Adenocarcinoma of the prostate is a condition which 10 years ago was viewed as indolent and non-aggressive with a low risk of causing harm in the ageing population in which it occurred.
However, it is now seen as a major health problem, with an increasing incidence and resulting rise in mortality. The increase in incidence paralleled the introduction of prostate specific antigen (PSA) testing in the early 1990s. In addition, men in their 50s and beyond are less likely to succumb to other disease and are therefore more at risk of developing prostate cancer.
If we wait for prostate cancer to present clinically it will often have spread locally or metastasised, and palliative hormonal therapy is the only therapeutic option. PSA testing allows early detection but it has not been established that earlier intervention results in significantly better survival. However the availability of ïscreeningÍ tests and potentially curative therapies has led to a shift in emphasis towards early detection and radical therapies.
Men with prostate cancer or even a suspicion of the disease have been poorly served in the past. A possible diagnosis of prostate cancer may not have been dealt with by either the GP or the hospital department as an urgent referral; diagnostic tests may have taken weeks to arrange, and staging scans, weeks or months. Once the diagnosis was made and the tumour staged the discussion would often have been as limited as ñNo need to worry - most men die with prostate cancer not from it. WeÍll keep an eye on you and give you some hormones if it starts to play up.î
The NHS is undergoing a revolution in the way treatment is offered to cancer patients. Management should be patient-focused, based on a multidisciplinary team approach and integrated with primary care. It should also be efficient.
The urologists in North Bristol, Weston-super-Mare and Taunton are linked by their involvement in the Avon, Somerset and Wiltshire Cancer Services (ASWCS) network.
We had contributed to regional audits of the management of early prostate cancer and were disturbed to find delays of up to 2 years between referral and definitive therapy. In part, this was because many patients presented with lower urinary tract symptoms and prostate cancer was discovered by serendipity during investigation. However, significant delays were found to have occurred at every stage of the patient journey.
In 1999, we became involved as a pilot site in phase 1 of the National Cancer Collaborative. Prostate cancer was one of the five cancer sites studied. Initially we seconded a nurse to examine the prostate cancer patientÍs journey. The aim was to map the process by which patients gained access to our service and reduce the time from referral to diagnosis.
Several points where delays were occurring were identified in the journey. These included the time a letter from the GP took to reach the urologist, the time spent waiting for the consultant to prioritise and assign an appointment and lack of urgent slots for assessment and biopsy.
The advice of a small group of local GPs was sought at this point to identify blockage points from their perspective. The local urologists also met with the cancer leads from each of our local primary care organisations.
A number of changes were instituted in line with the Cancer CollaborativeÍs ethos of PDSA (Plan the change, Do it, Study its effect, Act and implement or modify). Such changes may be small, for example placing a fax machine for urgent referrals in the urology outpatient office, or large, for example instituting a dedicated rapid access diagnostic clinic.
The referral to diagnosis pathway is now as follows (Figure 1 below). If a GP suspects prostate cancer a standard form is faxed to the hospital cancer office. On receiving this form the office books the patient into a RAPAC clinic slot within 14 days. The clinic immediately informs the specialist urological cancer nurses. The patient is sent details of the RAPAC clinic, an information leaflet on prostate biopsy and a contact number for advice (the specialist nurse).
|Figure 1: The referral to diagnosis pathway for patients with suspected prostate cancer|
The patient attends the clinic and is seen by both nurse and doctor. A standard clinical assessment takes place and if indicated a biopsy is offered at the same visit. Initially, some clinicians felt that this was inappropriate, rushing the patient into an invasive investigation. For this reason, a survey of patientsÍ attitudes was carried out and this showed that most patients found the ïone-stopÍ service acceptable; some 75% elected to undergo biopsy at the first visit. Of the quarter who returned for biopsy, many did so because it was more convenient.
The way in which the biopsy result is communicated is important to patients. Most are happy to accept the result over the telephone; however, if cancer is confirmed they need to have an early appointment to discuss future management. The specialist nurses inform the patientÍs GP by telephone or fax immediately a new diagnosis of cancer is made.
Once a diagnosis of prostate cancer is made the patient enters a very different phase of his journey. Men want information about their condition and its management. They vary in their needs; some require direction while others seek advice from many sources, including friends, neighbours, physicians and the internet.
The RAPAC service has developed in partnership with patients and their families. Specialist nurses form the backbone of the team offering as much information and support as the patient wants. A urologist with a special interest in prostate cancer and a clinical oncologist are available to see each patient on one or more occasions.
The Cancer Collaborative highlighted the need for improved communication. We are piloting electronic and fax reporting to GPs, while the telephone has become the main method of keeping in contact with the patient through their journey.
All new prostate patients and any established cases with progression are discussed at a weekly multidisciplinary team meeting. Treatment options are identified and those patients suitable for enrolment in clinical trials noted. Information packs concerning trials are sent to patients.
The management plan and options are discussed with the patient in clinic or, if preferred, by telephone. The patient then has time to ask questions and seek clarification, for example of prognosis or possible complications.
A man with early disease suitable for radical local therapy is counselled about surgery and radiotherapy. All forms of therapy for prostate cancer and the disease itself can have an impact upon urinary control and sexual function. The cancer team has close links with continence and physiotherapy services and with the erectile dysfunction clinic in our department.
We aim to be proactive; the management of continence and potency begins before the treatment.
Pelvic floor exercises are taught and some patients are offered pelvic floor re-education with physiotherapy. In patients keen to retain potency, the early use of sildenafil is encouraged to kick-start the process.
The GP has a vital role at many stages of the process.
National guidelines have been published identifying patients needing urgent referral (those with clinical prostate cancer, bone pain or raised PSA). A high index of suspicion for prostate cancer can be tempered by offering education and a pragmatic approach to the man in his 80s with a slightly raised PSA and no symptoms.
We have developed a good professional relationship with our GP colleagues and they often write or call for advice. Typical questions concern the need for investigation in an 80-year-old man with a marginally raised PSA, and the management of a man who is stable on hormonal therapy but has an increasing serum PSA level.
Treatment is usually on a shared care basis if the disease is advanced and requires hormonal therapy. Locally we have agreed that an LH-RH agonist (e.g. goserelin) and antiandrogens should be commenced in hospital outpatient departments while the GP will take over subsequent care, sharing follow-up with the urologist. At the start of treatment the specialist nurse telephones the GP to coordinate therapy, for example, to decide whether the GP or the hospital will give the initial dose, and whether it will be one month or 3 month depots.
As a result of introducing this service, the role of the GP has been clarified. We have proposed an increased role for GPs and, in larger practices, named GPs with an interest in prostate cancer are taking the lead in providing care and advice. In general, feedback has been excellent, with GPs feeling that the service provides rapid access, support and information.
A review of our services for men with suspected prostate cancer during phase 1 of the National Cancer Collaborative revealed many failings in the system. By introducing rapid access clinics and specialist nurses and improving collaboration with the community, we now provide an efficient patient-centred service.
Regular audits confirm the impression that time to diagnosis and treatment has been greatly reduced. Patient satisfaction surveys have found that more than 90% of patients are ïhappyÍ or ïvery happyÍ with the service they receive.
The changes were also trialled in two other local urology units and are being rolled out to others in the South and West.