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Introduction: The treatment of prostate cancer varies between the United States (US) and England, however this has not been well characterised using recent data. We therefore investigated the extent of the differences between US and English patients with respect to initial treatment. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify men diagnosed with prostate cancer in the US and the treatments they received. We also used the National Prostate Cancer Audit (NPCA) database for the same purposes among men diagnosed with prostate cancer in England. Next, we used multivariable regression to estimate the adjusted risk ratio (aRR) of receiving radical local treatment for men with non-metastatic prostate cancer according to the country of diagnosis (US vs. England). The five-tiered Cambridge Prognostic Group (CPG) classification was included as an interaction term. Results: We identified 109,697 patients from the SEER database, and 74,393 patients from the NPCA database, who were newly diagnosed with non-metastatic prostate cancer between April 1st 2014 and December 31st 2016 with sufficient information for risk stratification according to the CPG classification. Men in the US were more likely to receive radical local treatment across all prognostic groups compared to men in England (% radical treatment US vs. England, CPG1: 38.1% vs. 14.3% – aRR 2.57, 95% CI 2.47–2.68; CPG2: 68.6% vs. 52.6% – aRR 1.27, 95% CI 1.25–1.29; CPG3: 76.7% vs. 67.1% – aRR 1.12, 95% CI 1.10–1.13; CPG4: 82.6% vs. 72.4% – aRR 1.09, 95% CI 1.08–1.10; CPG5: 78.2% vs. 71.7% – aRR 1.06, 95% CI 1.04–1.07) Conclusions: Treatment rates were higher in the US compared to England raising potential over-treatment concerns for low-risk disease (CPG1) in the US and under-treatment of clinically significant disease (CPG3-5) in England.

Background: Improvements in short-term outcomes have been reported for hospitals with higher radical prostatectomy (RP) volumes. However, the association with longer-term functional outcomes is unknown. Methods: All patients diagnosed with non-metastatic prostate cancer in the English NHS between 2014 and 2016 who underwent RP (N= 10,089) were mailed a survey ≥18 months after diagnosis. Differences in patient-reported urinary continence and sexual function (EPIC-26 on scale from 0 to 100) by hospital volume group (≤60, 61–100, 101–140, >140 RPs/year) were estimated using multilevel linear regression. Results: Overall, 7702 men (76.3%) responded. There were no statistically significant differences in urinary continence (p= 0.08) or sexual function scores with increasing volume group (p= 0.2). When modelled as a linear function, we found a non-significant increase of 0.70 (95% CI −0.41 to 1.80; p= 0.22) in urinary continence and a significant increase of 1.54 (0.62–2.45; p= 0.001) in sexual function scores for a 100-procedure increase in hospital volume, which did not meet the threshold for a minimal clinically important difference (10–12 points). The results were similar for robotic-assisted RP (5529 men [71.8%]). Conclusions: These results do not support further centralisation of RP services beyond levels in England where four in five hospitals perform >60 RPs/year.

Background: Many factors are implicated in the potential ‘under-treatment’ of prostate cancer but little is known about the between-hospital variation. Methods: The National Prostate Cancer Audit (NPCA) database was used to identify high-risk localised or locally advanced prostate cancer patients in England, between January 2014 and December 2017, and the treatments received. Hospital-level variation in radical local treatment was explored visually using funnel plots. The intra-class correlation coefficient (ICC) quantified the between-hospital variation in a random-intercept multivariable logistic regression model. Results: 53,888 men, from 128 hospitals, were included and 35,034 (65.0%) received radical local treatment. The likelihood of receiving radical local treatment was increased in men who were younger (the strongest predictor), more affluent, those with fewer comorbidities, and in those with a non-Black ethnic background. There was more between-hospital variation (P< 0.001) for patients aged ≥80 years (ICC: 0.235) compared to patients aged 75–79 years (ICC: 0.070), 70–74 years (ICC: 0.041), and <70 years (ICC: 0.048). Comorbidity and socioeconomic deprivation did not influence the between-hospital variation. Conclusions: Radical local treatment of high-risk localised or locally advanced prostate cancer depended strongly on age and comorbidity, but also on socioeconomic deprivation and ethnicity, with the between-hospital variation being highest in older patients.