Dr Catherine Briggs discusses how management of prostate cancer and the role of primary care may need to evolve in line with the changing NHS climate

The NICE guideline on Prostate cancer: diagnosis and treatment was published in 2008.1 Professor David Weller summarised the implications of this guidance for primary care in the July 2010 issue of Guidelines in Practice,2 but since then, there has been a dramatic change in health policy and it is interesting to reflect on these changes and the way in which they might impact on the care GPs provide to patients with prostate cancer.

The Government White Paper Equity and excellence: liberating the NHS was published in July 2010 and proposed radical changes to the commissioning of healthcare, giving patients a stronger voice in their care and in the shaping of services, and handing over commissioning responsibilities to GPs and other clinicians within consortia. It also put forward challenges to improve efficiency in service delivery, such as saving £20 billion by 2014.3

These challenges raise a number of issues around how and where care is best offered to patients, and task GPs to review pathways to ensure that people receive the best care in the right setting. For the purpose of this article, I will discuss these issues in the context of prostate cancer and the published NICE guideline, exploring how the recommendations might be developed to support the changing NHS climate.

Incidence

Prostate cancer is the most common cancer in UK men, accounting for nearly a quarter of new cancer diagnoses. Each year in the UK, over 35,000 men are diagnosed with prostate cancer and 10,000 die from the disease.4

There has been a rise in the incidence of prostate cancer over the past 20 years, but with no corresponding rise in mortality (see Figure 1, below). This can probably be accounted for by more frequent testing of suspected cases, with earlier diagnosis of the disease, in the context of an ageing population.

There are several implications of increasing rates of prostate cancer testing and diagnosis. The specificity and sensitivity of the prostate serum antigen (PSA) test are 63.1% and 34.9%, respectively.5 A raised PSA result often leads to urgent referral into secondary care, with associated patient anxiety and the question of whether to investigate. There is also a risk to the patient of infection and bleeding, associated with transrectal ultrasound (TRUS).6,7

The increase in testing for prostate cancer results in a significant cost burden to the NHS, with an increase in:8

  • the number of patients referred to specialists
  • the number of patients in hospital settings undergoing investigation and follow up
  • treatments offered, which in some cases may not change the overall outcome of the disease.

A significant number of patients with prostate cancer die with the disease rather than from it, particularly those individuals who have a life expectancy of less than 10 years.9,10 The disease should be considered a long-term condition, perhaps best managed in a primary care setting. However, this raises questions around safe and reliable follow up of patients, and demands robust recall systems in primary care, which will be discussed later in this article.

The NICE guideline covers the whole scope of prostate cancer management and is particularly focused around hospital care of the disease.1 In light of the current drive toward improving efficiency in the NHS, it may be worth NICE reviewing the recommendations and adding more information for primary care in some key areas as discussed further below.

Figure 1: European age-standardised incidence and mortality rates of prostate cancer in Great Britain, 1975–20084

Figure 1: European age-standardised incidence and mortality rates of prostate cancer in Great Britain, 1975–2008

Reproduced with kind permission. Cancer Research UK. Prostate cancer—UK incidence statistics. info.cancerresearchuk.org/cancerstats/types/prostate/incidence/ (accessed May 2011).

Prostate-specific antigen testing

The NICE guideline stresses the importance of provision of clear patient advice and counselling to facilitate decisions of whether to undergo PSA testing.1 This fits well with the White Paper philosophy of keeping the patient central to decision making: ‘no decision about me without me’.3

The Prostate cancer risk management programme (published in July 2009)10 includes patient guidance that supports GPs in providing information on the benefits, limitations, and implications of having a PSA test for prostate cancer. Clinical guidelines could be updated with recommendations that support the use of this patient guidance in clinical-decision making. In addition, patient decision aid tools around PSA testing are being developed by the Department of Health (www.nhsdirect.nhs.uk/decisionaids) to aid clinicians and patients, and inclusion of these in a guideline may also be useful.

Patient referral

There continues to be discussion about whether all patients with suspected prostate cancer should be referred to a 2-week pathway.11,12 Following 2-week referral, patients may subsequently be re-tested or monitored in secondary care before initiating TRUS/biopsy, raising questions on the appropriateness of such urgency in some cases. With current financial pressures, it may be worth NICE guidance being updated to include a detailed review of this area. This could include:

  • consideration of evidence around outcomes to determine whether some patients could be managed with monitoring for longer in the primary care setting
  • appropriateness of prompt and routine referral of patients with a raised PSA
  • recommended PSA cut-off values that would indicate a 2-week referral.

Management

The role of primary care in the management of prostate cancer is mainly supportive, but available guidance is particularly focused around secondary care. The NICE guideline stresses the importance of good communication between healthcare professionals and men with prostate cancer.1 It would be useful to have further guidance for GPs to enable them to be confident in advising and supporting patients with prostate cancer.

Follow up
NICE recommends a prompt return to primary care for men with prostate cancer on a watchful waiting regimen with no curative intent.1 In addition, it is recommended that after at least 2 years’ treatment, patients with a stable PSA and no significant treatment complications can be followed up outside the hospital (in primary care or through clinical nurse specialists).1 In practice, this does not always happen, with some patients remaining in the specialist setting for much longer.

It is vital that excellent communication systems are in place if prompt discharge of patients into primary care is to be achieved as recommended by NICE. Letters from hospital colleagues should provide specific advice on the frequency of PSA testing to ensure cost-effective use of biochemical tests and the PSA values that should trigger re-referral to specialist services. It is worth exploring methods of enabling patients to be actively involved in their care at all stages; for example, further development of hand-held patient PSA booklets or the use of alternative online or telephone advice links to local hospitals, which may help to prevent patients from being followed up unnecessarily in secondary care.

Treatment

After diagnosis, men may be offered a range of treatments for their prostate cancer. While localised cancers will be treated radically with active surveillance, radiotherapy or surgery, those patients who are not fit or those with local and/or distant metastases will be offered hormone manipulation or watchful waiting. Hormone manipulation is usually initiated in primary care under the advice of the specialist, and both this and watchful waiting could be undertaken more extensively in primary care with specialist nurse support or adequate advice from hospital teams.

Side-effects of treatment
As a result of increasing survival following treatment for prostate cancer, and moves to discharge patients to primary care, there is a need for further recommendations on the management of patients who developing post-treatment complications (e.g. urinary symptoms, erectile dysfunction). Robust guidance in this area may support commissioning decisions around which services should be developed.

The NICE guideline advises that patients who have troublesome urinary symptoms after treatment for prostate cancer should have access to specialist continence services for assessment, diagnosis, and conservative treatment. However, continence services are variable across the UK, sometimes with lengthy waiting times for appointments.13 With drives to maintain cost-effective care in the most appropriate setting, it may be worth commissioners exploring how best to develop continence services to meet increasing demands.

Erectile dysfunction
The NICE guideline states that men who experience loss of erectile function as a result of treatment for prostate cancer should be offered phosphodiesterase type 5 (PDE5) inhibitors to improve their chance of spontaneous erections.1 In addition, there is some evidence to suggest that daily PDE5 inhibitors may be of benefit post-radical therapy in maintaining long-term sexual function.14 At present, GPs may be limited in the amount of erectile dysfunction pharmacotherapy that can be prescribed per month as a result of medication rationing. It would be helpful if NICE could review the evidence for daily PDE5 inhibitor therapy following radical treatment of prostate cancer and provide guidance on whether or not to support this as a cost-effective management option.

Palliative care

The guidance offered around palliative care for prostate cancer patients is rather generalised. It states that once care is palliative, it is important to determine where the patient would prefer to receive care and tailor it accordingly.1 Patients often choose to die in their own home and the NICE manual on palliative care states the importance of primary and community services in supporting patients, as well as the importance of development of partnerships between patients, carers, and healthcare and social care professionals if best outcomes are to be achieved.13

Again, with the drive towards improving quality care and ensuring that the patient is treated in the right place at the right time, it may be worth NICE incorporating some of the advice from the manual on palliative care into the guideline on prostate cancer to focus specifically on areas that should be given priority when commissioning prostate cancer services.

Conclusion

The Government White Paper Equity and excellence: liberating the NHS poses huge challenges to clinicians for the next few years and beyond. We should seize the opportunity to explore methods of improving the quality of care offered to patients with prostate cancer. As commissioners of health services, we should work collaboratively across primary and secondary care to:

  • improve communication between clinicians and with patients, ensuring safe and effective handover of care at an appropriate time, with the patient empowered to self manage where possible
  • provide quality educational programmes for GPs so that patients can be managed confidently in primary care until the appropriate time
  • ensure that primary care has safe and effective recall systems in place to provide appropriate follow-up arrangements to patients with prostate cancer
  • ensure that care pathways are commissioned to ensure that patients receive the best care possible from diagnosis to cure or end of life.

It is hoped that any revised guidance from NICE would support the above goals.


  1. National Institute for Health and Care Excellence. Prostate cancer: diagnosis and treatment. Clinical Guideline 58. London: NICE, 2008. Available at: www.nice.org.uk/guidance/CG58 nhs_accreditation
  2. Weller, D. GPs can play a greater role in management of prostate cancer. Guidelines in Practice July 2010; 13 (7): 35–39. Available at: https://www.guidelinesinpractice.co.uk/jul_10_weller_cancer_jul10
  3. Department of Health. Equity and excellence: liberating the NHS. London: DH, 2010. Available at: www.dh.gov.uk/en/Healthcare/LiberatingtheNHS/index.htm
  4. Cancer Research UK. Prostate cancer—UK incidence statistics. Available at: info.cancerresearchuk.org/cancerstats/types/prostate/incidence/
  5. Crawford E, Leewansangtong S, Goktas S et al. Efficiency of prostate-specific antigen and digital rectal examination in screening, using 4.0 ng/ml and age-specific reference range as a cutoff for abnormal values. Prostate 1999; 38 (4): 296–302.
  6. Van Vugt H, Roobol M, Venderbos L et al. Informed decision making on PSA testing for the detection of prostate cancer: an evaluation of a leaflet with risk indicator. Eur J Cancer 2010; 46 (3): 669–677.
  7. Evans R, Edwards A, Elwyn G et al. "It's a maybe test": men's experiences of prostate specific antigen testing in primary care. Br J Gen Pract 2007; 57 (537): 303–310.
  8. Skolarus T, Zhang Y, Miller D et al. The economic burden of prostate cancer survivorship care. J Urol 2010; 184 (2): 532–538.
  9. Sakr W, Grignon D, Haas G et al. Age and racial distribution of prostatic intraepithelial neoplasia. Eur Urol 1996; 30 (2): 138–144.
  10. Burford D, Kirgby M, Austoker J. Prostate cancer risk management programme: information for primary care. PSA testing in asymptomatic men. NHS Cancer Screening Programmes, 2009.
  11. National Institute for Health and Care Excellence. Referral guidelines for suspect cancer. Clinical Guideline 27. London: NICE, 2005. Available at: www.nice.org.uk/guidance/CG27
  12. Hawary A, Warburton H, Brough R et al. The '2-week wait' rule for referrals for suspected urological cancers—urgent need for refinement of criteria. Ann R Coll Surg Engl 2008; 90 (6): 517–522.
  13. Jha S, Moran P, Blackwell A, Greenham H. Integrated care pathways: The way forward for continence services? Eur J Obstet Gynecol Reprod Biol 2007; 134 (1): 120–125.
  14. Guiliano F, Amar E, Chevallier D et al. How urologists manage erectile dysfunction after radical prostatectomy: a national survey (REPAIR) by the French urological association. J Sex Med 2008; 5 (2): 448–457.
  15. National Institute for Clinical Excellence. Improving supportive and palliative care for adults with cancer. The manual. London: NICE, 2004. Available at: www.nice.org.uk/guidance/CSGSPG