Article: The value of audit in identifying health inequalities
Published: 04 Jun 2025
Multiple inequalities in diagnosis and treatment are identified by the National Prostate Cancer Audit (NPCA)
What has the NPCA found?
The NPCA’s most recent State of the Nation report, published in January 2025, included a section which focused on inequalities in prostate cancer diagnosis and treatment. More specifically socioeconomic, demographic and ethnic differences between people diagnosed with prostate cancer between 2020 and 2023 in England. What they found showed that the inequalities identified in previous studies persist. Here they explain more…
Inequalities at diagnosis:
90% of men diagnosed with prostate cancer had their ethnicity recorded and of these 90% were white, 5% Black and 2.4% Asian. 84% of men diagnosed with prostate cancer were between 50 and 79 years old and 24% lived in the least deprived areas.
When adjusting for the size of the male population, white, Black or Asian, the Black population has the largest number of new diagnoses compared to the white and Asian groups, with 17 new diagnoses per 1000 men in black men aged 70-74. 79% of diagnoses had a stage recorded and of those, Black ethnic groups had a higher proportion of new diagnoses per 1000 men at stage 1 than other ethnic groups.
We found stage 4 cancer to be the most common diagnosis in white men aged 85 years and over, which highlights late diagnosis in older men. These findings are limited by the low data completeness (49%) of stage for white men aged 85 years and over.
Inequalities in treatment:
68% of black men aged 60 to 69 years with high-risk/locally advanced cancer received radical treatment compared to 82% white men of the same age and disease stage. We found a difference in radical treatment between least and most deprived areas, from 83% to 75% for men aged 60 to 69 years. A final finding was that treatment declines significantly from the age of 75 and that younger patients are more likely to receive treatment.
In men with prostate cancer that has already spread at diagnosis, Black men were 24% less likely than white men to receive chemotherapy or additional hormone treatments. The same difference (24%) was observed when comparing men living in the most deprived areas than in the least.
The special report on inequalities highlights a need for specific interventions to improve prostate cancer care so that it is equitable across all patient groups.
How can these findings be used to improve standards of care?
Results from the NPCA, in both our annual State of the Nation Reports and in our research articles, serve to highlight unwarranted differences in diagnoses and treatment at the population level which can be used as real-world evidence if national prostate cancer care guidelines are revised. Subsequent changes in wording would raise awareness of potential variation and provide support for patients to access equitable care at every step of their journey. This would ultimately lead to improved outcomes for people diagnosed with prostate cancer, regardless of when or where they were diagnosed and treated.
There are many factors which influence the differences in prostate cancer care which we have described, whether alone or in combination, some of which may relate to patient choice and preference. These are complex in nature and different approaches by multiple groups and decision makers will be required to ensure men diagnosed with prostate cancer are offered and receive optimal care, ultimately resulting in improved outcomes.
The NPCA, being commissioned by the English NHS and the Welsh Government, work closely with clinical leads to provide evidence of where improvements are needed and our stakeholders include professional bodies across the care pathway and colleges with influence on national level policy making.
What is the National Prostate Cancer Audit?
The National Prostate Cancer Audit is part of the National Cancer Audit Collaborating Centre (NATCAN), commissioned by Healthcare Quality Improvement Partnership (HQIP), on behalf of NHS England and the Welsh Government, as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).
What does the NPCA do?
The aims of the NPCA, and audits within NATCAN, are to provide cancer services in England and Wales with regular updates on their performance against national standards (when these exist) and other providers, through annual and quarterly reports. This means that we can also evidence whether different patterns of care are seen in different trusts or health boards. By shining a light on these differences, the audits enable NHS services to reflect on their provision and identify changes needed in order to provide equitable access to treatments for all patients, regardless of where they present.
The NPCA, and audits within NATCAN, don’t ‘collect’ clinical data, we receive it from the National Disease Registration Service (NDRS) in NHSE and the Wales Cancer Network in Public Health Wales, with whom we work to improve data completeness. We have access to information on the diagnosis, treatments and outcomes of all patients newly diagnosed with prostate cancer in England and Wales as recorded by the providers themselves. This includes staging, how the patient presented, what their health is like generally, and what procedures they underwent, including surgery, radiotherapy or if they received systemic treatment such as chemotherapy or hormonal treatment.
What are the aims of the NPCA?
The NPCA redefined the scope of its work in 2023 and alongside that, identified key Quality Improvement goals in 2024 which ensure patient benefit continues to be at the heart of the work of the audit. Among these, reducing variation in prostate cancer management among NHS providers and improving experience of care among men with prostate cancer.
How does the NPCA achieve this?
The NPCA summarises the information received from routine data collections and produces an annual report (since 2014) which provides a national picture of the state of prostate cancer care in England and Wales. This means we have been able to monitor variation and changes in prostate cancer care for over a decade and make targeted suggestions to providers and commissioners on how to improve care. The audit feeds back information and recommendations to each provider so that they can truly reach the clinicians who can act on it, through the use of local action plans. Since 2024, we also produce quarterly reports, and since April 2025, a data dashboard updated quarterly is available collating data quality of key items and one performance indicator.
Prior research undertaken by the audit reported on variation in care by ethnicity, age, socioeconomic status, and geographic location such as our report on treatment of men with high-risk or locally advanced prostate cancer. This identified differences in receipt of treatment for black and socio economically more deprived men. Short reports in 2020 and 2022 separately highlighted variation in diagnosis and care by ethnicity, age and socioeconomic status, so a comprehensive update on these findings was warranted to be able to identify the reasons behind the variation.
A research study published in April 2025, looking at the geographic, socioeconomic and demographic inequalities in the incidence of prostate cancer which has spread at time of diagnosis identified unwarranted variation in England (2018-2022). Key findings include:
- Regional annual rates of prostate cancer diagnoses where it has already spread (metastatic) were found to vary between 4 and 7 per 100 000 men
- Higher rates of metastatic prostate cancer were seen in regions with lower rates of prostate cancer diagnosis overall
- Higher rate of metastatic prostate cancer and a lower rate of prostate cancer overall was also seen among men living in more deprived neighbourhoods
In the future, the NPCA will aim to monitor the incidence of prostate cancer which has already spread at time of diagnosis considering these findings. This would provide an opportunity to assess improvements in timely diagnosis (and the ensuing ramifications for national policy about screening and early detection) more thoroughly than by just reporting the proportion of men diagnosed with prostate cancer who have metastatic disease. The programme of research of the NPCA is embedded in the audit activities and is key to the NPCA’s aim to get a better understanding determinants of variation and propose ways to ensure men diagnosed with prostate cancer at any stage benefit from equitable care.
What else is the NPCA doing?
The NPCA will be running a quality improvement initiative aiming to improve rates of treatment for men diagnosed with prostate cancer that has spread. We have already found that older men and Black men (when compared to white men) are less likely to receive treatment during earlier stages of the disease. We hope to understand the barriers to treatment which exist and by working with our partners at local and national levels, propose recommendations which will improve care, and ultimately outcomes, for men diagnosed with prostate cancer that has spread.
Further information – links:
This article was shared as part of Clinical Audit Awareness Week 2025. Have your say on #CAAW25: Feedback form.