Assessing the delivery of hormone therapy

Luteinizing hormone releasing hormone agonists (LHRHAs) have been fundamental to the non-surgical treatment of prostate cancer since their ability to improve survival was demonstrated four decades ago. Subsequent studies have shown the importance of optimal suppression of testosterone, and are a pre requisite to using the systemic anticancer therapy we give as Prostate cancer specialists in hospital.  In the NHS a model of initiation in secondary care with subsequent treatment in primary care has evolved, with each commissioned and funded separately. With effective communication, professionalism and the hard work of HCPs in both settings this model has delivered appropriate treatment to the majority of patients. Unfortunately, however there have been examples where it has failed, and subjectively this seems to be more common in patients less able to advocate for themselves.

A retrospective cohort study of patients published this month shows substantial delays in administration occurring with this model. (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0315208). The CPRD, HES and ONS databases were used to study 32,777 men with prostate cancer who had LHRHA initiated prior to the COVID pandemic in England, with a mean follow up of 4.5 years.

Dosing delays were seen in all the formulations (1,3 and 6 monthly), with delays of 4 weeks or more seen in 39.6-46.6% of patients at least once in their treatment. The Percentage of Days Covered (PDC) was calculated to give a single metric of delayed administration, and was 90-91% across the 3 different formulations.  Between 10.1 to 16% of patients had less than 80% of the intended days of treatment delivered, suggesting a disproportionate effect of delays on a minority of patients.  The Kaplan Meier graph for overall survival showed a trend in favour of those with 100% PDC compared with less effective coverage, although it is important to note that confounding factors may be contributing to the pattern seen. The prevalence of black or black British patients in the study population (0.40%) was nearly twice that expected from ONS data, consistent with patterns seen in other studies.

Less than 6% of patients had a testosterone check in primary care recorded in the CPRD data base. It is presumed that a greater proportion were having testosterone levels checked by their hospital based specialists given the association with survival.

Approximately 70% of the patients who died in the study group did so from prostate cancer according to their death certificates, compared with approximately 9% from Cardio- and Cerebro-vascular disease. While this re-enforces the need to reduce the risk from these conditions, it also indicates that the main threat to our patients’ lives is their prostate cancer. Efforts to improve the efficacy of our cancer treatments are therefore likely to have a greater overall impact than those directed at reducing mortality from other causes, although clearly, we should be doing both.

Those of us overseeing LHRHA treatments for prostate cancer should consider what we can do to improve the delivery of these treatments. Improving coverage for all patients under our care should be a priority for those clinicians with specialist knowledge, irrespective of their place of work. Decentralised administration should remain the standard of care, however systems for assurance of administration with testosterone checks should be considered. Monitoring and treatment of Bone, Cerebo- and Cardio- vascular risk should continue and the expertise of General Practice needs to be recognised in these areas. Increasing resources for LHRHA treatment for prostate cancer with the intent to improve patients lives, also has the potential to reduce NHS costs on complex systemic therapy required when these treatments fail.  Given the financial and workforce crisis facing both primary and secondary care, those commissioning treatment for prostate cancer should consider where finite NHS resources should be used for the greatest benefit to our patients.

(The opinions expressed are solely the author’s, rather than representing the views of any affiliated organisation)