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Prostate cancer care after the COVID pandemic

How has COVID-19 affected treatment for the most common cancer in men

This November, will be a particularly poignant Men’s Health Month, coming at the tail end of a pandemic which has severely strained the health service. In particular, causing huge backlog in referrals which is having a impact on prostate cancer in the UK.

Over 49,000 men in England were diagnosed with prostate cancer in 2018, making it the most commonly diagnosed cancer. However, the pandemic has made it more difficult for men to approach their GPs over the last year. As a result, 8,600 fewer men in England started treatment for prostate cancer in 2020 than in the previous year. This pattern is expected to be reflected across the UK once data is released. Some regions have been affected more than others, with the North East, Midlands and London seeing a greater drop in referrals compared to other parts of the country.

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‘During the pandemic, there was a huge drop in referrals of men into oncology, so the data shows that there were around 55,000 fewer referrals for prostate cancer compared to the previous year. We also know that during that period, there were 12,000 fewer men receiving treatment for prostate cancer,’ says Prostate Cancer Specialist Nurse Meg Burgess.

‘This has now plateaued but those referrals which were missing at the start of the pandemic are potentially men that are missing from the system. Because men weren’t able to easily see their GP, they chose to stay away from their surgery, were not having those conversations about prostate cancer, having a PSA test, and they were not seeing GPs about the minor urinary symptoms that may have led to these conversations. So we saw a drop in referrals and a drop in treatment and that hasn’t recovered.’

The factors behind the backlog are not just a lack of capacity in the NHS. Many patients are hesitant to access services as a result of the pandemic. Research by NHS England into cancer appointments found that 48% of the public would delay or not seek medical help at all if they noticed a sign or symptom that they would otherwise have checked. A further 22% would not want to be a burden on the health service while a similar number said that fear of getting COVID or passing it onto others was a major reason for not getting help. More than four in ten people would leave it longer to get health advice than they normally would have before the coronavirus outbreak. But delaying can have serious consequences for some cancers.

‘Initially our specialist nurses had a huge spike in calls from men, anxious about their risk of getting coronavirus, and if their treatment for prostate cancer made them more vulnerable, but for most men, their cancer and their treatment didn’t make them more vulnerable,’ says Ms Burgess.

The early stages of prostate cancer don’t usually cause any symptoms. Some men might notice changes in urination– greater frequency or hesitancy– and get an early diagnosis, while others might not have any signs until the cancer has spread. This means that an early diagnosis makes an enormous difference, something that has happened less frequently as fewer routine health checks were performed during the pandemic.

When the cancer is still in the early stages and hasn’t grown outside the prostate, treatments like surgery or radiotherapy are very effective. However, once the cancer spreads to other regions of the body, it can be incurable.

‘Prostate cancer is the most commonly diagnosed cancer in the UK, but until these missing men are found and referrals begin to rise, many more men could be diagnosed when it is too late for them to be cured,’ says Angela Culhane, Chief Executive at Prostate Cancer UK.

‘Detecting cancer earlier helps save lives, but sadly prostate cancer doesn’t have a screening programme, and most men with early prostate cancer don’t have any symptoms. That’s why we want men to be informed about their risk, which is higher if you are over 50, black or if your father or brother had the disease.’

Positives of the pandemic

One silver lining from the pandemic many be the opening up of new treatment pathways. Hormone therapies offer men with advanced prostate cancer similar life-extending benefits. Apalutamide is a type of hormone treatment that will now be offered to men with advanced prostate cancer who cannot or should not receive chemotherapy. It is unable to cure prostate cancer, but it can help keep it under control and has been shown to help some men live longer.

‘One of the positives of the changes in the treatment pathway since the start of the pandemic has been the approval of new hormone therapies as an alternative to chemotherapy for newly diagnosed men with advanced disease. That helps to reduce risk from COVID-19. We had the evidence for some time that those new hormone therapies were a good alternative but they have now become a standard of care as a result of the pandemic,’ says Ms Burgess.

‘The pandemic sped up this approval process. We were campaigning to be approved before the pandemic but enzalutamide was approved very quickly at the beginning of the pandemic, followed by apalutamide. So that was sped up and made into a standard of care. That would have happened anyway, but it has happened a lot more quickly.’

According to Prostate Cancer UK, apalutamide will also be available as an option to men who have become resistant to traditional hormone therapies and are at high risk of their prostate cancer spreading. These men are set to gain an additional average 14 months of life and can choose between apalutamide and another recently approved treatment called darolutamide.

‘The impact on treatment has been that there were initially delays and for most prostate cancers, they are slow growing, so that didn’t have an impact in long term outcomes for most men, but obviously caused huge anxiety. Where there were delays, many men were able to use hormone therapies if they had a high risk cancer. These could be used to delay treatment,

Until this year, men with advanced prostate cancer could have either docetaxel chemotherapy or traditional hormone therapy. Many men were not able to tolerate docetaxel chemotherapy due to the side effects. This included more than three-quarters of men aged 70 and over, making it essential for them to be offered an alternative treatment. This approval gives men a choice between apalutamide and enzalutamide.

‘This decision is great news, which will give thousands of men with prostate cancer more time with their families. This is the second new prostate cancer treatment for advanced disease to be approved in just a few months, giving men more options,’ says Karen Stalbow, Head of Policy at Prostate Cancer UK.

‘This is particularly important for those men with advanced cancer who aren’t able to have existing treatments, which is why we’re so pleased that NICE listened to our calls to consider this large group of men who would otherwise have missed out.’

As one of the most common cancers, many men are at increased risk in the near future. As part of Men’s Health month, it is important to recognise the physical and mental burden of prostate cancer, particularly in the aftermath of the pandemic.

‘The pandemic has had a big impact on and it is still having an impact,’ concluded Ms Burgess. However, with the possibility of new treatments emerging, as the pandemic trails off, there may be a silver lining for the UK’s men.