
treatment between:
01.09.
19-31.08.20
CaNISC
Patients who received radical treatment 
between:
01.09.
19-31.08.20
 
National picture/recover y from 
Covid-19
 
National picture / impact of Covid-19 
time period
RCRD
Patients diagnosed between:
01.01.
19-31.01.23
CaNISC
Patients diagnosed between:
01.01.
19-31.03.22
Diagnosed with metastatic 
disease (PI1)
Low-risk patients receiving 
radical treatment (PI2)
High-risk patient receiving radical 
treatment (PI3)
 Readmission within 90 days (PI4)
GU complication (PI5)
GI (gastrointestinal) complication 
(PI6)       
*NCRDI National Cancer Registration Dataset; **Cancer Network Information System Cymru; *** RCRDI Rapid Cancer Registration Dataset
2. Key messages
 
L The proportion of men diagnosed with high-risk/locally advanced prostate cancer undergoing radical prostate cancer 
treatment remained stable at 69% in England and Wales, $57680% by SMDT n=46, in England) when comparing to 2019 $71% 
and 39682% by SMDT%.
L The proportion of men diagnosed with low-risk localised prostate cancer undergoing radical prostate cancer treatment was 
8% in England and 9% in Wales $0629% by SMDT, n=46, in England). Comparison with previous years cannot be made since 
we have updated our low-risk definition to include patients with T stage 2 disease.
L There was an increase in men newly diagnosed with prostate cancer in 2022 in England $27% more in 2022 compared to 2021 
and 14% more compared to 2019% and in 2021 in Wales $15% more in 2021 compared to 2020 but 15% fewer compared to 
2019%.
L There was an increase in men newly diagnosed with prostate cancer treated with either radical prostatectomy or 
radiotherapy $RT% in 2022 in England $14% and 10% increase respectively in Q4 2022 compared to same quarter in 2019%¹. 
L The proportion of patients experiencing a genitourinary $GU% or gastrointestinal $GI% complication within two years of radical 
treatment remained stable in England and Wales at 8% (on average), when comparing to 201562019 $10% on average). The 
variation in GI toxicity post RT observed between centres has decreased year on year since reporting commenced in 2019.
L There were changes in some aspects of prostate cancer treatment, including an increased utilisation of ultra-
hypofractionated radiotherapy (from 0.3% of patients in 2019 to 5% in 2022 receiving ultra-hypofractionation) resulting in 
90% of RT patients receiving hypofractionated or ultra-hypofractionated radiotherapy, and a shift in the systemic agents 
used $26% of patients received apalutamide by Q3 2022%.
 
 
8

Recommendation
Audience
Results from 2023 
repor t
Results from 
previous repor ts
National Guidance
1. Aim to achieve 
high completeness 
of key data items at 
the point of 
collection by NHS 
organisations in 
England, par ticularly 
tumour, node and 
metastasis (TNM) 
staging variables
NHS England 
and Health 
Boards in 
Wales
 
Prostate 
cancer teams 
(local and 
specialist 
MDTs) within 
NHS Trusts
Per formance status:
England (59%)
Wales (100%)
 
TNM:
England (75%)
Wales (72%)
 
For both items, cohor t 
for England: NCRD 1st 
April 2020-31st March 
2021 and cohor t for 
Wales: 1st April 2021-
31st March 2022
Comparing to most 
recently published 
NCRD (NPCA 
AR2020):
 
Per formance status:
Increase: England 
(52%)
No change: Wales 
(100%)
 
TNM:
Decrease: England 
(79%)
Increase: Wales 
(70%)
 
The Cancer Outcome and 
Ser vices Data set (COSD) has 
been the national standard for 
repor ting cancer in the NHS in 
England since Januar y 2013. 
Feedback repor ts for the data 
submitted are available through 
the National Disease 
Registration Ser vice (NDRS) 
CancerStats2 website. COSD is 
the main source for the rapid 
cancer registration dataset. 
Improved completeness of this 
dataset is required to ensure 
quar terly repor ting.
 
The Cancer Network Information 
System Cymru (CaNISC) 
collects, analyses and releases 
information about cancer in 
Wales.
2. Continue to 
advocate active 
sur veillance for men 
with low-risk 
prostate cancer
NHS England 
and Health 
Boards in 
Wales
 
Professional 
bodies (Royal 
College of 
Radiologists, 
British 
Association of 
Urological 
Surgeons, 
Prostate 
Cancer UK)
8% of men diagnosed 
with low-risk localised 
cancer in England and 
9% in Wales 
underwent radical 
prostate cancer 
therapy within 12 
months of diagnosis
N/A*
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 
sur veillance.
 
NICE Guideline [NG131], 2019 
1.3.8 Offer a choice between 
active sur veillance, radical 
prostatectomy or radical 
radiotherapy to people with low-
risk localised prostate cancer for 
whom radical treatment is 
suitable.
3. Investigate why 
men with high-
risk/locally 
advanced disease 
are not considered 
for radical treatment 
and aim for 75% 
offered radical 
treatment
NHS England 
and Health 
Boards in 
Wales
 
Cancer 
Alliances (CA)
69% of men 
diagnosed with 
locally-advanced 
prostate cancer in 
England and Wales 
underwent radical 
treatment within 12 
months of diagnosis in 
England and Wales. 
Variation of 57-80% 
across SMDTs
 
Cohor t for England: 
NCRD 1st April 2020-
31st March 2021 and 
cohor t for Wales: 1st 
April 2021-31st March 
2022
NPCA AR2020
 
71% of men 
diagnosed with 
locally-advanced 
prostate cancer 
underwent radical 
treatment within 12 
months of diagnosis 
in England and 
Wales. Variation of 
39-82% across 
SMDTs.
NICE Guideline [NG131], 2019 
1.3.
11 Do not offer active 
sur veillance to people with high-
risk localised prostate cancer.
 
NICE Guideline [NG131], 2019 
1.3.
12, 1.3.21
Offer radical prostatectomy or 
radical radiotherapy in 
combination with androgen 
deprivation therapy (ADT) to 
people with high-risk localised 
prostate cancer when it is likely 
the person's cancer can be 
controlled in the long term.
 
Ongoing collaboration with NHS 
Cancer Programme and Cancer 
Alliance Treatment Variation 
Working Group to achieve as a 
target for this indicator that 75% 
of men diagnosed with locally-
advanced prostate cancer 
should receive radical treatment 
within 12 months of diagnosis.
*Change in definition of low-risk disease in NPCA SotN Report precludes comparisons to previous years
 
5
3. Recommendations

Recommendation
Audience
Results from 2023 repor t
Results from previous 
repor ts
National Guidance
4. Review variation 
between providers in 
rate of GU/GI 
complications and 
90 day readmission 
rates
NHS England 
and Health 
Boards in 
Wales
 
Professional 
bodies (Royal 
College of 
Radiologists, 
British 
Association of 
Urological 
Surgeons)
 
Cancer 
Alliances
Variation between 
providers for GU 
complications post radical 
prostatectomy is: 1%-31%; 
for GI complications post 
radical radiotherapy is 
3%-17%; for emergency 
readmission within 90 
days of surger y is: 3-37%
 
90 day readmission rate - 
cohor t for England: RCRD 
1st April 2020-31st March 
2021 and cohor t for 
Wales: 1st April 2021-31st 
March 2022
 
GU/GI complications rate: 
cohor t for both England 
and Wales: 1st September 
2019-31st August 2020
NPCA AR2022
 
Variation between 
providers for GU 
complications post 
radical prostatectomy 
was: 0%-36%; for GI 
complications post 
radical radiotherapy 
was: 2%-23%; for 90-
day emergency 
readmission rate 
following radical 
prostatectomy was: 3 – 
30%
Royal College of 
Radiologists Guidance: 
“Radiotherapy target 
volume definition and 
peer review”
5. Cancer Alliances 
should review 
processes of care to 
ensure equitable 
implementation of 
new technologies 
and pathways of 
care as evidence 
evolves
NHS England 
and Health 
Boards in 
Wales
 
Professional 
bodies (Royal 
College of 
Radiologists, 
British 
Association of 
Urological 
Surgeons)
 
Cancer 
Alliances
The RT fractionation 
schedules delivered in 
England and Wales during 
2019-2022 showed a  
steady decrease in 
conventional RT which 
was replaced by a 7% 
increase in 
hypofractionated RT (7 7% 
to 84%) and a 5% increase 
in ultra-hypofractionated 
RT (from 0.3% to 5%).
 
The use of systemic 
therapy in prostate cancer 
has changed over time, 
reflecting the change in 
landscape of treatment 
options available (e.g. 
prior to 2021 apalutamide 
had not been used but by 
Q3 of 2022, 26% of 
patients star ting systemic 
therapy received 
apalutamide)
N/A
This recommendation is 
based on NHS England 
“Roadmap for integrating 
specialised ser vices 
within Integrated Care 
Systems” 5.7
6

State of the Nation
Diagnosis
For men diagnosed between January - December 2022 in England and between January 
- December 2021 in Wales
50,702
2,168
men were diagnosed with prostate 
cancer in England in 2022
men were diagnosed with prostate 
cancer in Wales in 2021
27%
increase compared with 39,888 men in 2021
15%
increase compared with 1,886 men in 2020
This may be explained by the reporting being in the Covid-19 recovery period
Disease presentation
For men diagnosed between April 2020 - March 2021 in England and between April 2021 - 
March 2022 in Wales
19%
of men presented with metastatic disease in both England and Wales
Treatment allocation
For men diagnosed between April 2020 - March 2021 in England and between April 2021 - 
March 2022 in Wales
Low-risk*, localised disease
High-risk/locally advanced disease
of men had radical treatments in 
England (E) and Wales (W)
8%
9%W
E
of men had radical treatments in 
England (E) and Wales (W)
69%
69%W
E
*Low-risk: T stage 1/2, Gleason ≤6, M/N 0 or missing
Treatment outcomes
For men undergoing surgery between April 2021 - March 2022 in England and Wales
of men were readmitted within 3 
months following surgery in England
13%
9%
For men undergoing radical treatment between September 2019 - August 2020 in 
England and Wales
7%
8%W
E
of men experienced at least one 
genitourinary complication requiring 
a procedural/surgical intervention 
within two years after radical 
prostatectomy in England (E) and 
Wales (W)
10%
5%W
E
of men experienced at least one 
gastrointestinal complication 
requiring a procedural/surgical 
intervention within two years after 
radical radiotherapy in England (E) 
and Wales (W)
For the first time since the NPCA Annual Report 2020, we report results from all six of our performance indicators for both England and Wales, using the most 
recently available data to the audit. For disease presentation and treatment allocation, this corresponds to different time periods in England and Wales.
4. Infographic
of men were readmitted within 3 
months following surgery in Wales

8
5. National picture and regional variation in the patterns of prostate 
cancer care during the Covid-19 pandemic and its recovery²
Figure 1. The number of men newly diagnosed with
prostate cancer 2020-2022 presented as a proportion of
the diagnoses per quarter in 2019 for England and Wales.
Note: The 100% line indicates numbers equal to those in 2019,
above the line represents an increase and below a decrease.
Quarters are by calendar year (e.g., Q1 2020: Jan-March 2020).
Figure 2. The distribution of prostate cancer diagnoses by
cancer stage in England by year from 2019 to 2022.
Note: where stage is unknown, it has been excluded from
this Figure. Table S3 details number of patients with missing
stage information.
In England between 1st January 2022 and 31st December 2022, the number of men newly diagnosed with prostate cancer (n=50,702% 
reached e120% of diagnoses for the last three quarters of that year when compared to the same quarters in 2019. This was 
consistent across Cancer Alliances $Figure 1, Tables S1 and S2%. When analysing the clinical profile of patients diagnosed during this 
time period in England $Table S3% in the RCRD, we observed a consistent distribution of patients’ characteristics such as age at 
diagnosis, social deprivation $IMD%, Charlson comorbidity score, and stage. 13% of patients were ]60 years at diagnosis, 45% of 
patients were ]70 years and 15% of patients were aged 80 years or more. Of note, the proportion of men with metastatic disease at 
first presentation was much higher in those ≥80 years than in younger people $Table S4%. When looking at the cancer stage of 
patients diagnosed by year between 201962022 $Figure 2%, the stage distribution was unchanged in 2022 when compared to 2019.
 
In Wales, the number of men newly diagnosed with prostate cancer between 1st January 2021 and 31st December 2021, n=2,168 
$Figure 1, Table S5%, almost returned to levels seen in 2019 $90% in Q1 2022%. The clinical profile of patients in 2021 considering age at 
diagnosis, social deprivation $IMD%, Charlson comorbidity score, and stage, was similar both to 2019 and 2020 $Table S6%.
²Wales data includes only two-thirds or patients from Cardiff and Vale University Health Board

9
Figure 3. The number of radical prostatectomies (RPs)
2020-2022 presented as a proportion of the RPs per
quarter in 2019 for England and Wales.
Note: The 100% line indicates numbers equal to those in
2019, above the line represents an increase and below a
decrease. RP = radical prostatectomy.
Quarters are by calendar year (e.g., Q1 2020: Jan-March 2020).
In England, between 1st January 2022 and 31st December 2022, we observed a steady increase of RP performed by quarter, 
reaching 114% in Q4 2022 compared to same quarter in 2019 $Figure 3, Table S7%. Lymphadenectomy was performed in only 14% 
cases $Table S8%. In Wales, between 1st January 2021 and 31st March 2022, we observed a steady increase of RP performed by 
quarter, reaching 81% in Q4 2021 compared to the same quarter in 2019 $Figure 3, Tables S7 and S8%, the fall in Q1 2022 may be 
explained by an unusually high number of procedures in Q1 2019. Lymphadenectomy was performed in just over half of the 175 
procedures with information captured $54%, Table S8%.
Figure 4. The number of patients receiving RT 2020-2022
presented as a proportion of the RT per quarter in 2019 for
England and Wales.
Note: The 100% line indicates numbers equal to those in
2019, above this line shows an increase compared to 2019,
and below the line a decrease. RT = radiotherapy.
Quarters are by calendar year (e.g., Q1 2020: Jan-March 2020).
In England, between 1st January 2022 and 31st December 2022, levels of RT reached 110% by the last three quarters of 2022, 
compared to the same period in 2019, and this trend was consistent across Cancer Alliances $Figure 4, Table S9%. The most prevalent 
radiotherapy modality for the 16,343 patients undergoing radical radiotherapy and having data captured was Intensity Modulated 
Radiation Therapy $IMRT%, 92% of treatments $Table S8%. For 20% of patients undergoing RT $3,170/15,943% procedures, the planned 
radiotherapy region included the pelvic lymph nodes. In Wales, between 1st January 2021 and 31st March 2022, we also observed a 
steady increase in patients starting RT up to Q3 2021, reaching 95% of 2019 levels for that same quarter before returning to 90% in 
Q1 2022. The most prevalent radiotherapy modality for the 664 patients undergoing radical radiotherapy and having data captured 
was IMRT, 99% of treatments $Table S8%. For 28% undergoing RT $191/677% procedures, the planned radiotherapy region included the 
pelvic lymph nodes.
Figure 5I The number of patients starting different types of
radiotherapy in England and Wales, by quarter from January
2019 to December 2022.
Note: Conventional 70Gy in 35 fractions
Hypofractionated 50660Gy in 20 fractions
Ultra-hypofractionated 35Gy in 5 fractions
Quarters are by calendar year (e.g., Q1 2020I Jan-March 2020%.

10
Sub-analysis of the RT fractionation schedules delivered in England and Wales during 201962022 $Figure 5% showed a steady 
decrease in conventional RT (typically 74Gy in 37 fractions, or similar) from 22.6% total RT delivered in Q1 2019 to 10.8% in Q4 2022. 
This was replaced over the same time by a 7% increase in hypofractionated RT $50660Gy in 20 fractions, from 77% to 84%%, already 
the most frequently delivered type of RT, and a 5% increase in ultra-hypofractionated RT $35Gy in 5 fractions, from 0.3% to 5%%. 
These findings demonstrate a rapid uptake of evidence-based fractionation schedules³  in the NHS since the pandemic.
Figure 6: The number of patients starting different types
of systemic therapy in England, by quarter from 1st
January 2019 to 30th September 2022.
Note: Data for Wales is unavailable
Quarters are by calendar year (e.g., Q1 2020: Jan-March 2020)
For men diagnosed in England between 201962022 and starting systemic therapy, we tracked the changing usage of docetaxel, 
abiraterone, enzalutamide and apalutamide by quarter $Figure 6%. The number of patients starting apalutamide steadily increased 
from Q3 2021, prior to which it was used infrequently and accounts for the decreased use of enzalutamide over that period. By Q3 
2022, 26% of patients starting systemic therapy received apalutamide, 37% received docetaxel, following a large reduction in use at 
the start of the pandemic $Q26Q3 2020%, and 37% received enzalutamide. The use of abiraterone had always been low, between 36
6% Q2 20206Q1 2022 but had fallen to 1% Q3 2022, despite the patent for abiraterone running out in October 2022 and therefore a 
generic, more affordable version being available.
 
Overall, in England in the most recent audit period up to January 2023 and in Wales up to March 2022, we observed a substantial 
increase in diagnoses and treatments delivered, particularly radical prostatectomies and radiotherapy, when compared to previous 
audit periods which were affected by the Covid-19 pandemic but also in England, when compared to 2019, pre-pandemic. We did not 
observe a change in the clinical or demographic profile of patients diagnosed, however. In England, there continues to be a transition 
to hypofractionated radiotherapy fractionations. In addition, over the most recent audit period, we found a steady increase in the use 
of apalutamide, which by Q3 2022 was being given to 26% of patients starting systemic therapy, with a simultaneous reduction in the 
prescription of enzalutamide (from 60% in Q3 2021 to 37% in Q3 2022% and no change in the use of docetaxel $37%%.
 ³ NICE Guideline &NG131', 2019 1.3.19. For people having radical external beam radiotherapy for localised prostate cancer offer hypofractionated radiotherapy $60 Gy in 20 fractions) 
using image-guided intensity modulated radiation therapy $IMRT%, unless contraindicated https://www.nice.org.uk/guidance/ng131/chapter/recommendations

6. Performance indicator results and patient risk groups
 
In England and Wales, we report our performance indicators across three and two separate time periods respectively, in order to be 
able to report on all our performance indicators.
Table 2. England and Wales performance indicators table
 
 
England
 
 
Wales
 
 
No. of 
patients
No. of 
events
%
(range %; 
provider n)
No. of 
patients
No. of events
%
(range%; 
provider n)
Time period covered for 
patients diagnosed
 
1 Apr 2020 
– 31 March 
2021
 
 
1 Apr 2021 – 
31 March 
2022
 
PI1: Propor tion of men 
diagnosed with metastatic 
disease¹
29,058
5,625
19
(8-27%;  
n=47)
2,203
421
19
(16-28%;  
n=4)
PI2: Propor tion of men with 
low-risk localised cancer 
undergoing radical prostate 
cancer treatment¹
3,258
275
8
(0-29%;  
n=46)
422
39
9
(5-12%; 
n=4)
PI3: Propor tion of men with 
high-risk/locally advanced 
disease undergoing radical 
prostate cancer treatment¹
10,838
7
,505
69
(57-80%; 
n=46)
665
460
69
(65-7 7%;  
n=4)
Time period: Patients who 
underwent a radical 
prostatectomy 1 Apr 2021 – 
31 March 2022
 
 
 
 
 
 
PI4: Propor tion of patients 
who had an emergency 
readmission within 90 days 
of radical prostate cancer 
surger y²,*
6,459*
813
13
(3-37%; 
n=47)
200
18
9
(3-13%; 
n=3)
Time period: Patients who 
received radical prostate 
cancer therapy 1 Sep 2019 
– 31 Aug 2020
 
 
 
 
 
 
PI5: Propor tion of patients 
experiencing at least one 
GU complication requiring a 
procedural/surgical 
inter vention within 2 years 
of radical prostatectomy²
5,728
374
7
(1-31%; 
n=48)
195
16
8
(5-10%; 
n=4)
PI6: Propor tion of patients 
receiving a procedure of the 
large bowel and a diagnosis 
indicating radiation toxicity 
(GI complication) up to 2 
years following radical 
prostate radiotherapy²
12,625
1,287
10
(3-17%; 
n=51)
522
28
5
(5-7%; n=3)
¹ Provider: SMDT; ² Provider: treatment centre, *For England, this PI used the Rapid Cancer Registration Dataset whereas the other PIs used the ‘gold-standard’ National Cancer 
Registration Dataset. Acronyms: PI = performance indicator; GU = genitourinary; GI = gastrointestinal
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In England, between 1st April 2020 and 31st March 2021, 19% men with newly diagnosed prostate cancer had metastatic disease at 
first presentation $Table 2%. The rate varied between 8% and 27% among SMDTs $Table 2, provider level results). In Wales, between 
1st April 2021 and 31st March 2022, 19% men with newly diagnosed prostate cancer had metastatic disease at first presentation 
$Table 2%I varying between 16% and 28% by SMDT.
 
Starting with this State of the Nation report, we have updated our definition of low-risk disease due to an improvement in the data 
quality and to better reflect current clinical practice. We are therefore unable to compare findings from this report with previous 
reporting periods. The new definition of low-risk disease used in this report, and in future, is patients with T stage 1/2, Gleason ≤6 
and M/N stage 0 or missing. In England, of the 31,775 men newly diagnosed with prostate cancer between 1st April 2020 and 31st 
March 2021, 39% were considered high-risk/locally advanced, 29% were considered intermediate risk and 12% low-risk⁴ $Table S11%. 
In Wales, of the 2,286 diagnoses between April 20216 March 2022, 31% were high-risk/locally advanced, 30% intermediate and 20% 
low-risk $Table S11%.
 
In England, few patients diagnosed with low-risk localised disease underwent radical treatment $8%I inter-SMDT range 0629%% and in 
Wales a similarly low proportion: 9%, range amongst SMDTs 5612%. The updated definition of low-risk disease meant 3,258 patients 
were identified as such in England and 422 in Wales.
 
In England, 69% of patients diagnosed with high-risk/locally advanced disease received radical treatment. A significant number who 
were untreated were elderly and with co-morbidity, which may influence suitability of treatment, but after adjustment for these 
factors substantial variation remained between SMDTs with the radical treatment rate ranging between 57 and 80%. In Wales, the 
same proportion, 69% of patients diagnosed with high-risk/locally advanced disease, received radical treatment. This varied between 
65% and 77% by SMDT. Again, this variation is after adjustment for age and comorbidity and further local investigation is necessary.
 
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Figure 7. Adjusted funnel plot for the proportion of
patients readmitted as an emergency within 90 days
of radical prostatectomy (between 1st April 2021 and 31st
March 2022) by surgical centres in England (n=47)
and Wales (n=3).
In England, using Rapid Cancer Registration Data for patients undergoing radical prostate cancer surgery between 1st April 2021 and 
31st March 2022, 13% had an emergency readmission within 90 days of surgery: this varied between 3 and 37% by surgical centre, 
of which there were 47 $Figure 7%. In Wales, for patients undergoing radical prostate cancer surgery between 1st April 2021 and 31st 
March 2022, 9% had an emergency readmission within 90 days of surgery: this varied between 3 and 13% by surgical centre, of 
which there were three. Where high rates were identified, this will be fed back to individual Trusts for further investigation.
⁴ A three-tiered disease status category, assigned according to their TNM stage, Gleason score and PSA level, using an algorithm previously developed by the NPCA. NPCA Annual 
Report 2016. Download from: https://www.npca.org.uk/reports/npca-annual-report-2016/

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Figure 8. 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 (surgery between
1st September 2019 and 31st August 2020) by surgical
centres in England (n=48) and Wales (n=4).
In England, 7% of patients undergoing radical prostatectomy experienced a genitourinary $GU% complication within two years of 
treatment $Figure 8, surgery centre range 1631%% and in Wales, it was 8%. Where high rates were identified, this will be fed back to 
individual Trusts for further investigation.
 
In England, 10% of patients undergoing radiotherapy experienced a gastrointestinal $GI% complication over the same time-period 
$Figure 9, radiotherapy centre range 3617%% and in Wales it was 5% across the three providers. Where high rates were identified, this 
will be fed back to individual Trusts for further investigation.
 
Overall, the underlying rate in each of our performance indicators (whose definitions remained unchanged) has remained stable when 
compared to previous audit periods. The proportion of men with high-risk/locally advanced prostate cancer undergoing radical 
prostate cancer treatment was 69% for both England and Wales in this report and was 67671% between 2016 and 2019. This needs 
careful evaluation as improvement in the rate of people receiving radical treatment for high-risk disease has slowed.
Figure 9. 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 (radiotherapy
between 1st September 2019 and 31st August 2020) by RT
centre in England (n=51) and Wales (n=3).

7. Commentary
 
This is the first State of the Nation report from the NPCA and it provides a succinct summary of the care received by patients newly 
diagnosed with prostate cancer between September 2019 and January 2023 in England and Wales. Users of this report should take 
time to identify areas for improvement in data completeness, service availability and patient outcomes. An important aspect of this is 
the engagement of clinicians to ensure that the data reported on their behalf is both complete and accurate. The NPCA team are 
aware of Covid-19 related changes in the process and breadth of data collection and collation. However, where we have reported 
indicators, we are confident that the data are robust and it is therefore reasonable to act appropriately in relation to these findings. 
These results can be used by patient charities and support groups to inform their patient and carer networks and by patients to start 
conversations with their care providers.
 
Several important findings regarding prostate cancer care have been identified in this report. Both diagnosis and treatment numbers 
have surpassed those of pre-pandemic years in England and the number of men newly diagnosed with prostate cancer in 2022 in 
England and 2021 in Wales has increased compared to the previous year. Subsequently, there has also been an increase in men 
newly diagnosed with prostate cancer treated with either radical prostatectomy or radiotherapy in 2022 in England. This 
demonstrates a recovery of treatment services following the Covid-19 pandemic which is ‘above and beyond’ treatment levels seen 
pre-pandemic. The proportion of men who received radical treatment for high-risk disease remained stable in England and Wales 
when compared to previous years. Since our definition of low-risk disease has been updated in this report, comparisons to previous 
audit periods have not been made.
 
Given the increasing number of patients being diagnosed and treatments being given, it is important to maintain quality of care. This 
is reflected in the proportion of patients experiencing a GI or GU complication within two years of treatment which has remained 
stable for the reporting period of this State of the Nation report. Substantial variation between providers for the GU complications 
indicator remains and providers should review their performance and address problems in treatment delivery where they are 
required. However, a notable decrease in variation between providers has been observed for the GI complications indicator in the 
last two audit periods. Given the focus on two-year outcomes for these indicators, the data pertains to patients treated in 2019/2020. 
We therefore expect that practices of care may have already been adapted in the interim and any improvements will be reflected in 
later audit reports.
 
Management options for patients needing prostate cancer care are continuing to grow and there is increasing specialisation of 
radiotherapy and systemic therapy practice. Within this report we have identified that ultra-hypofractionation has been utilised more 
frequently by radiotherapy departments and the choice of systemic agents in metastatic disease has evolved in light of emerging 
evidence.
 
Going forward it is important that the NPCA plays a role in continuing to improve the care of prostate cancer patients in England and 
Wales. Structural considerations for how prostate cancer services are designed and implemented as well as advances in new 
treatment techniques are a key focus for NPCA reporting in the future. Following the NPCA’s move into NATCAN $National Cancer 
Audit Collaborating Centre), the NPCA will move to more timely and more frequent reporting (on a quarterly basis) for certain 
indicators, with others remaining in the annual reports. There will also be a greater emphasis on quality improvement working with 
professional bodies, hospital Trusts and societies.
 
Further work reflecting on the findings described in this report will be undertaken by the audit team. Better understanding of the 
differences between England and Wales with respect to readmission rates is one of the topics under review, particularly any 
association with pre-op management and modality type, although incomplete data makes this a challenge. Additionally, a more 
detailed investigation mapping the regional variation in incidence of men being diagnosed with metastatic disease given the size of 
the population at risk (e.g. men over 50% is currently being undertaken. Finally, an exploration of the utilisation of systemic and radio-
therapeutic treatments in metastatic prostate cancer is being conducted to provide insights into this key issue.
 
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