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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Men with prostate cancer may have to choose between surgery or radiotherapy treatment. Research found that their decision was influenced by how far they needed to travel. If the alternative treatment was an extra 15 minutes away (or more), men were more likely to receive the option closer to home.  

Surgical services for cancer are being centralised. This means specialist services are offered by fewer, larger centres. Centralisation can improve treatment outcomes (including better survival), but it also means that some people need to travel further for treatment.

This study analysed national data to determine where two of the most common prostate cancer treatments (surgery and radiotherapy) were available. Researchers assessed whether the treatment men received was influenced by how far they needed to travel.

It found that fewer than half of the hospitals provided both surgery and radiotherapy. Men’s travel time influenced the treatment they received, as did their age, ethnic and economic background, and the number of long-term conditions they had.

The researchers hope the study will influence the planning and provision of cancer services. It is part of a larger project exploring access to cancer treatment services.

More information on prostate cancer is available on the NHS website.

The issue: men’s treatment choice might mean extra travel

Some men with prostate cancer do not need treatment. Others, with disease that is intermediate risk (has not spread from the prostate), receive treatment to prevent spread in the long-term. Two of the most common treatments are surgery to remove the prostate gland (prostatectomy) and external beam radiotherapy to kill cancer cells. These treatments have similar success rates.

Men’s choice of treatment may therefore depend on other factors such as their general health, and their view of the potential side effects. Both treatments can cause erectile dysfunction (impotence) and urinary incontinence. Radiotherapy can also cause bowel side effects.

Centralisation of surgical services for cancer has been shown to improve outcomes. However, it also means that surgery and radiotherapy may not be provided in the same hospital.

In this study, the researchers assessed the treatment options nearest to people with prostate cancer. They explored whether travel times (by car) made a difference to the treatment men received.

What’s new?

The study was based on data from a cancer registry, and hospital records , which included travel times to hospitals. More than 16,000 men diagnosed with intermediate-risk prostate cancer between 2017 and 2018 were included; they had received either surgery or radiotherapy.

The researchers found that:

  • of 78 hospitals that provided treatment, fewer than half (41%) offered both surgery and radiotherapy
  • for nearly half (47%) of the men in the study, their nearest hospital provided both treatments; 1 in 3 (31%) were nearest a radiotherapy-only hospital, 1 in 5 (22%) were nearest a surgery-only hospital
  • men were more likely to receive the treatment (surgery or radiotherapy) closest to them if the alternative was an extra 15 minutes or more by car (compared to men whose nearest hospital provided both options)
  • less than 15 minutes' extra travel did not impact treatment choice.

Men were more likely to receive radiotherapy if they were from a deprived background, were 70 years or over, or had one or more long-term conditions. By contrast, men from minority ethnic backgrounds were more likely to receive surgery. Extra travel times had the most impact on men who were older or poorer.

Why is this important?

Half of the men undergoing treatment for prostate cancer lacked the choice of surgery or radiotherapy at their nearest hospital. The need to travel an extra 15 minutes or more by car influenced the treatment they received.

Centralising surgical services means that some men will need to travel further to receive surgery; they may therefore be less likely to choose it. This could impact their treatment experience. However, the researchers say the men may also have been influenced by access to public transport and perceptions of hospital quality. This was not captured in the study.

Men’s choice was also influenced by their age, ethnic and economic background, and the number of long-term conditions they had. Centralisation of services may be creating unequal access to cancer services.

However, the researchers say age and other factors might explain some choices. For example, older men were more likely to receive radiotherapy; this may be because of the worse outcomes from surgery for men over 75. By contrast, men from ethnic minority backgrounds were more likely to receive surgery. This may be because these men tend to be diagnosed with prostate cancer earlier, when the chances of better outcomes from surgery are higher.

What’s next?

Policymakers need to be aware that centralising services can have an impact on patient experience and quality of care. The researchers recommend that centralisation policies for prostate cancer consider the full range of treatment options (rather than single types of treatment). This will protect patient choice and help prevent inequality in access to treatment.

The researchers developed a health service planning model to estimate how centralisation policies affect travel time, access to services, patient outcomes, and hospital workload. It could guide complex decisions about the closure of centres, and inform strategies to improve access to cancer treatments.

Ideally, comprehensive treatment centres should provide both treatments, the researchers say. However, they recognise this will not always be possible. They call on policymakers to come up with solutions that ensure patients’ choice of treatment is not dictated by where they live. For example, senior nurses could guide patients through all the treatments available to them. Electronic decision aids could be used to help people decide on treatment . Free hospital transport could also be provided.

Further research is needed to explore why travel times have an impact on patients’ choice of treatment. It could be because people struggle to take time off work for treatment, for example, or to pay for extra travel. In addition, researchers could explore whether these findings apply to other conditions or other cancers.

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This Alert is based on: Aggarwal A. and others. Impact of centralization of prostate cancer services on the choice of radical treatment. BJU International 2022

The paper describing the planning model for the centralisation of cancer services: Aggarwal A. and others. Health service planning to assess the expected impact of centralising specialist cancer services on travel times, equity, and outcomes: a national population-based modelling study. Lancet Oncology 2022;23:1211–1220

More information about prostate cancer services is available on the National Prostate Cancer Audit website.

Funding: The study was funded by the NIHR Advanced Fellowship Programme.

Conflicts of Interest: One of the authors received funding from Elekta, Varian and Accuray.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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