NPCA Annual Report 2021
Source: data.gov.uk (2022-01-26)

npca-annual-report-2021. In the 2021 Annual Report, we present the results for patients diagnosed between 1st April 2019 and 31st March 2020 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 and key aspects of the diagnostic and staging process they underwent and the treatments they received . 3. 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 2018. 4. The variation in treatment for men with low-risk, localised disease and high-risk/locally advanced disease in Wales only. In addition, we also present: 5. The impact of COVID-19 on the diagnosis of prostate cancer, receipt of radical treatment and systemic therapy in England only.

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 2021
Results of the NPCA Prospective Audit in England and Wales
for men diagnosed from 1 April 2019 to 31 March 2020 and the
Impact of COVID-19 in England during 2020
(published January 2022)

Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
National Prostate Cancer Audit
Eighth Year Annual Report – Results of the NPCA Prospective Audit in England and Wales for men
diagnosed from 1 April 2019 to 31 March 2020 and the Impact of COVID-19 in England during 2020
(published January 2022)
London: The Royal College of Surgeons of England, 2022.
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(HQIP)
Published January 2022 by the National Prostate Cancer Audit
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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, 2021.
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 © 2022 Healthcare Quality Improvement Partnership (HQIP)
Contents
Acknowledgements
2
Foreword
4
Executive Summary
6
Background
6
Data collection and analysis
6
How to use this report and the NPCA website
6
Key Findings
7
Infographics
16
1. The National Prostate Cancer Audit (NPCA): Introduction
18
1.1.
Aim and objectives
18
2. Methods
19
2.1.
Patient cohort
19
2.2. Definitions
19
2.3. Performance indicators included in this report
20
2.4. Statistical Analysis
21
3. Results
22
3.1.
Audit participation and data completeness
22
3.2. Audit findings
23
3.3. NPCA performance indicators
26
4. Impact of COVID-19
32
4.1.
Data sources and completeness
32
4.2. Methods
33
4.3. Findings
34
5. Discussion
45
6. Future Plans for the NPCA
46
Acronym list
47
Glossary
48

2
Copyright © 2022 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 (NCAPOP). 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).
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 and provides these results to underpin
quality improvement activities.
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 ongoing
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 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 2022.
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 Disease Registration Service, which is part of NHS Digital. 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
Julie Nossiter, NPCA Audit Lead
Melanie Morris, NPCA Lead Epidemiologist
Adrian Cook, NPCA Senior Statistician
Ajay Aggarwal, Clinical Audit Coordinator (Oncology)
Brendan Berry, Academic Clinical Fellow
Paul Cathcart, Clinical Audit Coordinator (Urology)
Joanna Dodkins, NPCA Clinical Research Fellow
Jan van der Meulen, NPCA Chair and Methodological Lead
Arjun Nathan, Academic Clinical Fellow
Matthew Parry, NPCA Clinical Research Fellow
Arun Sujenthiran, NPCA Clinical Research 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
Wouter Verstraete, Cancer Intelligence Analyst
NCRAS Data Liaison and Registration teams
Wales Cancer Networks, Public Health Wales
(PHW)
Gareth Popham, Network Assistant Manager
Julie Cowling, Wales information Specialist

3
Copyright © 2022 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)
Chloe Bright, Principal Cancer Intelligence Analyst, NCRAS,
PHE
Adam Glaser, Clinical Associate Professor, UK Cancer
Survival Initiative
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, MAHSC Professor of Urology, NHS England
Specialised Commissioning Specialist Cancer Surgery CRG
Rebecca Leszczynski, Senior Knowledge Officer, Prostate
Cancer UK
Members of the NPCA Project Team
NPCA Project Board:
Jonathan Glass (Chair), Consultant Urological Surgeon,
Trustee of RCS Council
Chiara DeBiase, Director of Support and Influencing,
Prostate Cancer UK
Roger Kockelbergh, Consultant Urological Surgeon,
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 Clinical Oncologist, BUG
Caroline Rogers, Associate Director, HQIP
Sarah Walker, Project Manager, HQIP
Members of the NPCA Project Team

4
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Foreword
This 2021 NPCA report has been produced in another
challenging year. The COVID-19 pandemic, still ongoing at
the time of writing, has continued to bring challenges
during the data-gathering process which underpins the
production of this report. This year we have used a new
dataset for England – the Rapid Cancer Registration Dataset
(RCRD) – collated successfully by NCRAS staff in difficult
circumstances, giving us access to information we might
otherwise have been unable to acquire. We have also
received the standard (i.e. ‘usual’) dataset from the team at
Public Health Wales despite considerable pressures and
COVID-related demands. These teams’ diligence and
resourcefulness have ensured that this and future NPCA
reports can be developed and distributed in a more timely
and clinically useful manner. We would like to thank all
teams for their outstanding contributions, meeting and
overcoming the challenges resulting from the global events.
This 8th NPCA Annual Report covers the diagnostic period
between April 1st 2019 and March 31st 2020 in order to bring
clinicians and patients up to date with the prostate cancer
landscape as it stood just before the pandemic in England and
Wales. It also covers the period, for England, up to the end of
December 2020, giving an insight into the effect of the
pandemic on prostate cancer diagnosis and treatment.
The new data source for England provided quick access to
information which would otherwise have been inaccessible,
but because of its rapid acquisition, without having the
comprehensive range of data available for previous reports,
there was inevitably some missing detail that would usually be
included in a ‘normal’ year. This has meant we were only able
to report on four of our usual indicators for both England and
Wales and a further two for Wales alone.
It is reassuring to see from these that the overall quality of the
diagnostic and treatment services is good. That said, there are
areas of practice highlighted in the report where there is
significant variation between hospitals. Given the unusual
public health circumstances, the NPCA have not carried out
an outlier process for this annual report. However, individual
provider results can still be accessed on our website, and we
would urge health-care commissioners, hospital trusts,
individual practitioners and patients to make use of these.
The NPCA Quality Improvement (QI) Programme will also
continue to address issues of variation in provision, building
on its successes in 2019 and 2020, which included the addition
of new quality standards, the organisation of a highly effective
QI workshop and a designated QI section on the NPCA
website. This website has information about individual units.
Please take a look and use it when you can!
Having data on services in England up to the end of 2020
from the RCRD, we were also able to report the national and
regional picture relating to the impact of COVID-19 on
diagnosis and treatment provided compared to the same time
periods in 2019. The inevitable disruption caused by the
pandemic is clear as diagnosis and treatment rates fell steeply,
and some treatment modalities replaced others. The data also
reveal the significant shortfall in the number of prostate
cancer cases diagnosed during the period of study. This is a
significant concern, whose effects will be studied and reported
in the future.
An organisational audit, first carried out in 2013 and regularly
updated, has been repeated during August/September 2021.
We will publish on our website a ‘state-of-the-nation’
overview illustrating how prostate cancer diagnostic and
treatment services are organised, in parallel with the launch of
this report.
For 2022, the NPCA will continue to work with our data
collection partners in England and Wales, the National
Cancer Registration and Analysis Service and the Wales
Cancer Network, to receive the most complete, accurate,
timely data possible and to develop our activities aimed at
maintaining and improving the quality of services for
patients. 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.
/continued over

5
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Foreword
As a result of the efforts of the UK prostate cancer community
the NPCA has now created a prostate cancer data resource of
national and international importance. This is available for
interrogation and study by clinicians, patients and health-care
commissioners across the spectrum of prostate cancer care.
“UK prostate cancer” can be justifiably proud of this
achievement. The NPCA team would like to encourage
research-interested groups to put this information to work to
continue to improve the delivery of prostate cancer care.
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 © 2022 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.3 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 to improve prostate cancer diagnosis and treatment.
In this report we make use of a new rapid dataset for England
as well as the standard or ‘usual’ dataset from Wales (i.e. data
from the same source as in previous reports) to describe
process and outcome measures from selected 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 2019 and 31st March 2020 in England and Wales. The
basis of the audit is usually routine data sources. However,
in this unprecedented year, data flows have been disrupted.
Notwithstanding this we have still been able to receive Cancer
Network Information System Cymru (CaNISC), Patient
Episode Database for Wales (PEDW) and Office for National
Statistics (ONS) data in Wales. We have also been given access
to a Rapid Cancer Registration Dataset (RCRD) in England
which has been linked to Hospital Episode Statistics (HES),
ONS, the Radiotherapy Data Set (RTDS) and the Systemic
Anti-Cancer Therapy (SACT) database. In future, this could
potentially lead to the regular rapid reporting of information,
once data quality going forward has been further evaluated.
A comparison of data from the standard NPCA dataset with
the RCRD can be found here.
Using the RCRD and the data from Wales we report specific
information for six performance indicators relating to
diagnosis, staging and treatment during the period
immediately before the COVID pandemic started. These
include one disease presentation indicator and three
treatment-outcome performance indicators for both England
and Wales, and two related to treatment allocation for Wales.
For England, thanks to the RCRD, we report on the impact
that COVID-19 had at a regional level on diagnosis and
treatment rates in 2020.
How to use this report and the NPCA
website
The information presented here reports prostate cancer
services in England and Wales, showing variation across
providers. Due to the unusual circumstances underpinning
data collection and collation, resulting in the unavailability of
standard cancer registration data4, the NPCA has not carried
out a formal outlier process in this report. Rather, a
breakdown of results at the level of each Trust/Health Board
and specialist MDT is provided in the appendices and is
available on our website to facilitate local quality
improvement activities. We recommend that these data
provide a starting point for reflection on the reasons behind
variation in practice and outcome, and that this report be
used to identify such areas.
The NPCA team are aware of COVID-related changes in the
process and breadth of data collection and collation and, as a
consequence, its potential shortfalls. For this reason, we
would encourage circumspection in making comparisons
with every aspect of the findings in our previous reports.
However, where we have reported indicators we are confident
that the data are robust and it is therefore reasonable in
relation to these to take action appropriately.
As always, the audit provides an impetus to maintain and
improve data collection for the most accurate reflection of
prostate cancer care in England and Wales, as the findings are
only as good as the data collected. Users of this report should
take time to identify areas for improvement in data
completeness, service availability and patient outcomes,
especially as we come out of the current pandemic. An
important aspect of this is the engagement of clinicians to
ensure that the data reported on their behalf is both complete
and accurate. We also encourage clinical leads and other
MDT members to attend our next Quality Improvement
workshop (the last was in December 2021), where audit results
provide a foundation for discussion and improvement in care.
The next will be advertised on our QI webpage in due course.
We also welcome feedback on how the NPCA audit outputs
can be improved.
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. A lay
summary of the report will be published alongside this report
in early 2022. Previous lay summaries of our Annual Reports
and patient-focussed slide sets for use by support groups can
be found on our website at www.npca.org.uk
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 2018.
4
Standard cancer registration data for diagnoses in England from 1st January 2019 were unavailable during the preparation of this report. For updates regarding future availability
please refer to the monthly National Disease Registration Service newsletters

7
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Key Findings
Data quality
• Data completeness of key variables necessary to assign a
risk group remains high for Wales (PSA, Gleason score
and TNM variables; 86%, 86% and 79%, respectively).
Information on PSA and Gleason score were unavailable
for England this year so it was not possible to place men in
a risk group.
• Data completeness of performance status reached 100%
in Wales and increased in England compared with the
previous report (61% versus 52%).
Prospective audit in England and Wales
• The number of men diagnosed with prostate cancer, in the
pre-pandemic period covered by this audit (1st April 2019
to 31st March 2020), is 45,885. This is an increase on the
number reported for 2017-2018 (42,668) but down from the
unusually high number for 2018-2019 (52,850). It is thought
that the surge in numbers in that year (diagnosed 1st April
2018 to 31st March 2019) may have been explained by
increased public awareness following diagnosis of two high
profile celebrities with prostate cancer (https://www.npca.
org.uk/reports/npca-annual-report-2020/).
• The proportion of men presenting with metastatic disease
at diagnosis in England and Wales is stable at 13%.
• The proportion of men recorded as having an emergency
readmission within 90 days of radical prostate cancer
surgery is 13%, similar to the 14% reported in 2020.
• Medium-term outcomes are similar or better than previous
years:
a. Genitourinary complications following radical
prostatectomy have reduced slightly since last
year’s report. 7% of men experienced at least one
genitourinary complication within two years of their
prostatectomy compared to 9% the previous year.
b. Gastrointestinal complications following radical
radiotherapy remain stable: 11% of men experiencing a
gastrointestinal complication within two years of their
radiotherapy as was the case in the previous year.
Prospective audit in Wales
(Figures from last year’s report included English data, so
comparative figures are given only for Wales)
• 10% of men with low-risk disease had radical treatments
and were potentially “over-treated” in Wales.5 This
represents a decrease from 2018-2019 when 16% of men
were potentially “over-treated” in Wales.
• 40% of men with high risk disease did not have radical
treatments and were potentially “under-treated” in
Wales.5 This has increased from 2018-2019 when 34% of
men were potentially “under-treated” in Wales.
Impact of the COVID-19 pandemic in England
• The COVID-19 pandemic has had a profound impact on
the care provided to patients with cancer, with delays in
diagnosis and treatment. While the audit did not measure
the reasons behind each case, other evidence shows us
that this situation was likely to be due to the steps taken to
mitigate transmission of the virus, changes to the provision
of services due to capacity pressures and patients being
reluctant to seek care.6,7,8,9,10
• There was a 54% reduction in the number of patients newly
diagnosed with prostate cancer during April – June 2020
compared with the same period in 2019. From July 2020
onwards there was an increase in diagnostic activity across
all regions but this had not returned to 2019 levels by the
end of 2020.
• Of the men diagnosed with prostate cancer since April
2020, a higher proportion were diagnosed at stage IV
compared with 2019 (21% vs 17%).
• There was a 48% reduction in the number of men
undergoing radical prostatectomy from April – June 2020
compared with 2019. Surgical activity increased July –
September 2020, but there was an overall 5% reduction
compared with 2019. From October to December, there
was a 25% overall reduction, compared with the same
period in 2019. This effect did vary by region.
5
Prostate Cancer. NICE Quality Standard [QS91], 2015 (Updated May 2019) 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’; 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’
6
Gathani T, Clayton G, E M, Horgan K. The COVID-19 pandemic and impact on breast cancer diagnoses: what happened in England in the first half of 2020.
British Journal of Cancer 2020.
7
Greenwood E, Swanton C. Consequences of COVID-19 for cancer care — a CRUK perspective. Nature Reviews Clinical Oncology 2021; 18: 3-4.
8
Kuryba A, Boyle JM, Blake HA, Aggarwal A, Van Der Meulen J, Braun M, Walker K, Fearnhead NS. Surgical Treatment and Outcomes of Colorectal Cancer Patients During the
COVID-19 Pandemic: A National Population-based Study in England. Annals of Surgery Open. 2021 Jun 1;2(2):e071.
9
McCormack V, Aggarwal A. Early cancer diagnosis: reaching targets across whole populations amidst setbacks. British journal of cancer 2021.
10 Rutter M, Brookes M, Lee T, Rogers P, Sharp L. Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis.
Gut 2020.

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Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
11 Zaorsky NG, James BY, McBride SM, Dess RT, Jackson WC, Mahal BA, Chen R, Choudhury A, Henry A, Syndikus I, Mitin T. Prostate cancer radiation therapy recommendations
in response to COVID-19. Advances in radiation oncology. 2020 Nov 1;5:26-32.
12 NICE, 2020. COVID-19 rapid guideline: delivery of radiotherapy. NICE guideline [NG162], 2020 https://www.nice.org.uk/guidance/NG162
13 NICE Guideline [NG161], 2020. NHS England interim treatment changes during the COVID-19 pandemic
• There was a 45% reduction in the number of men initiating
radical radiotherapy from April – June 2020 compared
with 2019. During July – September 2020, radical
radiotherapy activity increased above the levels observed in
2019 in every region and by 23% overall.
• Increasing use of a hypofractionated regimen was evident
across each region reflecting guidance for the safe
maintenance of radiotherapy services without reducing
treatment effectiveness.11,12
There was a rapid and marked fall in the use of docetaxel
use from April 2020 in each region for men with metastatic
hormone-sensitive prostate cancer and a concomitant
increase in the use of enzalutamide. This reflects updated
guidance published in April 2020.13 However, there was
significant inter-regional variation.

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Copyright © 2022 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 2019 to 31st March 2020 just before 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 2021 findings underlying
recommendation
Previous results
(Annual Report 2020)
National guidance
Data quality
R1
Aim to achieve high completeness of key
data items captured by NHS organisations in
England, including TNM staging variables and
performance status.
-
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
Performance status:
England, from COSD (61%)
Wales (100%)
(Results 3.1, Table 3).
Stage variable assigned:
England, from RCRD (74%)
Risk group assigned:
Wales (94%)
(Results 3.2, Table 3)
Performance status Increase: England, from
COSD (52%)
No change: Wales (100%)
Risk group assigned:
England (91%)
Wales (95%)
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.
The Welsh Cancer Intelligence and
Surveillance Unit collects, analyses and
releases information about cancer in Wales.
R2
Review recording of radical treatments, in
particular radical prostatectomy, working with
data specialists in the Wales Cancer Network.
NHS Organisations
in Wales. Prostate
cancer teams (local
and specialist MDTs)
within NHS/Health
Boards
Recommendation in light of R10 – R13.
N/A
The Welsh Cancer Intelligence and
Surveillance Unit collects, analyses and
releases information about cancer in Wales.
Diagnosis
R3
Increase the use of trans-perineal biopsy
methods, which is advised wherever clinically
appropriate, 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
40% of men in England and 24% of men in Wales had a
trans-perineal prostate biopsy.
(Results 3.2, Table 4).
The availability of different data sources*
in England for this report precludes a
valid comparison to previous results in the
Annual Report 2020
https://www.england.nhs.uk/wp-content/
uploads/2018/04/implementing-timed-
prostate-cancer-diagnostic-pathway.pdf
This recommendation is based on the views of
the NPCA Clinical Reference Group (CRG).

10
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2021 findings underlying
recommendation
Previous results
(Annual Report 2020)
National guidance
Disease status
R4
Seek advice from a doctor if any of the
following new symptoms are experienced:
urinary symptoms, erectile problems, blood in
their urine or unexplained back pain, as early
diagnosis improves outcomes.
Patients
Overall 13% of men in England and Wales were diagnosed
with metastatic disease at diagnosis. (ranging from 4% to
23% by specialist MDT; unadjusted results).
(Results 3.3.1, Performance indicator 1, Figure 1).
No change: 13% of men in England and
Wales
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’
R5
Ensure that a family history of prostate, breast
or ovarian cancer is reported to a healthcare
provider with a view to a possible genetic
counselling referral.
Patients / patient
groups
Overall 13% of men in England and Wales were diagnosed
with metastatic disease at diagnosis. (ranging from 4% to
23% by specialist MDT; unadjusted results).
(Results 3.3.1, Performance indicator 1, Figure 1).
No change: 13% of men in England and
Wales
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’
Outcomes of treatment
R6
Consider establishing radiotherapy centre
specialist gastrointestinal services to offer
advice to people with bowel-related side effects
of radiotherapy.
-
Identification of these side-effects
could be improved with the
initiation of hospital-level PROMs
programmes.
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.
(Results 3.3.1, Performance indicator 4, Figure 4).
No change: 11% of men in England and
Wales
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).
/Table 1 continued

11
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2021 findings underlying
recommendation
Previous results
(Annual Report 2020)
National guidance
Outcomes of treatment
R7
Ensure that men who are offered prostate
cancer treatment are made 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 (local
and specialist MDTs)
within NHS Trusts/
Health Boards
Radical prostatectomy – urinary complications
7% of men experienced at least one genitourinary
complication requiring a procedural/surgical intervention
within two years after radical prostatectomy.
(Results 3.3.1, Performance indicator 3, Figure 3).
Reduction: 9% of men in England and Wales 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.
Radical radiotherapy – bowel complications
11% of men experienced at least one bowel complication
within two years after radical radiotherapy.
(Results 3.3.1, Performance indicator 4, Figure 4).
Bowel complications are consistent with
previous report – 10% of men in England
and Wales
R8
Empower patients to ask to be referred
to specialist support services if they are
experiencing physical or psychological side
effects during, or following, prostate cancer
treatment.
-
These should be offered early and
on an ongoing basis, in keeping with
national recommendations.
Patients and Prostate
cancer teams (local
and specialist MDTs)
within NHS Trusts/
Health Boards
Recommendation in light of R13.
N/A
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.
R9
Make available sources of further information
and support 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 (local
and specialist MDTs)
within NHS Trusts/
Health Boards
Recommendation in light of R6 and R13.
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.
/Table 1 continued

12
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2021 findings underlying
recommendation
Previous results
(Annual Report 2020)
National guidance
Treatment allocation: recommendations on the basis of Welsh data*
R10
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
10% of men diagnosed with low-risk localised cancer in
Wales underwent radical prostate cancer therapy within
12 months of diagnosis.
(Results 3.3.2, Performance indicator 5, Table 5).
Decrease: 16% of men were ‘potentially over-
treated’ in Wales
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.
R11
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
60% of men diagnosed with locally-advanced prostate
cancer underwent radical treatment within 12 months
of diagnosis in Wales equating to 40% of men being
‘potentially under-treated’.
(Results 3.3.2, Performance indicator 6, Table 5).
Increase: 34% of men were ‘potentially under-
treated’ in Wales
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.
R12
Discuss with your clinical specialist the option
of disease monitoring with active surveillance
in the first instance.
Patients with low-risk
prostate cancer and
clinical specialists
10% of men diagnosed with low-risk localised cancer in
Wales underwent radical prostate cancer therapy within
12 months of diagnosis.
(Results 3.3.2, Performance indicator 5, Table 5).
Decrease: 16% of men were ‘potentially over-
treated’ in Wales
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.
/Table 1 continued
/Table 1 continued

13
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2021 findings underlying
recommendation
Previous results
(Annual Report 2020)
National guidance
Treatment allocation: recommendations on the basis of Welsh data*
R13
Discuss with your clinical specialist the radical
treatment options available to men with high-
risk/locally advanced disease.
Patients and clinical
specialists
60% of men diagnosed with locally-advanced prostate
cancer underwent radical treatment within 12 months
of diagnosis in Wales equating to 40% of men being
‘potentially under-treated’.
(Results 3.3.2, Performance indicator 6, Table 5).
Increase: 34% of men were ‘potentially under-
treated’ in Wales
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.
Overall recommendations
R14
Review of the NPCA indicators for providers
should be undertaken within the region and
nationally, and fed through to providers
-
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 Trusts and Health
Boards which should follow-up
implementation progress.
Commissioners and
health care regulators
Recommendation in light of R1 – R12.
N/A
This recommendation is based on the views of
the NPCA CRG.
R15
Ensure that radiotherapy and surgical
treatment centres are able to deliver a full
range of treatments and support services for
patients.
Commissioners and
health care regulators
Recommendation in light of R6–R8 and R13.
N/A
This recommendation is based on the views of
the NPCA CRG.
* In this report we make use of a new rapid dataset for England (the RCRD) as well as the ‘usual’ dataset from Wales to describe process and outcome measures from selected aspects of the care pathway for men with prostate cancer. The RCRD does not contain
information on metastases, Gleason grade or PSA which precluded using our risk-stratification algorithm to assign a risk group. As a result, it was not possible to produce indicators based on a risk group for England in this report.
Standard cancer registration data for diagnoses in England from 1st January 2019 were unavailable during the preparation of this report. For updates regarding future availability please refer to the monthly National Disease Registration Service newsletters
/Table 1 continued

14
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Table 2. Impact of COVID-19: recommendations, key findings and related national guidance
These recommendations are based on results from data collected in England during 2019 and 2020.
No.
Recommendation
Audience
Annual Report 2021 results findings underlying
recommendation: comparison of 2019 vs 2020
National guidance
Diagnosis and radical treatment
CR1
Review the diagnostic and treatment
activity for your region during 2020
illustrating how your service responded
during this time and to support decision
making in response to current changes
in demand.
Cancer alliances. Prostate cancer
teams (local and specialist MDTs)
within NHS Trusts/Health Boards
From April – December:
There was a 33% reduction in the number of men newly diagnosed
with prostate cancer (31,541 vs 21,260; 2019 vs 2020, respectively).
(Results 4.2, Figure 6)
There was a 26% reduction in the number of men undergoing radical
prostatectomy (5,141 vs 3,798; 2019 vs 2020, respectively).
(Results 4.2, Figure 9)
There was a 13% reduction in the number of men initiating radical
radiotherapy (9,144 vs 7,930; 2019 vs 2020, respectively).
(Results 4.2, Figure 11)
NHS England Cancer Recovery Taskforce: Cancer Services Recovery
Plan, 2020
‘Phase 1: ensure continuation of essential cancer treatment and screening
for high risk individuals during the initial peak of the pandemic.
Phase 2: restore disrupted services as far as possible to at least pre-
pandemic levels.
Phase 3 (to run until March 2021): full recovery of NHS cancer services in
England, including ensuring that care for all patient groups continues to
be safe, effective and holistic.’
NHS England 2021/22 priorities and operational planning guidance, 2021
‘ To restore full operation of all cancer services…local systems, drawing
on advice and analysis from their Cancer Alliance, will ensure that there
is sufficient diagnostic and treatment capacity in place’
CR2
Monitor adherence to the recommended
diagnostic pathway for suspected prostate
cancer.
Cancer alliances. Prostate cancer
teams (local and specialist MDTs)
within NHS Trusts/Health Boards
From April – December:
There was a 33% reduction in the number of men newly diagnosed
with prostate cancer (31,541 vs 21,260; 2019 vs 2020, respectively).
(Results 4.2, Figure 6)
NHS England Implementing a timed prostate cancer diagnostic pathway,
2018
‘Improve performance against national standards (particularly 62 day
performance and the 28 day faster diagnosis standard)’
NHS England Cancer Recovery Taskforce: Cancer Services Recovery
Plan, 2020
‘Phase 1: ensure continuation of essential cancer treatment and screening
for high risk individuals during the initial peak of the pandemic.
Phase 2: restore disrupted services as far as possible to at least pre-
pandemic levels.
Phase 3 (to run until March 2021): full recovery of NHS cancer services in
England, including ensuring that care for all patient groups continues to
be safe, effective and holistic.’
NHS England 2021/22 priorities and operational planning guidance, 2021
‘All systems are expected to work with regions to deliver increased
capacity to meet the diagnostic needs for their population, in line with
the recommendations of the Richards review.’

15
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
No.
Recommendation
Audience
Annual Report 2021 results findings underlying
recommendation: comparison of 2019 vs 2020
National guidance
Hypofractionation
CR3
Continue to increase the use of
hypofractionated radiotherapy.
Radiotherapy centres. Cancer
alliances. Prostate cancer teams
(local and specialist MDTs) within
NHS Trusts/Health Boards
Of the men undergoing radical radiotherapy during April-December
there was an increase in the use of a hypofractionated regimen, 78%
(7148/9109) in 2019 vs 85% (6595/7772) in 2020.
(Results 4.2, Figure 12)
Guidance pre-dating the COVID-19 pandemic:
NICE Guideline [NG131], 2019
‘1.3.17 For people having radical external beam radiotherapy for localised
prostate cancer: offer hypofractionated radiotherapy (60 Gy in 20
fractions) using IMRT, unless contraindicated’
Guidance published during the COVID-19 pandemic recommended
‘the wider use of short, high daily dose (hypofractionated) radiotherapy’
including:
NICE Guideline [NG162], 2020
RCR Coronavirus Guidance
Systemic anti-cancer treatment
CR4
Offer enzalutamide (or apalutamide)
with androgen deprivation therapy (or
abiraterone for patients intolerant of
enzalutamide) to people with newly
diagnosed metastatic disease instead of
docetaxel, where appropriate.
Cancer alliances. Prostate cancer
teams (local and specialist MDTs)
within NHS Trusts/Health Boards
From April –December, there was a 74% reduction in the number of
men with hormone-sensitive metastatic disease receiving docetaxel
(1458 vs 377; 2019 vs 2020, respectively)
During the same time period, there was a marked increase in the
number of men receiving enzalutamide (3 vs 1011; 2019 vs 2020,
respectively)
(Results 4.2, Figure 14)
Guidance pre-dating the COVID-19 pandemic:
NICE Guideline [NG131], 2019
‘1.5.6 Offer docetaxel chemotherapy to people with newly diagnosed
metastatic prostate cancer who do not have significant comorbidities’
Updated guidance 2020:
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’
Updated guidance 28.10.21:
Project information | Apalutamide for treating prostate cancer [ID1534] |
Guidance | NICE
[NICE updated guidance to add when published]
/Table 2 continued

16
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
For men diagnosed in England and Wales April 2019 - March 2020:
For men undergoing surgery in England and Wales between April 2019 - March 2020:
For men diagnosed in Wales April 2019 - March 2020:
Low-risk, localised disease
High-risk/locally advanced disease
For men undergoing radical treatment in 2018:
Annual Report 2021

Diagnosis & staging
Treatment outcomes
Treatment allocation
men were diagnosed with prostate cancer
in England and Wales between 1st April
2019 and 31st March 2020
experienced at least one
gastrointestinal complication
requiring a procedural/surgical
intervention within two years after
radical radiotherapy
of men were readmitted within
3 months following surgery
This is stable compared
with 2018-2019
experienced at least one
genitourinary complication
requiring a procedural/surgical
intervention within two years after
radical prostatectomy
of men presented with
metastatic disease
*this may be explained by the
diagnosis of two high-proﬁle
celebrities during this previous
reporting period, which was
publicised by the media
decrease compared with
52,580 men in 2018-2019*
of men were
70 years or older
Stable compared to 11% in 2017
Decrease compared to 9% in 2017
of men did not have radical
treatments and were potentially
'under-treated' - 34% in 2018-2019
of men had radical treatments and
were potentially 'over-treated'
16% in 2018-2019
Infographics

17
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Number of patients newly diagnosed with prostate cancer in 2020 (compared to same period in 2019)
Number of patients undergoing radical prostatectomy in 2020 (compared to same period in 2019)
Number of patients undergoing radical radiotheraphy in 2020 (compared to same period in 2019)
Annual Report 2021
Impact of COVID19 in England in 2020
April-June
July-September
October-December
-50%
0%
50%
* There was a 54% reduction in the number of men diagnosed between April - June 2020 compared with same period in 2019
* There was a 48% reduction in the number of men undergoing prostatectomy between April - June 2020 compared with same period in 2019

Impact on Diagnosis
Impact on Radical treatment received
Impact on systemic therapy
Rapid and marked fall of Docetaxel
use from April 2020 in metastatic
hormone-sensitive prostate cancer.
Conversely, rapid and marked
increased use of Enzalutamide
54%*
28%
16%
April-June
July-September
October-December
-50%
0%
50%
48%*
5%
25%
April-June
July-September
October-December
-25%
0%
25%
50%
45%*
23%
19%
* There was a 45% reduction in the number of men undergoing radiotherapy between April - June 2020 compared with same period in 2019

600
400
Patient starting treatment
200
0
Docetaxel
JUL-SEP
OCT-DEC
JAN-MAR
APR-JUN
Enzalutamide

18
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
14 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
15 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
16 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.
17 For example, a short report published in October 2020 explored geographical variation in the management of high-risk/locally advanced prostate cancer in England and
investigated potential determinants for receipt of treatment including age, comorbidities, socioeconomic status and ethnicity, which was explored further in a corresponding
peer-reviewed publication.
18 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.
The National Prostate Cancer Audit has been reporting
annually for seven years, developing and adding indicators
year-on-year but for the first time, we report fewer
indicators in this audit cycle than previously. Although the
NPCA still covers the whole patient care pathway from
diagnosis through to treatment and treatment-related
outcomes, the unprecedented circumstances of the
pandemic mean that data capture, collection and collation
has been severely affected. We are fortunate to be able to
report as usual for Wales and in addition, we have been able
to access a Rapid Cancer Registration Dataset (RCRD) for
England, provided by NCRAS.
Limiting the impact of the adverse events of radical
treatments remains a 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]).14,15 We have been able to do this for this
report using the RCRD for England and the audit dataset
for Wales.
The key indicators regarding potential “over-treatment” of
low-risk disease and potential “under-treatment” of high-risk
localised/locally advanced disease, which have shown
improving trends over the first years of the Audit, could only
be reported for Wales this year as risk stratification was not
possible using the English RCRD dataset. When full data
availability returns, the NPCA audit will use an updated,
widely-accepted risk stratification score (the Cambridge
Prognostic Grouping16) 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.
Despite the unusual circumstances that have led to an updated
structure for this report, we have been able to report on
several key indicators and describe the impact of COVID-19
on diagnosis and treatment services during the first phase of
the pandemic. We hope that the findings included, reporting
where we have robust data available, will continue to drive
quality improvement in centres across the country.
1. The National Prostate Cancer Audit (NPCA): Introduction
1.1. 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 and the
determinants of variation.17
• overall and disease-free survival with further follow-up.18
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 to improve care for patients. 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. This year we focus on
particular indicators for selected parts of the pathway for
which we have robust, complete data.

19
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
For full details of our methodology including the data used,
definition of variables and details of statistical analysis, please
see the most recent version of the NPCA Annual Report
Methodology Supplement (www.npca.org.uk).
NPCA dataset and Rapid Cancer
Registration Dataset
The NPCA uses patient data collected routinely by the national
Cancer Registration and Analysis Service (NCRAS) in England
and the Wales Cancer network (WCN) including data on the
diagnosis, management and treatment of every patient newly
diagnosed with prostate cancer in England and Wales.
For England, the NCRAS provide data from its cancer analysis
system, which collates patient data from a range of national
data feeds across all NHS providers. For this annual report,
the NCRAS provided data from the Rapid Cancer Registration
Dataset (RCRD), which is sourced mainly from the Cancer
Services and Outcomes Dataset (COSD), containing proxy
tumour registrations, as the standard Cancer Registration data
were unavailable. This dataset has been provided more quickly
than has been possible in the past and includes men diagnosed
up to December 2020. However, the speed of production and
the pandemic has meant that several of the standard data items
are unavailable or too incomplete for use (section 2.3) and
others should be interpreted with caution (section 3.3.1).
The RCRD is linked to 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, the standard NPCA data items (which can be found
on our website19) were available for men diagnosed up to
31st March 2020. These data are captured through CaNISC
and linked to additional data items from the Patient Episode
Database for Wales (PEDW), ONS and CaNISC. RTDS
data are currently unavailable. 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.
2.1. Patient cohort
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 2019 and 31st March 2020 in
England and Wales for an assessment of 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 for these is therefore over a whole
calendar year (1st January 2018 to 31st December 2018).
For England only, we report on the impact of the COVID-19
pandemic on the diagnosis and treatment of men with
prostate cancer during 2020 and compare this to the ‘usual’
patterns of care in 2019.
Level of reporting
It is recommended that the care of patients eligible for radical
prostate cancer treatments should be coordinated by specialist
MDTs (SDMT).20 These hubs are made up of one or more
specialist cancer centres coordinating services for referring
local Trusts or Health Boards.21
This year, findings are presented locally and nationally with
results at the level of the specialist MDT or the surgery or
radiotherapy centre found in the appendices and on our
website.
2.2. Definitions
Disease status and risk stratification
Using the Welsh data, men were assigned to a prostate cancer
‘risk group’ 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 level,
using an algorithm previously developed by the NPCA.22
In England, the RCRD did not contain information on
Gleason grade or PSA which precluded using our risk-
stratification algorithm to assign a risk group. Disease staging
(stage I-IV) derived by NCRAS from TNM status was
available but did not map well to the previous risk groups. For
example, the group of men with primary metastatic disease
did not map to stage IV, which also included N1 patients. The
locally advanced risk group comprised men with T3/4, N1,
Gleason≥8 or PSA>20mg/dl, while stage III included only
men with T3/4. The low-risk group included only T1 patients,
while stage I included T2a.
The RCRD disease staging was used to adjust for extent of
disease for the treatment-outcome performance indicators
(section 2.4). However, because of the mapping problems
described above it was not possible to produce indicators
based on a risk group for England.
2. Methods
19 https://www.npca.org.uk/resources/npca-minimum-dataset/
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 Annual Report 2016. Download from: https://www.npca.org.uk/reports/npca-annual-report-2016/

20
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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.
2.3. Performance indicators included
in this report
In this Annual Report, the NPCA report on six performance
indicators which are summarised here. For further detail,
please see the most recent version of the NPCA Annual
Report Methodology Supplement (www.npca.org.uk).
For England and Wales:
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 variation
of the proportion of men diagnosed with metastatic prostate
cancer, at a point at which they are normally beyond
curative treatment. This could potentially indicate a late
diagnosis.
Outcomes of treatment: short-term
• Performance indicator 2: 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. An overnight stay is not
required for a patient to fall into this category. An
emergency readmission code indicates that “admission
was unpredictable and at short notice because of clinical
need” (from the HES data dictionary23). It may reflect that
a patient experienced a complication related to radical
prostate cancer surgery after discharge from hospital.
Outcomes of treatment: medium-term
• Performance indicator 3: 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.24 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. Men
who are both diagnosed and treated in 2018 are included
in this indicator for England, and all those treated in
2018 are included for Wales.
• Performance indicator 4: 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. This indicator also required
the presence of specific ICD-10 diagnosis codes relating
to GI toxicity.25 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. Men who are
both diagnosed and treated in 2018 are included in this
indicator for England, and all those treated in 2018 are
included for Wales.
23 http://content.digital.nhs.uk/media/23711/Admitted-Patient-Care/pdf/Admitted_Patient_Care_.pdf
24 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
25 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

21
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
26 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.
For Wales only:
Treatment allocation
• Performance indicator 5: 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 6: 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.
2.4. Statistical Analysis
Centres that perform less than 10 procedures per year are
excluded; however, there were none of these this year.
Indicators 1, 2 and 3 were adjusted for patient age,
comorbidity, socio-economic status and disease stage (for
English patients). Multivariate logistic regression was used to
estimate the probability of a patient having an event, at trust
level the individual probabilities were summed to give the
expected number of events, and the number of events was
then divided by the expected.
Comorbidity was captured using the Royal College of
Surgeons (RCS) Charlson comorbidity score26 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 treatment-outcome
performance indicators 1-3 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 treatment centres for our
performance indicators according to patient volume.

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Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
3. Results
3.1. Audit participation and data
completeness
43,330 men were identified with prostate cancer in England
from 1st April 2019 to 31st March 2020, of whom 43,324
could be assigned a valid NHS provider (Table 3). Prostate
cancer diagnostic services are provided at 126 NHS Trusts
across 45 specialist MDTs in England and 6 Health Boards
across 4 specialist MDTs in Wales.27 Surgical services were
provided by 52 centres and radiotherapy services by 53
centres during this time period.
In Wales we received a total of 2,561 NPCA records of
newly diagnosed men and all could be assigned to a valid
NHS provider.
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 (Table 3). 94% of Welsh men
could be assigned to a risk group due to the high
completeness of PSA, Gleason score and TNM variables
(86%, 86% and 79%, respectively).
On the basis of RCRD, completeness of performance status
in England (61%) increased compared with the previous
year’s result (52%), but is lower than in Wales. Information
on PSA and Gleason score were unavailable in the RCRD so
it was not possible to place men in a risk group. RCRD
staging information was missing for approximately one
quarter of men in the cohort.
27 https://www.npca.org.uk/reports/npca-organisational-audit-2019/
Table 3. Data completeness for selected data items for men newly diagnosed with prostate cancer
in England and Wales over the period of 1 April 2019 and 31 March 2020.
Data variable
England
Wales
N
%
N
%
Diagnostic and staging variables
No. of men with new diagnosis of prostate cancer
43,330a
[RCRD]
100%
2,561
[NPCA]
100%
Performance status completed
26,301
[RCRD]
61%
2,561
[NPCA]
100%
Biopsy performed
34,379
[HES]
79%
1,269
[NPCA]
50%
PSA completed b
2,208
[NPCA]
86%
Gleason score completed b
2,208
[NPCA]
86%
TNM completed
24,641
(RCRD)
57%
2,026
[NPCA]
79%
Stage variable assigned c
31,934
[RCRD]
74%
N/A
Risk group assigned c
N/A
2405
[NPCA]
94%
Acronyms: RCRD = Rapid Cancer Registration dataset; NPCA = National Prostate Cancer Audit dataset; PSA = Prostate Specific Antigen; TNM = Tumour, Nodes, Metastases Classification of Malignant
Tumours.
a
including 6 men who could not be assigned a provider
b
unavailable in the RCRD for England.
c
Stage variable only available for England from RCRD; PSA and Gleason score unavailable in RCRD therefore unable to assign a risk group for English men
Data quality: recommendations
R1. Aim to achieve high completeness of key data items captured
by NHS organisations in England, including TNM staging
variables and performance status.
- 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.
R2. Review recording of radical treatments, in particular
radical prostatectomy, working with data specialists in the
Wales Cancer Network.

23
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
3.2. Audit findings
Patient and diagnostic characteristics are summarised in
Table 4.).
Patient characteristics
Over a third of men are aged between 70 and 80 (40% for
England and 38% for Wales) 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 (16% and 14% in England and
Wales, respectively). This is consistent with last year’s report.
In England and Wales, most men had no comorbidities
recorded (81% and 79%). Of the men who had performance
status recorded in England, 73% had a performance status of
zero (fully active) versus 66% of men in Wales, similar to
last year’s report.
Table 4. Patient and diagnostic characteristics for men newly diagnosed with prostate cancer in England
and Wales over the period of 1 April 2019 and 31 March 2020.
Data variable
England
Wales
N
%
N
%
No. of men with new diagnosis of prostate cancer
43,330a
2,561
Age
<60
5,585
13%
294
11%
60-69
13,695
32%
924
36%
70-79
17,302
40%
984
38%
≥80
6,748
16%
359
14%
Total
43,330
100%
2,561
100%
Missing
0
0
Performance status
0
19,256
73%
1,686
66%
1-2
6,593
25%
839
33%
≥3
452
2%
36
1%
Total
26,301
100%
2,561
100%
Missing
17,029
0
Charlson score
0
34,916
81%
2,035
79%
1
3,985
9%
368
14%
≥2
4,429
10%
158
6%
Total
43,330
100%
2,561
100%
Missing
0
0
Biopsy performed
Trans-rectal
20,623
60%
969
76%
Trans-perineal
13,756
40%
300
24%
Total
34,379
100%
1,269
100%
Missing
8,951
1,292
Prostate Specific Antigen (PSA) b
<10
1,283
58%
10-20
464
21%
>20
461
21%
Total
2,208
100%
Missing
353

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Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Data variable
England
Wales
N
%
N
%
Gleason score b
≤6
783
35%
7
1,017
46%
≥8
408
18%
Total
2,208
100%
Missing
353
T stage
T1
2,753
6%
385
16%
T2
13,813
32%
1,204
50%
T3
10,231
24%
640
27%
T4
1,685
4%
174
7%
Total
28,482
100%
2,403
100%
Missing
14,848
158
N stage
N0
24,892
90%
2,129
91%
N1
2,851
10%
212
9%
Total
27,743
100%
2,341
100%
Missing
15,587
220
M stage
M0
23,137
87%
1,855
85%
M1
3,518
13%
328
15%
Total
26,655
100%
2,183
100%
Missing
16,675
378
Risk group ce
Low risk
218
9%
Intermediate
1,091
45%
High-risk/locally advanced
768
32%
Metastatic
328
14%
Total
2,405
100%
Insufficientd
156
Stage ef
I
11,774
37%
II
5,064
16%
III
9,666
30%
IV
5,430
17%
Total
31,934
100%
Missing
11,396
Acronyms: PSA = Prostate Specific Antigen; TNM = Tumour, Nodes, Metastases Classification of Malignant Tumours; RCRD = Rapid Cancer Registration Dataset
Some columns do not add to 100% due to rounding
a
including 6 men who could not be assigned a provider
b
unavailable in the RCRD for England.
c
unadjusted values
d
Insufficient data indicates that one of the criteria needed for the risk group algorithm is missing so it could not be assigned.
e
Stage variable only available for England from RCRD; PSA and Gleason score unavailable in RCRD therefore unable to assign a risk group for English men
f
Please see Glossary in annual report for staging notation
/Table 4 continued

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Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Diagnostic investigations
The trans-rectal ultrasound guided method remains the
most common biopsy technique at 60% in England and 76%
in Wales, with 40% and 24% of men undergoing a trans-
perineal biopsy (in England and Wales respectively). There
is a significant amount of missing data in each of the
countries, however, making these figures difficult to
compare across the years.
Diagnosis: recommendations
R3. Increase the use of trans-perineal biopsy methods, which is
advised wherever clinically appropriate, when targeting lesions
in the anterior region of the prostate, whilst balancing against
resource constraints and the risk of side effects.
Treatment information
Treatment characteristics are summarised in Table 5.
6,988 men were identified as undergoing a radical
prostatectomy in England; most were robotically assisted
(93%), with the remainder being performed laparoscopically
(3%) or through open surgery (4%). There has been a
continued adoption of the robotic-assisted approach with
last year’s proportion being 89% (2018/2019) up from 74% in
2015/2016. Robotic prostatectomies were performed less
frequently in Wales (82%) but this is steadily increasing
from 74% last year and 68% and 63% in the two previous
years. Just over one fifth of the prostatectomies were
performed with a lymphadenectomy in England (21%) but
more so in Wales (59%).
4,831 men underwent radical radiotherapy in England; the
vast majority were performed with Intensity-modulated
Radiotherapy (IMRT) (Table 5) for first line therapy, which
is consistent with the figure reported last year, but 7% still
had 3D conformal radiotherapy. Of all men receiving
radiotherapy, 17% 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 15% of Welsh men
appear to be having “regional” vs “prostate only”
radiotherapy, although these figures for both countries rely
on data on “planned region of treatment”.
Table 5. Treatment characteristics for men receiving radical radiotherapy or prostatectomy in England
and Wales over the period of 1 April 2019 and 31 March 2020.
Data variable
England
Wales
N
%
N
%
Radical prostatectomy information
No. of men undergoing radical prostatectomy
6,988
306
Prostatectomy type
Robotic
6,494
93%
244
82%
Laparoscopic
211
3%
30
10%
Open
283
4%
25
8%
Total
6,988
100%
299
100%
Missing
0
7
Lymphadenectomy performed
No
5,502
79%
115
41%
Yes
1,486
21%
164
59%
Total
6,988
100%
279
100%
Missing
0
27
Radical radiotherapy information
No. of men undergoing radical radiotherapy
14,831
821
Radiotherapy modality
Intensity Modulated Radiation Therapy
13,759
93%
795
100%
3D conformal
1,072
7%
2
<1%
Total
14,831
100%
797
100%
Missing
0
24
Planned radiotherapy region
Prostate and/or seminal vesicles
12,015
83%
671
85%
Whole pelvis incl. lymph nodes
2,461
17%
120
15%
Total
14,476
100%
791
100%
Missing
355
30

26
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
3.3. NPCA performance indicators
3.3.1. For England and Wales
Disease status at presentation
Performance indicator 1: Proportion of men diagnosed with
metastatic disease (presented at the level of the SMDT).
The average proportion of men diagnosed with metastatic
disease in England and Wales is 13%, across 49 specialist
MDTs (ranging from 4% - 23%) (Figure 1). Variation in
the proportion of men diagnosed at a point at which they
are normally beyond curative treatment could potentially
indicate late diagnosis for some men. Although these results
are similar to last year’s, two data quality issues in the RCRD
mean that this indicator should be interpreted cautiously: a
high proportion of men have missing data on their metastatic
status; and some men referred to a tertiary centre had their
diagnosis allocated to the SMDT associated with that centre,
rather than their diagnosing centre.
Disease status: recommendations
R4. Seek advice from a doctor if any of the following new
symptoms are experienced: urinary symptoms, erectile
problems, blood in their urine or unexplained back pain, as
early diagnosis improves outcomes.
R5. Ensure that a family history of prostate, breast or ovarian
cancer is reported to a healthcare provider with a view to a
possible genetic counselling referral.
Figure 1. Unadjusted funnel plot for the proportion of patients with metastatic disease at diagnosis across
the specialist MDTs in England and Wales.
Diagnosis between 1st April 2019 and 31st March 2020
National percentage = 13.0%
0
10
20
30
40
50
60
70
80
90
100
0
250
500
750
1000
1250
1500
1750
Patients with metastatic disease (%)
English provider
Welsh provider
99.8% limit
National percentage
95% limit
Number of Patients
Footnote: This indicator should be interpreted with caution due to the amount of missing data on metastases in the RCRD, and as some men referred to a tertiary centre had their diagnosis allocated to the SMDT
associated with that centre, rather than their diagnosing centre

27
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Outcomes of treatment: short-term
Performance indicator 2: Proportion of patients who had an
emergency readmission within 90 days of radical prostate
cancer surgery (presented at the level of the surgery centre).
7,244 men underwent a radical prostatectomy at 50 surgical
centres between 1st April 2019 and 31st March 2020. The 90-day
emergency readmission rate following radical prostatectomy
was 13% (range 3 – 30%) (Figure 2).
Figure 2. 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.
Surgery between 1st April 2019 and 31st March 2020
National percentage = 13.4%
0
10
20
30
40
50
60
70
80
90
100
Readmissions within 90 days of surgery (%)
0
100
200
300
400
500
Number of Patients
English provider
Welsh provider
99.8% limit
National percentage
95% limit

28
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Outcomes of treatment: medium-term
Performance indicator 3: 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).
5,188 men underwent a radical prostatectomy at 52 surgical
centres during 2018. Overall 7% of men experienced at least
one treatment-related GU complication within two years
following surgery, with a range of 1 – 20% (Figure 3).
Figure 3. 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.
Surgery between 1st January 2018 and 31st December 2018
National percentage = 7.2%
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 provider
Welsh provider
99.8% limit
National percentage
95% limit

29
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Performance indicator 4: 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).
6,806 men received EBRT at 53 radiotherapy centres during
2018. Overall 11% (range 0 – 23%) experienced at least one
bowel complication within two years of radiotherapy
(Figure 4).
Figure 4. 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.
Surgery between 1st January 2018 and 31st December 2018
National percentage =10.9%
0
10
20
30
40
50
60
70
80
90
100
0
100
200
300
400
Gastrointestinal complication (%)
Number of Patients
English provider
Welsh provider
99.8% limit
National percentage
95% limit

30
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
These performance indicators show that the picture of
readmissions and complications is unchanged or improving
since last year’s report. The national average for 90-day
readmissions after radical prostatectomy (RP) is stable at 13%
(compared to 14% last year). The proportion of men
experiencing a treatment-related GU complication within two
years of surgery has improved somewhat from 9% in last
year’s report to 7% this year.
The proportion of men experiencing a treatment-related GI
complication within two years of radiotherapy remained
consistent with last year at 11%. The number of men found to
have undergone radiotherapy is far fewer than reported last
year (6,806 compared to 11,683 for 2017). This was due to the
use of the RCRD which identified men diagnosed since 1st
January 2018 and then found their matching records in the
HES database, so men included were both diagnosed and
treated in 2018. Few men diagnosed in the first six months of
2018 would also have begun radiotherapy in the first half of
that year, as men often go through other treatments first.
Despite this, the indicator for GI complications robustly
reports the complication rate, following up those for whom
we have a confirmed record of radiotherapy.
Although a formal outlier process has not been undertaken
this year, Centres with performance that is worse than the
national average for any of the indicators should review their
treatment pathway and engage with other providers to
understand any differences in care. The most recent NPCA
Quality Improvement workshop took place in December 2021
and we encourage all Clinical Leads and MDT members to
attend the next event.
Outcomes of treatment: recommendations
R6. Consider establishing radiotherapy centre specialist
gastrointestinal services to offer advice to people with bowel-
related side effects of radiotherapy.
- Identification of these side effects could be improved
with the initiation of hospital level PROMS
programmes.
R7. Ensure that men who are offered prostate cancer treatment
are made 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.
R8. Empower patients to ask to be referred to specialist support
services if they are experiencing physical or psychological side
effects during, or following, prostate cancer treatment.
- These should be offered early and on an ongoing basis,
in keeping with national recommendations.
R9. Make available sources of further information and support
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
3.3.2. For Wales only
Treatment allocation
Performance indicator 5: Proportion of men with low-risk
localised prostate cancer undergoing radical prostate cancer
therapy (presented at the level of the SMDT).
10% of men diagnosed with low-risk localised cancer
underwent radical prostate cancer therapy within 12 months
of diagnosis in Wales (range: 0% - 13%). In last year’s report
16% of Welsh men were found to be potentially “over-treated”,
which shows improvement. The average appears substantially
higher, however, than last year’s national average (for England
and Wales) of 5% but is only based on the 4 specialist MDTs
in Wales, and small numbers of potential “over-treatment”
events in each (Table 6).
Performance indicator 6: Proportion of men with high-risk/
locally advanced disease receiving radical prostate cancer
therapy (presented at the level of the SMDT).
60% of men diagnosed with high-risk/locally advanced
prostate cancer were found to have undergone some form of
radical therapy in Wales within 12 months of diagnosis (range:
40% - 74%). This appears very different from last year’s
national average figure (for England and Wales) of 71%, but
again is based on only the 4 specialist MDTs in Wales.
However, the figure for potential “under-treatment” in
high-risk/locally advanced men (at an average of 40% in
Wales by these results) is high and has increased since the 34%
found in Wales last year. This should give a focus to this issue
for Welsh providers, but may be relevant to many English
providers too. These men receive ADT only or a watch and
wait policy as opposed to ADT and radiotherapy to the
prostate. Three out of the four Health Boards reported here
have, both historically and this year, performed better than
the national average but the proportions have dropped and
could potentially improve for all (Table 6).

31
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Table 6. Provider level (specialist MDT) data for the performance indicators 5 and 6 in Wales only.
Provider name
No of patients
No of events
%
Performance Indicator 5: % low risk given radical treatment – average = 10.1%
Abertawe Bro Morgannwg University Health Board
50
5
10.9
Aneurin Bevan University Health Board
42
6
13.3
Betsi Cadwaladr University Health Board
18
0
0
Cardiff and Vale University Health Board
108
11
9.8
Performance Indicator 6: % high risk given radical treatment – average = 59.5%
Abertawe Bro Morgannwg University Health Board
305
117
39.9
Aneurin Bevan University Health Board
81
57
66.3
Betsi Cadwaladr University Health Board
217
159
71.8
Cardiff and Vale University Health Board
165
124
74.1
Performance indicator 5: Proportion of men with low-risk localised prostate cancer undergoing radical prostate cancer therapy.
Performance indicator 6: Proportion of men with locally advanced disease receiving radical prostate cancer therapy.
Treatment allocation: recommendations based
on Welsh data
R10. Continue to advocate active surveillance in the first
instance for men with low-risk prostate cancer.
R11. Investigate why men with high-risk/locally advanced
disease are not considered for radical treatment.
R12. Discuss with your clinical specialist the option of disease
monitoring with active surveillance in the first instance.
R13. Discuss with your clinical specialist the radical treatment
options available for men with high-risk/locally advanced
disease
Overall recommendations for England and
Wales
R14. Review of the NPCA indicators for providers should be
undertaken within the region and nationally, and fed through
to providers
- 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 Trusts and Health
Boards which should follow-up implementation progress.
R15. Ensure that radiotherapy and surgical treatment centres
are able to deliver a full range of treatments and support
services for patients.

32
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
The COVID-19 pandemic has had a profound impact on the
care provided to patients with cancer, with delays in diagnosis
and treatment due to the steps taken to mitigate transmission
of the virus, changes to the provision of services due to capacity
pressures and patients being reluctant to seek care.28,29,30,31,32
In this section we focus on the patterns of prostate cancer-
related activities and events during 2020 underpinned by
the analysis of RCRD linked to HES/RTDS/SACT/ONS data
for England only. We describe the activity of prostate cancer
services over time (from 1st January 2020 – 31st December
2020) including diagnosis and treatment, and compare this
with the ‘usual’ activity during 2019. Comparable data from
the same diagnostic and/or treatment periods were
unavailable for Wales.
Our paper reporting on the impact of the COVID-19
pandemic on the diagnosis and treatment of men with
prostate cancer during 2020 at a national level in England
will be published shortly. This section reports regional
variation in the patterns of diagnostic and treatment activity
(radical treatment and systemic anti-cancer treatments in
keeping with updated NICE guidance in 202033,34) over each
quarter of 2020 (Q1: January – March, Q2: April – June, Q3:
July – September and Q4: October – December) compared
with the same periods in 2019. Results at the regional and
cancer alliance level are provided in the COVID Impact
appendices on our website.
4.1. Data sources and completeness
For England, data from the RCRD was used to identify
prostate cancer diagnoses between 1st Jan 2019 and 31st
Dec 2020. These were linked to data from Hospital Episode
Statistics (HES), the Radiotherapy Dataset (RTDS) and the
Systemic Anti-Cancer Therapy dataset (SACT). As noted in
section 2, the RCRD captures approximately 90% of cancer
diagnoses that are seen in the full NCRAS dataset, with
relatively consistent completeness across trusts.
4. Impact of COVID-19
28 Gathani T, Clayton G, E M, Horgan K. The COVID-19 pandemic and impact on breast cancer diagnoses: what happened in England in the first half of 2020. British Journal of
Cancer 2020.
29 Greenwood E, Swanton C. Consequences of COVID-19 for cancer care — a CRUK perspective. Nature Reviews Clinical Oncology 2021; 18: 3-4.
30 Kuryba A, Boyle JM, Blake HA, Aggarwal A, Van Der Meulen J, Braun M, Walker K, Fearnhead NS. Surgical Treatment and Outcomes of Colorectal Cancer Patients During the
COVID-19 Pandemic: A National Population-based Study in England. Annals of Surgery Open. 2021 Jun 1;2(2):e071.
31 McCormack V, Aggarwal A. Early cancer diagnosis: reaching targets across whole populations amidst setbacks. British journal of cancer 2021.
32 Rutter M, Brookes M, Lee T, Rogers P, Sharp L. Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis.
Gut 2020.
33 NICE, 2020. NHS England interim treatment changes during the Covid-19 pandemic. NICE guideline [NG161], 2020 NICE Guideline [NG161], 2020. NHS England interim
treatment changes during the COVID-19 pandemic
34 NICE, 2020. COVID-19 rapid guideline: delivery of radiotherapy. NICE guideline [NG162], 2020 https://www.nice.org.uk/guidance/NG162

33
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
4.2. Methods
Data are presented at NHS region level for the seven
English regions and for the 21 cancer alliances. Each quarter
of the 2020 calendar year is compared to the same quarter
of 2019, with 2020 data presented as a percentage of 2019
for the seven English regions. Diagnoses are broken down
by stage, using RCRD disease stage. The number of radical
prostatectomy procedures undertaken is analysed, to assess
the extent and duration of disruption to surgery. Use of
radiotherapy is broken down into conventional/hypo-
fractionated, to assess whether any change in practice was
observed. Use of docetaxel and enzalutamide during 2020 is
analysed, to assess the effect of guidance to substitute
docetaxel with enzalutamide.35
The proportion of all hospital beds occupied by COVID
patients by region is shown in Figure 5.
Figure 5. The proportion of hospital beds (all) occupied by Covid-19 patients by region.
Information from the NHS England Covid-19 daily situation report published 13.05.21.
East of England
London
Midlands
North East and Yorks
NorthWest
South East
South West
0
10
20
30
% beds with Covid-19 patients
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
35 NICE, 2020. NHS England interim treatment changes during the Covid-19 pandemic. NICE guideline [NG161], 2020 NICE Guideline [NG161], 2020. NHS England interim
treatment changes during the COVID-19 pandemic

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Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Table 7. Patient and diagnostic characteristics for men newly diagnosed with prostate cancer in
England over the period of 1 January - 31 December in 2019 and 2020.
Data variable
2019
2020
N
%
N
%
No. of men with new diagnosis of prostate cancer
42,591
33,045
Age
<60
5,486
13%
3,945
12%
60-69
13,480
32%
10,332
31%
70-79
16,924
40%
13,454
41%
≥80
6,701
16%
5,314
16%
Total
42,591
100%
33,045
100%
Missing
0
0
Charlson score
0
34,206
80%
26,846
81%
1
3,926
9%
3,002
9%
≥2
4,459
11%
3,197
10%
Total
42,591
100%
33,045
100%
Missing
0
0
Biopsy performed
Trans-rectal biopsy
21,757
63%
10,779
43%
Trans-perineal biopsy
12,634
37%
14,496
57%
Total
34,391
100%
25,275
100%
Missing
8,200
7,770
Stage
I
11,358
36%
8,599
37%
II
5,078
16%
3,500
15%
III
9,545
30%
6,739
29%
IV
5,408
17%
4,518
19%
Total
31,389
100%
23,356
100%
Missing
11,202
9,689
4.3. Findings
Patient and diagnostic characteristics in 2019 vs 2020 are
summarised in Table 7.
Patient characteristics
The distribution of patient characteristics, including age,
Charlson score, deprivation and stage were all similar in 2020
compared to 2019. There was slightly more missing data for
stage in 2020 (Table 7).

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Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Diagnoses
Most biopsies performed in 2019 used the trans-rectal
ultrasound guided method (63%) but this changed in 2020 to
the majority being trans-perineal biopsies (57%). There was a
fifth of the data on biopsy method used missing in 2019 (19%)
and almost a quarter (24%) in 2020.
During the first ‘lockdown period’ in the UK (counted here
as covering Q2, April – June 2020), there was a 54% reduction
in the number of patients newly diagnosed with prostate
cancer compared with the same period in 2019 (Figure 6).
This varied by region from a 65% reduction in the number of
expected diagnoses in London, the region with the highest
proportion of hospital beds (both ICU and beds in general
wards) occupied by COVID patients during Q2 (Figure 5), to
a 41% reduction in the South West, the region with the lowest
hospital bed occupancy. Lockdown restrictions were lifted
in July 2020 and the number of men newly diagnosed with
prostate cancer increased over time during July – September
(Q3) and October – December 2020 (Q4) (Figure 6). Overall,
there was a 28% reduction (7,375 in 2020 vs 10,177 in 2019) in
the number of men diagnosed in Q3 (range across regions:
24% - 34%) and a 16% reduction (9,041 vs 10,805) in Q4 2020
(range: 12% - 28%) compared with the same time periods in
2019 (Figure 6).
Figure 6. The number of men newly diagnosed with prostate cancer in 2020 presented as a proportion of
the diagnoses per quarter in 2019 for each region in England.
From April – December there was a 33% reduction in the number of men newly diagnosed with prostate cancer (31,541 vs 21,260; 2019 vs
2020, respectively).
40
60
80
100
120
Percentage of 2019
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
East of England
London
Midlands
NE & Yorkshire
North West
South East
South West

36
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
A comparison of the number of men newly diagnosed
in 2020 and 2019 by cancer alliance is shown in Figure 7,
grouped by region and then ordered by 2019 numbers.
There was a substantial decline in the number of men
diagnosed with prostate cancer April – June 2020 (Q2) in
each cancer alliance. Diagnostic activity increased across all
cancer alliances during Q3 and Q4 2020 but did not reach
2019 levels in any alliance.
Figure 7. The number of men newly diagnosed with prostate cancer by Cancer Alliance in England.
2019 and 2020, quarters 2, 3 and 4
0
250
500
750
1000
1250
Somerset, Wilts, Avon & Gloucs
Peninsula
South West
Surrey and Sussex
Wessex
Thames Valley
Kent and Medway
South East
RM Partners
South East London
North Central London
North East London
London
East of England - South
East of England - North
East of England
West Midlands
East Midlands
Midlands
Greater Manchester
Cheshire and Merseyside
Lancashire and South Cumbria
North West
Northern
West Yorkshire and Harrogate
South Yorkshire and Bassetlaw
Humber, Coast and Vale
North East &
Yorkshire
Quarter 2 (April - June)
Quarter 3 (July - September)
Quarter 4 (October - December)
0
250
500
750
1000
1250
0
250
500
750
1000
1250
2020
Number of patients diagnosed
2019

37
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Since April 2020 (Q2), a higher proportion of men were
diagnosed with a more advanced stage of disease compared
with the same period in 2019 (Figure 8).
Figure 8. The distribution of prostate cancer diagnoses by cancer stage in England.
Percentage of patients
0
20
40
60
80
100
2019
2020
Jan-Mar
Apr-Jun
Jul-Aug
Sep-Dec
Jan-Mar
Apr-Jun
Jul-Aug
Sep-Dec
Stage I
Stage II
Stage III
Stage IV

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Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Surgery
There was a 48% reduction (898 in 2020 vs 1,734 in 2019) in
the number of men undergoing radical prostatectomy from
April – June 2020 (Q2) compared with 2019 which varied
by region (range: 25% – 67%; Figure 9). Surgical activity
increased during July – September 2020 (Q3) with only an
overall 5% reduction (1,603 vs 1,682) compared with 2019.
However, in two regions, there was an increase in the number
of radical prostatectomies performed in Q3 compared with
the same period in 2019 (Midlands, 271 vs 244; East of
England, 211 vs 147). During October – December 2020 (Q4),
there was a 25% reduction (1,297 vs 1,725) in surgical activity
compared with 2019 (range: 10% - 40%).
Figure 9. The number of men undergoing radical prostatectomy in 2020 presented as a proportion of
surgical activity per quarter in 2019 for each region in England
From April – December, there was a 26% reduction in the number of men undergoing radical prostatectomy (5,141 vs 3,798; 2019 vs 2020,
respectively).
40
60
80
100
120
140
Percentage of 2019
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
East of England
London
Midlands
NE & Yorkshire
North West
South East
South West

39
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
A comparison of the number of men undergoing radical
prostatectomy in 2020 and 2019 by cancer alliance is shown
in Figure 10. The number of surgical procedures performed
fell sharply in each cancer alliance during April – June 2020
(Q2), followed by increasing surgical activity across all
cancer alliances during Q3 and Q4 2020.
Figure 10. The number of men undergoing radical prostatectomy by cancer alliance in England.
2019 and 2020, quarters 2, 3 and 4
South West
South East
London
Midlands
North West
North East &
Yorkshire
Quarter 2 (April - June)
Quarter 3 (July - September)
Quarter 4 (October - December)
2020
Number of patients diagnosed
2019
0
100
200
Somerset, Wilts, Avon & Gloucs
Peninsula
Surrey and Sussex
Wessex
Thames Valley
Kent and Medway
RM Partners
South East London
North Central London
East of England - South
East of England - North
East of England
West Midlands
East Midlands
Greater Manchester
Cheshire and Merseyside
Lancashire and South Cumbria
Northern
West Yorkshire and Harrogate
South Yorkshire and Bassetlaw
Humber, Coast and Vale
0
100
200
0
100
200

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Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Radiotherapy
During April – June 2020 (Q2), 1,390 fewer men initiated
radical radiotherapy, a 45% reduction compared with 2019
(range: 37% - 57%; Figure 11) in keeping with guidance
published at the outset of the COVID-19 pandemic
advocating avoidance or deferral of EBRT.36 Overall, there
was a 23% increase in radiotherapy activity during July –
September 2020 (Q3) above 2019 levels (3,879 vs 3,162), which
ranged from 13% to 35% by region (Figure 11). Increasing use
of a hypofractionated regimen was evident across each region
compared with the same periods in 2020 reflecting guidance
for the safe maintenance of radiotherapy services without
reducing treatment effectiveness (Figure 12).27,37
In the final quarter of 2020 (October – December), there
was an overall 19% reduction in the number of men starting
radical radiotherapy (2,393 vs 2,934) compared with Q4
in 2019. A reduction in activity was observed in 6 out of 7
regions (range: 14% - 32%) with the exception of the South
East where activity increased 7% above Q4 levels in 2019
(Figure 11).
36 Zaorsky NG, James BY, McBride SM, Dess RT, Jackson WC, Mahal BA, Chen R, Choudhury A, Henry A, Syndikus I, Mitin T.)
Prostate cancer radiation therapy recommendations in response to COVID-19. Advances in radiation oncology. 2020 Nov 1;5:26-32.
37 NICE, 2020. COVID-19 rapid guideline: delivery of radiotherapy. NICE guideline [NG162], 2020 https://www.nice.org.uk/guidance/NG162
Figure 11. The number of men undergoing radical radiotherapy (EBRT) in 2020 presented as a proportion
of EBRT activity per quarter in 2019 for each region in England. From April – December,
From April – December, there was a 13% reduction in the number of men initiating radical radiotherapy (9,144 vs 7,930; 2019 vs 2020,
respectively).
East of England
London
Midlands
NE & Yorkshire
North West
South East
South West
40
60
80
100
120
140
Percentage of 2019
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec

41
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Figure 12. The number of men undergoing a) conventional or b) hypofractionated radiotherapy (EBRT) regimen in 2020 presented as a proportion of activity
per quarter in 2019 for each region in England.
Of the men undergoing radical radiotherapy during April-December there was an increase in the use of a hypofractionated regimen, 78% (7148/9109) in 2019 vs 85% (6595/7772) in 2020.
0
50
100
150
Percentage of 2019
Apr-Jun
Jul-Sep
Oct-Dec
Jan-Mar
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
a)
b)
East of England
NE & Yorkshire
North West
South East
South West
London
Midlands
Number of patients treated
0
50
100
150

42
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
A comparison of the number of men undergoing radical
radiotherapy in 2020 and 2019 by cancer alliance is shown
in Figure 13. There was a substantial decline in the number
of men initiating radical April – June 2020 (Q2) across
each cancer alliance. However, activity increased above the
levels in 2019 during Q3 for 19 out of the 21 cancer
alliances. By Q4, 6 out of the 21 cancer alliances
maintained an increase in activity.
Figure 13. The number of men undergoing radical radiotherapy by cancer alliance in England.
2019 and 2020, quarters 2, 3 and 4
Somerset, Wilts, Avon & Gloucs
Peninsula
South West
Surrey and Sussex
Wessex
Thames Valley
Kent and Medway
South East
RM Partners
South East London
North Central London
North East London
London
East of England - South
East of England - North
East of England
West Midlands
East Midlands
Midlands
Greater Manchester
Cheshire and Merseyside
Lancashire and South Cumbria
North West
Northern
West Yorkshire and Harrogate
South Yorkshire and Bassetlaw
Humber, Coast and Vale
North East &
Yorkshire
Quarter 2 (April - June)
Quarter 3 (July - September)
Quarter 4 (October - December)
2020
Number of patients diagnosed
2019
0
100
200
300
400
500
0
100
200
300
400
500
0
100
200
300
400
500

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Systemic treatments

There was a rapid and marked fall in docetaxel use from
April 2020 (Q2) across all regions and a concomitant
increase in the use of enzalutamide, which varied by region
(Figure 14). Overall, from April – December, there was a 74%
reduction in the number of men with hormone-sensitive
metastatic disease receiving docetaxel (377 in 2020 vs 1458
in 2019). During the same time period, there was a marked
increase in the number of men receiving enzalutamide
(1011 in 2020 vs 3 in 2019). These results reflect the rapid
NICE guidance published in April 2020 on systemic anti-
cancer therapy recommending using enzalutamide (or
abiraterone) as an alternative to docetaxel in men with
newly-presenting hormone-sensitive prostate cancer, given
that these treatments are less immunosuppressive and can be
administered at home.38
38 NICE, 2020. NHS England interim treatment changes during the Covid-19 pandemic. NICE guideline [NG161], 2020 NICE Guideline [NG161], 2020. NHS England interim treatment changes during the COVID-19 pandemic
Figure 14. The number of men with hormone-sensitive metastatic prostate cancer receiving a) docetaxel or b) enzalutamide in 2020 per quarter in 2019 for
each region in England.
From April – December, there was a 74% reduction in the number of men with hormone-sensitive metastatic disease receiving docetaxel (1458 vs 377; 2019 vs 2020, respectively). During the same time period,
there was a marked increase in the number of men receiving enzalutamide (3 vs 1011; 2019 vs 2020, respectively)
East of England
London
Midlands
NE & Yorkshire
North West
South East
South West
Number of patients
0
25
50
75
100
125
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
Number of patients treated
0
25
50
75
100
125
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
a)
b)

44
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Overall recommendations on the basis of
English data
CR1. Review the diagnostic and treatment activity for your
region during 2020 illustrating how your service responded
during this time and to support decision making in response to
current changes in demand.
CR2. Monitor adherence to the recommended diagnostic
pathway for suspected prostate cancer.
CR3. Continue to increase the use of hypofractionated
radiotherapy.
CR4. Offer enzalutamide (or apalutamide) with androgen
deprivation therapy (or abiraterone for patients intolerant of
enzalutamide) to people with newly diagnosed metastatic
disease instead of docetaxel, where appropriate.

45
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5. Discussion
For the performance indicators in this NPCA annual report,
the data cover a period before the start of the COVID-19
pandemic, but they were collected and collated during that
very challenging time. Despite this, the information specialists
at NCRAS in England were able to provide the NPCA with a
rapidly produced, proxy cancer registration dataset (RCRD)
and those at the Wales Cancer Network were able to pull
together the same dataset as in previous years. Thanks to the
RCRD, the NPCA is also able to provide a picture of how
services were impacted during 2020 as the first and second
phases of the pandemic continued.
An awareness of the potential limitations of the RCRD led us
to carry out investigations into how this method of data
gathering compared to the standard NPCA data (for a time
period where both were available). We were reassured to find
that around 90% of diagnoses were captured, a figure which
was roughly consistent across Trusts (ranging from 80-100%
complete). There were more missing data in the individual M
stage variable used for measuring the proportion of men
diagnosed with metastatic disease and it emerged that some
men referred to a tertiary centre had their diagnosis allocated
to the SMDT associated with that centre, rather than their
diagnosing centre; thus this indicator should be interpreted
with caution. Unfortunately, the usual cancer characteristics
and variables collected by the NPCA for annual reporting
(Gleason and PSA scores) were not available in the English
data, meaning that we were unable to carry out the usual risk
stratification. Instead, we have used the disease stage variable
provided in the RCRD which is based on TNM status alone.
This is not ideal as it is not a measure used clinically and the
completeness of it does vary between providers, with an
average of 25% of these data missing. In previous years, the
NCRAS team has been able to supplement the data captured
at Trusts through time-consuming liaison with hospital teams,
and examination of imaging data and other datasets not
routinely shared with the NPCA, in order to provide the audit
with a highly complete set of T, N and M values. Given data
were collected pre-pandemic, improvements need to be made
at Trust level to increase the completeness of routine data.
This would benefit clinical practice and reduce the data
validation required.
The lack of certain key items has also meant that several of
our usual indicators could not be robustly estimated and so
are missing from this report. However, this means that the
indicators reported were chosen because we are confident
that they are underpinned by robust data and could be
adjusted for case mix where appropriate. The similarity of
many of the indicators’ results to previous years provides
further reassurance and, although we did not carry out a
formal outlier process (as the data were not fully validated),
many of the same providers fell outside the funnel limits as
had previously.
The data collected by clinical teams are obviously a vital
part of clinical practice, but it also continues to be
extremely valuable, both for examination of practice and for
this opportunity for national benchmarking and
comparison. We encourage all providers to examine their
own results, with the caveats noted above in mind, and to
look for ways to improve their performance – even in those
centres who already do well.
The next annual report will face further challenges as data
were collected during the COVID-19 pandemic. The agility of
teams in responding to the changing circumstances is
laudable but we acknowledge that data collection may have
been reduced. Preliminary examination of the data covering
2020 shows that services were impacted, including reduced
diagnoses and treatments. Providers may have to prepare, in
future practice, to see men diagnosed at later stages and
potentially with higher disease-risk profiles which may impact
the outcomes of patients in the future.
The COVID recovery period has been outlined in the NHS
England Cancer Recovery Taskforce: Cancer Services
Recovery Plan, 2020 and identifies three stages to cancer
services recovery39. Phase 1 is to ensure continuation of
essential cancer treatment and screening for high risk
individuals during the initial peak of the pandemic. Phase 2 is
to restore disrupted services as far as possible to at least
pre-pandemic levels and Phase 3 is full recovery of NHS
cancer services in England, including ensuring that care for all
patient groups continues to be safe, effective and holistic.
We will continue to provide robust reporting to help inform
the prostate cancer care community. Wales has been leading
the way in continuing to provide clinician-approved data
and England is pushing forward with rapid registration
data, and thus we aim to report more rapidly as these new
datasets become the norm. We also continue to encourage
each provider to engage firstly with their own data, and
then with other providers, for instance at our Quality
Improvement events, where we can share best practice and
meet challenges together.
39 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/12/C0821-COVID-19-Cancer-services-recovery-plan-14-December-2020.pdf

46
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6. Future Plans for the NPCA
The NPCA in England no longer collects bespoke data items
within the NPCA minimum dataset. For men diagnosed from
the 1st April 2019 COSD data items have only been collected
in keeping with the monthly routine submission of data to
the NCRAS, PHE. Circumstances have meant, however,
that we have shifted to a new data source, the Rapid Cancer
Registration Dataset. This opens new possibilities for more
timely reporting, although it has the disadvantage that some
data items are currently not available.
Working with our data collection partners we were able
to access the RCRD more rapidly, enabling the NPCA to
determine the impact of COVID-19 in a more timely manner.
We were able to examine the influence on the diagnosis and
treatment of men with prostate cancer, including treatment
delay, the potential receipt of sub-optimal treatment and
how diagnosis and treatment varies by region. 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.
Our regular organisational survey, although it was delayed
until this year, went out to providers in order to provide up
to date information about service availability across the
country. Data were gathered in 2021 and will be published
early in 2022.
We were unable to publish data in England as part of the
Clinical Outcomes Programme (COP) and the National
Clinical Audit Benchmarking (NCAB) this year, but plan to
do so again in future years. This enables wider
dissemination of our findings to clinicians, stakeholders,
patients and the public.
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. In this way, the audit will be able to report using
the most accurate data.
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. In future, the NPCA will recommence using 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.

47
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Acronym list
ADT
Androgen Deprivation Therapy
BAUS
British Association of Urological Surgeons
BUG
British Uro-Oncology Group
CaNISC
Cancer Network Information System Cymru
COSD
Cancer Outcomes and Services Dataset
CEU
Clinical Effectiveness Unit
CNS
Clinical Nurse Specialist
COP
Clinical Outcomes Programme
CRG
Clinical Reference Group
EBRT
External Beam Radiation Therapy
GI
Gastrointestinal
GP
General Practitioner
GU
Genitourinary
HQIP
Healthcare Quality Improvement Partnership
HES
Hospital Episode Statistics
IMRT
Intensity Modulated Radiation Therapy
ICD
International Classification of Disease
MRI
Magnetic Resonance Imaging
MDT
Multi-Disciplinary Team
NCRAS
National Cancer Registration and Analysis Service
NCAPOP
National Clinical Audit and Patient Outcomes Programme
NCAB
National Clinical Audit Benchmarking
NHS
National Health Service
NICE
National Institute for Health and Care Excellence
NPCA
National Prostate Cancer Audit
RTDS
National Radiotherapy Data Set
ONS
Office for National Statistics
OPCS
Office of Population Censuses and Surveys
PEDW
Patient Episode Database for Wales
PPI
Patient and Public Involvement
PSA
Prostate Specific Antigen
PHE
Public Health England
RP
Radical Prostatectomy
RCS
Royal College of Surgeons
SMDT
Specialist Multidisciplinary Team
IMD
The Index of Multiple Deprivation
TNM
Tumour, Nodes, Metastases
WCN
Wales Cancer Network
WCISU
Welsh Cancer Intelligence and Surveillance Unit

48
Copyright © 2022 Healthcare Quality Improvement Partnership (HQIP)
Active Surveillance
The initial monitoring of prostate cancer with low risk clinical
characteristics.
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 external beam 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.
Cancer Network Information System Cymru
(CaNISC)
An online computer system that provides information for
health professionals on cancer patients across Wales.
Glossary
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 levels
commensurate with castration.
Charlson Co-morbidity Score
A scoring system used commonly to quantify the co-existence
of other medical conditions (medical co-morbidities: see
below). Many patients may other medical conditions 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)
An experienced senior nurse who has undergone
specialist training and plays an essential role in improving
communication and coordinating treatment in cancer patients.
Specialist nurses 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.
Co-morbidity
Medical condition(s) or disease process(es) that are
additional to the disease under investigation (in this case,
prostate cancer).

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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.
Gleason Score
The Gleason score is a measure assigned by a pathologist to
determine how aggressive an individual’s prostate cancer is
when the prostate cancer tissue is examined using a
microscope. It is made up of two separate scores between 3
and 5 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 used for risk
stratification, i.e. to help to predict how a specific cancer
might progress and/or respond to treatment.
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.
Hypofractionated radiotherapy
Patients undergoing radiotherapy receive one treatment
(known as a fraction) with each hospital visit.
Hypofractionated radiotherapy is where the total dose of
radiation is divided into larger doses (per treatment session)
over a shorter period of time. In prostate cancer treatment,
conventional radiotherapy involves 37 treatment sessions
over seven or eight weeks compared with hypofractionated
radiotherapy which involves 20 treatment sessions over four
weeks. Having fewer treatment sessions over four weeks
has been found to work just as well for men with localised
prostate cancer as having more sessions over a longer time.
The risk of side effects is also similar and as it involves fewer
hospital visits, men may find a shorter course of radiotherapy
more convenient.
Intensity-modulated Radiotherapy (IMRT)
Conformal radiotherapy shapes the radiation beam to closely
fit the area of the cancer in order to avoid healthy tissue. A type
of conformal radiotherapy with highly shaped and focussed
beams of X Rays enabling higher doses of radiotherapy
to be given to the prostate gland with reduced dose to the
surrounding normal structures (bladder and bowel).
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.
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.
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).
/Glossary continued

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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 Registration and Analytical
Service (NCRAS)
A national body which collects, analyses and reports on
cancer data for the NHS population in England.
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
Potentially curative 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.
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” operation is one which uses laparoscopy (the
insertion of a telescope and small instruments into the
abdomen) as opposed to a conventional “open” operation
involving a larger incision. A laparoscopic operation is
commonly associated with the use of a robotic device which
is controlled from a separate console by a surgeon, who
carries out removal of the prostate. The robotic device
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.
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.
/Glossary continued

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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 lymph node involvement and “M” represents the
presence of metastatic disease.
T1 means the cancer is too small to be seen on a scan40, T2
means the cancer is completely inside the prostate gland, T3
means the cancer has broken through the capsule (covering)
of the prostate gland and T4 means the cancer has spread
into other body organs nearby, such as the back passage,
bladder, or the pelvic wall. N0 means that the nearby lymph
nodes do not contain cancer cells and N1 means there are
cancer cells in lymph nodes near the prostate. M0 means the
cancer has not spread to other parts of the body and M1
means the cancer has spread to other parts of the body
outside the pelvis.
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.
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 access some areas of the prostate more easily than
trans-rectal ultrasound biopsies, particularly those 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.
‘Usual’ / standard dataset
This is the dataset that has been historically provided by our
data partners and reported in previous Annual Reports (e.g.
in the 2020 annual report, which can be found at https://www.
npca.org.uk).
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.
40 https://www.cancerresearchuk.org/about-cancer/prostate-cancer/stages/tnm-staging
/Glossary continued