Prostate cancer: good care in Switzerland 2020–2023

Context

TL;DR

• More than 35'000 cases analyzed between 2020 and 2023
• 8'929 new cases and 1'340 average annual deaths
• 76% is detected through opportunistic screening
• Three-year survival: 97%

Key facts

• Cases analyzed → more than 35'000
• Period → 2020-2023
• Average new cases per year → 8'929
• Average deaths per year → 1'340
• Opportunistic screening → 76%
• Tumor board → 56%
• One-year survival → 99%
• Three-year survival → 97%

The picture emerging from the registries

ZURICH - More than 35'000 cases of prostate cancer diagnosed between 2020 and 2023 were examined in the first national analysis of indicators for diagnosis and treatment. The work was carried out by the National Cancer Registration Service (SNRT), together with the Swiss Society of Urology (Swiss Urology).

The report assesses care positively: compared with other European countries, Switzerland has low mortality and high survival rates. During the same period, there were an average of 8'929 new cases and 1'340 deaths per year. Among men, it is the most frequently diagnosed neoplasm in the country.

76% of cases are identified through opportunistic screening; 13% of diagnoses arise from an incidental finding and 7% from symptoms. As age increases, the share of incidental discoveries or those related to symptoms rises.

Opportunistic screening includes the PSA test, that is, prostate-specific antigen; doctor and patient weigh its advantages and disadvantages and decide on a case-by-case basis whether to perform it. In Switzerland, there is no national systematic and uniform screening program for this cancer; for breast and colon cancer, however, screening is organized at national level.

Stages and risk

36% of tumors are diagnosed at stage I and 30% at stage II, when the disease is still limited to the prostate. 14% of cases belong to risk group 1, while a further 14% are classified in group 2a: for both categories, the risk of progression is limited.

The report does, however, point out the downside of early diagnosis. Especially in older men, tumors may emerge that would not have acquired clinical relevance or reduced life expectancy. For those with a limited life expectancy, screening tests should therefore be used with caution.

For low-risk tumors confined to the prostate, the strategy normally indicated is active surveillance, not immediate treatment. In risk group 1, it concerns about 72% of patients and involves close monitoring with PSA, magnetic resonance imaging and biopsy. For the separate issue of health insurance coverage, guide LAMal/cassa malati is available.

Operational details

Risk-calibrated therapies

The crux of the analysis concerns low-risk tumors: in 20% of cases, treatment is nevertheless pursued, such as surgery or radiotherapy, instead of active surveillance. According to the report, many of these treatments would likely be avoidable: compared with active surveillance, they would provide no additional benefits and could cause side effects.

The proposal put forward by the authors is uniform, evidence-based screening, with clear inclusion and exclusion criteria. Such an approach could limit both overdiagnosis and overtreatment, keeping distinct the need to detect the disease early from the risk of treating tumors that would not have had clinical significance.

Among all patients, radical prostatectomy is the most common intervention and concerns 35% of cases. Hormone therapy was administered to 25%, while 19% received radiotherapy. The possible combination of the different options depends on the characteristics of the tumor, the patient's condition and the therapeutic objective.

In tumors with intermediate to high risk, surgery is used in 37%-57% of cases. Radiotherapy, with or without hormone therapy and/or additional chemotherapy, concerns 17%-43%. When distant metastases are already present at the time of diagnosis, hormone therapy and/or chemotherapy alone is used in 69% of cases. These data refer to different clinical groups, not to a single pathway applicable to everyone.

Multidisciplinary discussion

In 56% of cases, the treatment decision is made by an oncology committee, or tumor board. Within it, specialists from different disciplines discuss the options and formulate recommendations in line with the most up-to-date treatment standards.

The report recommends that, whenever possible, every new diagnosis of prostate cancer be reviewed by one of these committees. Collegial discussion is identified as a tool to improve care and reduce the risk of excessive treatment. For separate in-depth information on health coverage, guide LAMal/cassa malati is available.

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Key points

Five operational steps

The report can also be read as an operational framework for navigating diagnosis, monitoring and treatment decisions. The sequence follows the elements indicated in the analysis.

1. Define how the disease was identified: opportunistic screening, incidental finding or symptoms. The distribution changes with age, because the proportion of incidental or symptom-related diagnoses increases.

2. Place the PSA test within the individual discussion between doctor and patient. The advantages and disadvantages are assessed before deciding whether to perform it, in the absence of a systematic and uniform national program for prostate cancer.

3. Consider stage and risk together. The disease may still be confined to the prostate, while risk groups 1 and 2a are described as having a limited risk of progression. These elements distinguish low-risk cases from the others.

4. In low-risk cases confined to the prostate, assess the active surveillance pathway, which includes close monitoring with PSA tests, magnetic resonance imaging and biopsy. In older men with limited life expectancy, the report recommends caution in the use of screening.

5. Check the multidisciplinary step: the recommendation is that every new diagnosis be discussed, whenever possible, by an oncology committee. The tumor board brings together specialists from different disciplines to assess the options and formulate recommendations according to the most recent treatment standards.

This framework keeps separate two objectives that the report presents together: early diagnosis, which is beneficial for treatment and prognosis, and the reduction of unnecessary findings or therapies. Relative survival is calculated in relation to the general population: 99% one year after diagnosis, 98% after two years and 97% after three years. The report places these figures alongside a low mortality rate compared with the rest of Europe. For a separate in-depth look at healthcare coverage, consult LAMal/cassa malati.

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Source: tio.ch