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GPs should review stable prostate cancer patients every six months, suggests NICE

GPs should take over responsibility for following up with stable prostate cancer patients and offer them six-monthly reviews, NICE has suggested.

The current NICE guideline recommends that prostate cancer patients remain under hospital care for at least two years from when their PSA levels were first measured as stable, however NICE now wants patients transferred to primary care after just six months.

This forms part of new draft guidelines for prostate cancer, which also says general practice should manage patients where there is a low suspicion of prostate cancer, or where tests have confirmed prostate cancer but no treatment has been recommended.

The draft recommendations, published last week, said that following prostate cancer treatment, and after the initial six months’ follow up, secondary care clinicians should ‘consider a non-hospital based follow-up strategy for people with a stable PSA who have had no significant treatment complications’.

GPs should invite these patients to have their PSA levels checked ‘at least every six months for the first two years’ and then ‘at least once a year’ following that, NICE added.

GPs should also take responsibility for patients with a low level of suspicion for prostate cancer – those who have negative MRI or biopsy results - according to the guidelines.

For those without biopsy results, PSA follow-ups should be performed at six months and then every year, while those with negative results should have follow-ups every two years.

In addition, NICE wants GPs to take on the follow-up treatment for patients who have prostate cancer but who are not in treatment - patients on a ‘watchful waiting regimen with no curative intent’ - offering these PSA testing 'at least once a year'.

BMA GP Committee clinical and prescribing policy lead Dr Andrew Green said: 'What is vital is that the out-of-hospital care is done through a properly commissioned scheme which ensures that patients do not get lost to follow-up and are cared for with adequate resources.

'There are good examples of this happening in many areas, often aided by dedicated IT which can guide non-specialists as to the importance of any biochemical changes found.'

The new guidance comes at the same time as a new study suggests GPs should lead prostate cancer patient follow-ups to reduce workload for urologists and improve continuity of care.

The study, published last week in the BJGP Open, suggests that GPs should lead prostate cancer patient follow-ups to reduce workload for urologists and improve continuity of care.

The research tested the feasibility of a GP-led prostate cancer follow-up pathway with a small cohort, and concluded that it was 'successful' and warranted a 'larger study to provide evidence for the (cost-)effectiveness' of such a pathway.

Recommendations in full:

If the MRI or biopsy is negative:

  • For people who have a raised PSA, and MRI Likert score of 1 or 2 and have not had a prostate biopsy, repeat PSA test at 3–6 months and:
    • offer prostate biopsy if there is a strong suspicion of prostate cancer (for example, PSA density greater than 0.15 ng/ml/ml or PSA velocity greater than 0.75 ng/year, or strong family history), taking into account their life expectancy and comorbidities
    • discharge the person to primary care if the level of suspicion is low: advise PSA follow-up at 6 months and then every year, and set a level for primary care at which to re-refer based on PSA density 2 (0.15 ng/ml/ml) or velocity (0.75 ng/year). [2019]
  • For people who have a raised PSA, an MRI Likert score of 1 or 2 (or a 4 contraindication to MRI), and negative biopsy, repeat PSA at 3–6 months and:
    • offer prostate biopsy if there is a strong suspicion of prostate cancer (for example, PSA density greater than 0.15 ng/ml/ml or PSA velocity greater than 0.75 ng/year, or strong family history), taking into account their life expectancy and comorbidities
    • discharge the person to primary care if the level of suspicion is low: advise PSA follow-up every 2 years, and set a PSA level for primary care at which to re-refer, based on PSA density (0.15 ng/ml/ml) or velocity (0.75 ng/year). [2019]

Follow ups:

  • Check PSA levels for all people with prostate cancer who are having radical treatment no earlier than 6 weeks after treatment, at least every 6 months for the first 2 years, and then at least once a year after that. [2019]
  • After at least 6 months’ initial follow-up, consider a non-hospital based follow-up strategy for people with a stable PSA who have had no significant treatment complications, unless they are taking part in a clinical trial that needs formal clinic-based follow-up. [2019] 
  • Follow up people with prostate cancer who have chosen a watchful waiting regimen with no curative intent in primary care if protocols for this have been agreed between the local urological cancer MDT and the relevant primary care organisation(s). Measure their PSA at least once a year. [2019]

Source: NICE

Readers' comments (15)

  • Show me the money!

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  • National Hopeless Service

    In a perfect world with no GP recruitment issues this isn't unreasonable. But I/we are at full capacity of following stuff up.

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  • Why do I feel 'national guidance' seems to be pushing secondary care work to us, without funding? Are the people of NICE trying to get onto the new years honours list. The answer is no. Cancers reviews and management are secondary care work and should be done by them. Isnt that why we have specialist cancer nurses to take this on/organise.

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  • Ivan Benett

    Certainly this needs to be costed, but it is a really sensible way forward of taking relatively low risk work out of hospital care. This is not complicated and need not be contentious.
    Then perhaps we can move to a more systematic approach to offering PSA testing to those at high risk, and those who want to know. At this point I will duck out of the volley of bullets heading my way.

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  • AlanAlmond

    Fair enough, might expose a few Urologists who hold on to stable prostrate patients to keep their clinics a little easier ;)

    I remain concerned about who exactly NICE serves. From what I can see NICE guidance is basically a handbook for the legal profession, not the medical one, everything is conveniently codified to ease the flow of the negligence claim. It’s mostly a codifying what GPs ‘should be doing’ with the question of resources conveniently omitted from the equation. As far as NICE is concerned that’s someone else’s problem..usually the GPs.

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  • The weapons grade idiots are at it again!!
    Trebles and New Years honours all round to those good chaps at NICE and RCGP...

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  • Dear All,
    its not life's slings and arrows Ivan needs to duck, its the carpet under his feet. Wouldn't an appraiser expect him to know that anyone, symptomatic or not, who wants to know their PSA, can have the test, as part of NHS policy, providing they've been counselled. Perhaps its difficult keep abreast with all that bobbing about?
    Regards
    Paul C

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  • NICE inspects its own prostate on a daily basis; however this has resulted in a degree of vitamin D deficiency because they focus on an area where the sun don't shine.

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  • This 'simple and routine work'should not be dumped on us. We're already too busy. It should go to the cancer specialist nurses wh can then kick it up directly to the urologist if needed. We can't take everything on.

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  • When our IT systems are improved sufficiently to cope - a computer that works when switched on and a printer that works then we will be better placed to mange this sort of care. Until we are given the resources we need as GPs then we are unable to provide this type of care efficiently and effectively. Until I can get through a surgery without having to restart and reset everything each time then I am not sure how this additional work can be delivered safely when on a daily basis our IT lets us down as it is old and resistance to upgrade to save money and difficulty to get offsite IT support delays surgeries and creates risk with inadequate access to patient information. Once the basic IT can be sorted out and we can get more rooms and more computer terminals with more staff then clearly we may be able to do this type of additional work. Until then sorry no it just isn’t safe.

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