1: Radiofrequency water vapour thermal energy: a potential new treatment for benign prostate hyperplasia

A multi-centre American trial has just reported the three-year outcomes of a new, minimally invasive treatment for benign prostate hyperplasia (BPH). This new procedure utilises convective radiofrequency (RF) water vapour thermal therapy, causing cell death without dessication, and has the advantages of a shorter heating time and lower required temperatures than conductive heat transfer methods.

197 men over the age of 50, with an international prostate symptom score (IPSS) equal to or over 13, a prostate volume of 30cc to 80cc, a maximum flow rate of less than 15 ml/s and a measured post-void residual urine volume of over 250ml were included in the study. Men with a PSA above 2.5ng/ml with a free PSA above 25% were excluded from study.

The men were randomly assigned 2:1 to thermal therapy (n=136) or a sham or control procedure with rigid cystoscopy (n=61), and were required to discontinue any BPH medication before treatment. A double-blind method was maintained for three months’ comparison of the RF and control treatments, after which 53 of the 61 patients undergoing the control procedure opted for the RF treatment. Data was subsequently compared to patient-reported baseline values.

At the 3 month treatment follow-up period, IPSS was significantly improved in the RF-treated patients compared to the control group (p<0.0001), and the early response of a 50% improvement in IPSS was consistently sustained at this level throughout the three years of follow-up. Similarly, there were corresponding and durable improvements in urinary flow rate, quality of life and incontinence compared to baseline results (p<0.0001), although the increased urinary flow of >50% from three-to-24 months reduced to a reported 39% improvement at the 36-month follow up.

Sexual function was preserved in patients, with erectile function improved in 16% of sexually active patients at the 36-month follow up point. Reported adverse events were infrequent and of short duration: the most commonly reported event was dysuria (16.9%), haematuria (11.8%), frequency and urgency (5.9%), acute urinary retention (3.7%) and suspected urinary tract infection (3.7%). All were treated routinely or resolved without treatment within three weeks. Surgical retreatment was at 4.4% over the three-year follow-up period and primarily related to the failure to initially treat the median lobe in four (3%) of the 135 patients.

Analysis by the study group showed RF to be more cost-effective than TURP, and another advantage of the treatment is that it doesn’t require inpatient hospitalisation. However, the retreatment rate and longer-term efficacy of RF treatment will have to be compared to other BPH surgical treatments before it could be suggested as a first-line therapeutic option for men.

2: Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit

This month also saw the release of the latest National Cancer Diagnosis Audit (NCDA), based on data collected in 2014 from 17,042 patients who had received a new diagnosis of cancer, and was a follow-up of the first audit performed in 2010. The aim of the NCDA is to generate a detailed understanding of the diagnostic process for cancer in primary care for patients, providing a baseline against which to audit future interventions, such as the revised 2015 National Institute of Clinical Excellence (NICE) guidance for the recognition and referral of patients with suspected cancer.

All patients with new cancer diagnoses (with the exception of non-melanoma skin cancer) were invited to participate in the audit. Once registered, patients’ GPs and other healthcare professionals could enter primary care data on the patient’s characteristics, place of presentation and symptoms presented, primary care-led investigations, the number of pre-referral consultations and whether any diagnostic delays have been incurred.

439 practices submitted data on 17,042 patients, representing approximately 5% of all British practices. Of these patients, 50% were male, the median age was 69 years, and the most numerous cancer sites were female breast (16%), lung (13%), prostate (13%) and colon/rectal cancer (12%). Most patients were white (95%) and native English speakers (95%). 24% of patients had no recorded comorbidities before diagnosis, whilst 21% had three or more. The most commonly reported comorbidities were hypertension (38%), cardiovascular disease (21%) and arthritis/musculoskeletal disease (18%). Patients included in the audit were representative of the 2014 national incidence cohort of age, sex and cancer site. However, there were relatively fewer participating practices from the least and most deprived quintiles.

65% of patients with suspected prostate cancer were diagnosed as a result of the two-week wait system (TWW), which was the highest score for all cancers included in the analysis. Overall, 51.8% of patients were diagnosed through the TWW. However, the median primary care interval (the number of days from first presentation of relevant symptoms to date of first referral from primary care; PCI) and diagnostic interval (number of days from first presentation to diagnosis; DI) show that patients with suspected prostate cancer had to wait longer for referral and diagnosis than the reported median for all cancers. The PCI and DI for prostate cancer were recorded as 11 and 55.5 days, compared to the all-cancer PCI and DI of five and 40 days, respectively.

In terms of DI, prostate cancer outperformed only suspected cancers of the bladder (56 days), and kidneys (66 days). However, this could potentially be explained by the fact that prostate cancer patients generally received the greatest number of primary care-led investigations before referral (76% of patients, compared to 45% for all-cancer), including urine and blood tests.

Overall, GPs reported avoidable delays for approximately one in every 5 patients (22%). These delays were most frequently attributed to the patient (26%), the primary/secondary care clinician (28%) and system factors (34%). Specifically, GPs concluded that 22% of prostate cancer patients received unavoidable delays in their diagnosis, although this wasn’t further broken down into whether this was patient or healthcare-orientated.

Importantly, the audit has also shown that there has been a 71% increase in the number of TWW referrals in the five-year period from 2009/2010 to 2014/2015, although the proportion of those receiving a diagnosis decreased from 10.8% to 8.2%.

In summary, the current NCDA audit has provided a current snapshot of the cancer diagnostic pathway, which will provide a useful baseline against which to measure any medical interventions. It also provides pointers to where implementation efforts might best be directed in the future, for example in achieving the 28-day standard from referral to diagnosis.

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