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Recommendations for Urological Cancers Issued by NICE
Clinical Oncology (2003) 15: 55–56 doi:10.1053/clon.2003.0209
Editorial Recommendations for Urological Cancers Issued by NICE D. M. A. Wallace The Queen Elizabeth Hospital, Edgbaston, Birmingham, U.K.
Although the NICE guidance for urological cancers has only recently been issued it was widely circulated in draft form some 10 months before release. Urologists and oncologists have had time to read and debate the major issues and are already likely to have started to change practice. Urologists have expressed many anxieties about regulation of their surgical activity and provision of the resources for the inevitable centralization that is going to occur. This centralization will be given considerable impetus as a result of this document, but also as a result of many other pressures such as junior staff hours, that are making the smaller units simply not viable options for performing major cancer surgery. The effect of the increase in the number of consultant urologists and trainees in recent years, with the consequent inevitable dilution of urological cancer surgery has been recognized for several years. Five years ago the British Association of Urological Surgeons (BAUS) Section of Oncology was formed which today has a membership of over 300. The formation of this section was in recognition of the fact that sub-specialization was inevitably going to occur and that urologist should be playing a leading role in the re-organization of urological cancer services. The section has collected data on new urological cancer cases since it started. Although this database misses a proportion of cases, the analyses of the 26 746 new urological tumours presenting in 2001 gives an invaluable picture of practice today. We do have evidence of increasing sub-specialisation with a very wide spread of cases seen per year (median 135 new tumours per centre, range 3–757) [1]. We also have evidence of the wide spread of numbers per urologist for prostate, bladder and kidney cancer (median 27, 15 and 3 and range 0–155, 0–66 and 0–26 respectively). The key recommendation in the guidance that has caused most debate in urology naturally concerns the provision of surgery for prostate and bladder cancer in centres doing more than 50 radical operations per year. While this may be causing fierce debate in urological cancer networks and in healthcare planning, it is the second sentence in this key recommendation that may already be having a profound effect. This is the recommendation that surgeons carrying out five or fewer such operations should now make arrangements to pass these cases on to more specialized colleagues. It is likely that 0936–6555/03/020055+02 $30.00/0
this is already resulting in a major shift of work. In our own unit in a cancer centre we have seen tertiary referrals for urological cancer cases more than double in the last 12 months since the release of the draft Guidance document. The five or less rule, as it may come to be known, may have wide-ranging effect. Further evidence in support of this was published after the NICE guidance was completed [2]. The majority of urologists are likely to support this although it leaves us with some issues to address such as the newly appointed consultant. If this rule is widely accepted for radical cystectomy and prostatectomy why should it not apply to all major cancer surgery and indeed all major surgery, and why was radical nephrectomy not included? The numbers of radical nephrectomies being performed on average has been falling with the expansion of urologists, but urologists must all maintain some expertise in open renal surgery if they are to remain on call for urological trauma. For renal cancer the recommendations for referral of the complex cases to centres is timely and welcome and compensates for radical nephrectomy not being included in the five and 50 cases rules. Urologists will feel that they particularly have been targeted to change practice with these threshold levels. What about the oncologists? Should they also have threshold numbers for treating complex urological cancers? This should come naturally with the development of multidisciplinary team meetings and discussion of all cases. Whilst all units would like to have the resources to provide multidisciplinary review of all cases, in many units this is still not possible due to lack of staff and pressure of work. It is not unreasonable for us to provide some sort of review of all new cases, even if it is just to ensure that they are being treated according to protocol such as for new pTa G1–2 tumours of the bladder which need very little discussion. However, it is treatment failures and progression that often need the full input of the multidisciplinary team and most time for discussion. Will this Guidance document improve the care of urological cancer patients? Undoubtedly it will but it is also likely to cause one of the biggest changes in urological practice for the last two decades. The changes in work that are going to occur must be fully planned
2003 Published by Elsevier Science Ltd on behalf of The College of Radiologists
56
and resourced if patient care is not going to suffer. This is the area where the guidance is weakest and the challenge for all involved will be greatest. References 1 The British Association of Urological Surgeons Section of Oncology. Analysis of Minimum Data Set for Urological Cancers 1 January 2001–31 December 2001. London, U.K.: BAUS.
2 Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346:1128–1137.
Editorial Recommendations for Urological Cancers Issued by NICE D. M. A. Wallace The Queen Elizabeth Hospital, Edgbaston, Birmingham, U.K.
Although the NICE guidance for urological cancers has only recently been issued it was widely circulated in draft form some 10 months before release. Urologists and oncologists have had time to read and debate the major issues and are already likely to have started to change practice. Urologists have expressed many anxieties about regulation of their surgical activity and provision of the resources for the inevitable centralization that is going to occur. This centralization will be given considerable impetus as a result of this document, but also as a result of many other pressures such as junior staff hours, that are making the smaller units simply not viable options for performing major cancer surgery. The effect of the increase in the number of consultant urologists and trainees in recent years, with the consequent inevitable dilution of urological cancer surgery has been recognized for several years. Five years ago the British Association of Urological Surgeons (BAUS) Section of Oncology was formed which today has a membership of over 300. The formation of this section was in recognition of the fact that sub-specialization was inevitably going to occur and that urologist should be playing a leading role in the re-organization of urological cancer services. The section has collected data on new urological cancer cases since it started. Although this database misses a proportion of cases, the analyses of the 26 746 new urological tumours presenting in 2001 gives an invaluable picture of practice today. We do have evidence of increasing sub-specialisation with a very wide spread of cases seen per year (median 135 new tumours per centre, range 3–757) [1]. We also have evidence of the wide spread of numbers per urologist for prostate, bladder and kidney cancer (median 27, 15 and 3 and range 0–155, 0–66 and 0–26 respectively). The key recommendation in the guidance that has caused most debate in urology naturally concerns the provision of surgery for prostate and bladder cancer in centres doing more than 50 radical operations per year. While this may be causing fierce debate in urological cancer networks and in healthcare planning, it is the second sentence in this key recommendation that may already be having a profound effect. This is the recommendation that surgeons carrying out five or fewer such operations should now make arrangements to pass these cases on to more specialized colleagues. It is likely that 0936–6555/03/020055+02 $30.00/0
this is already resulting in a major shift of work. In our own unit in a cancer centre we have seen tertiary referrals for urological cancer cases more than double in the last 12 months since the release of the draft Guidance document. The five or less rule, as it may come to be known, may have wide-ranging effect. Further evidence in support of this was published after the NICE guidance was completed [2]. The majority of urologists are likely to support this although it leaves us with some issues to address such as the newly appointed consultant. If this rule is widely accepted for radical cystectomy and prostatectomy why should it not apply to all major cancer surgery and indeed all major surgery, and why was radical nephrectomy not included? The numbers of radical nephrectomies being performed on average has been falling with the expansion of urologists, but urologists must all maintain some expertise in open renal surgery if they are to remain on call for urological trauma. For renal cancer the recommendations for referral of the complex cases to centres is timely and welcome and compensates for radical nephrectomy not being included in the five and 50 cases rules. Urologists will feel that they particularly have been targeted to change practice with these threshold levels. What about the oncologists? Should they also have threshold numbers for treating complex urological cancers? This should come naturally with the development of multidisciplinary team meetings and discussion of all cases. Whilst all units would like to have the resources to provide multidisciplinary review of all cases, in many units this is still not possible due to lack of staff and pressure of work. It is not unreasonable for us to provide some sort of review of all new cases, even if it is just to ensure that they are being treated according to protocol such as for new pTa G1–2 tumours of the bladder which need very little discussion. However, it is treatment failures and progression that often need the full input of the multidisciplinary team and most time for discussion. Will this Guidance document improve the care of urological cancer patients? Undoubtedly it will but it is also likely to cause one of the biggest changes in urological practice for the last two decades. The changes in work that are going to occur must be fully planned
2003 Published by Elsevier Science Ltd on behalf of The College of Radiologists
56
and resourced if patient care is not going to suffer. This is the area where the guidance is weakest and the challenge for all involved will be greatest. References 1 The British Association of Urological Surgeons Section of Oncology. Analysis of Minimum Data Set for Urological Cancers 1 January 2001–31 December 2001. London, U.K.: BAUS.
2 Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346:1128–1137.