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The 2022/23 Primary Care Network DES marks a significant shift in NHS practice around prostate cancer, requiring a ‘plan to increase the proactive and opportunistic assessment of patients for a potential cancer diagnosis in population cohorts where referral rates have not recovered to their pre-pandemic baseline’. It highlights that those at risk are aged 50+; men with a family history of prostate cancer aged 45+ (who have two and a half times the risk); black men aged 45+ (who have double the risk). This article sets out five things PCNs should know when enacting the guidance.
As a result of the pandemic, there were 14,000 men who missed out on a diagnosis of prostate cancer. This is over a third of all the missing cancer cases. Analysis of the Rapid Cancer Registration Data that in prostate cancer stage 1, 2 and 3 diagnoses had all been impacted proportionately – creating a significant fall in the proportion of curable diagnoses both in the short term, and we fear for years to come. ‘It is likely that some men with high-risk early-stage prostate cancer will progress to advanced stage disease if their diagnosis is further delayed, thereby losing the opportunity for curative treatment.’
2. Symptoms in Earlier Diagnosis
Cancer awareness campaigns typically focus on symptom awareness but the problem with that is that most men with early prostate cancer don’t have any symptoms. One reason for this is the way the cancer grows. You’ll usually only get early symptoms if the cancer grows near the urethra and presses against it, changing the way you urinate. But because prostate cancer usually starts to grow in the outer part of the prostate, early prostate cancer doesn’t often press on the urethra and cause symptoms. Urinary symptoms are far more likely to have a benign cause e.g. Benign Prostatic Hyperplasia (BPH) and where they are present in men with prostate cancer it is often incidental.
NICE guidance focusses on PSA testing for symptomatic patients, despite evidence that suggests an inverse correlation between prostate cancer detection rates and presence of urinary symptoms. For example, the absence of voiding symptoms in men with a PSA concentration of ≥ 3.0 ng/mL is an independent risk factor for prostate cancer. Under current guidelines there are different PSA referral levels for symptomatic and asymptomatic patients. An asymptomatic 60-year-old man with a PSA of ≥3 should be referred with suspected prostate cancer, BUT if he presents with symptoms a referral would only be considered if his PSA was ≥ 4.5. Prostate cancer is a condition where the presence of so-called ‘symptoms’ may make a diagnosis less likely.
3. Changing Diagnostic Pathway
We now have better technologies (mpMRI scans) which can rule out 27% of men from needing a biopsy, reducing the number of clinically insignificant diagnoses. In February this year NICE recommended local anaesthetic transperineal (LATP) prostate biopsy which reduce the chances of biopsy related sepsis. The combination of mpMRI and image guided biopsies mean that we can be more confident that we have accurately diagnosed low risk disease and those lower risk cancers can be very safely monitored with Active Surveillance, reducing potential harms. The clock now stops on the 62-day treatment target as soon as men are informed of their diagnosis and their eligibility for Active Surveillance – ensuring that they do not feel any time pressure to make a treatment decision that may push them unnecessarily towards radical treatment.
4. Reducing Over Treatment
The National Prostate Cancer Audit shows radical treatment of low-risk men has steadily reduced in recent years, from 12% of men diagnosed with low-risk cancer in 2014/15, to 8% in 2015/16, and has held steady at 4% since 2016/17. Recent developments are designed to further reduce overtreatment, including in December 2021 the introduction of a new risk stratification (Cambridge Prognostic Groupings) in NICE guidance which broadens the definition of men who could safely avoid treatment and should allow more men to safely avoid radical treatment in future.
5. Informed Choice
We want a screening programme that will effectively identify all those men who need treatment for prostate cancer, while avoiding any harm through overdiagnosis. We are investing heavily in research to get us to that point. However, we are many years from that being a reality. In the meantime, in line with the Prostate Cancer Risk Management Programme, we believe men should be able to understand their risk and make an informed choice as to whether the PSA test is right for them.
The Prostate Cancer UK risk checker and the accompanying awareness campaign are designed to support informed choice making. More than 200k men have completed the impact survey at the end of the risk checker. Of those 77% said they felt fully informed and able to decide whether or not to have a PSA (64% fully informed and want a PSA: 13% fully informed and don’t want a PSA). A further 21% say they need more information to decide and they’re signposted to our specialist nurses who have the knowledge and crucially (unlike GPs) the time to counsel these men further. The risk checker was designed to ensure all men could access and understand the pros and cons of the PSA test and had an easy route to more extensive counselling if needed.
The pandemic has cast a long shadow over the prostate cancer pathway, and we welcome efforts to mitigate the impact. While our long-term aspiration is for an effective screening programme, in the short term, we must make best use of the tool that we have – the PSA test. This will require ongoing efforts to reduce overdiagnosis and minimise the harm to patients who are over diagnosed, while investing in awareness raising. Our ambition is that men understand their own risk and can make an informed choice about whether or not to have the PSA test and we believe that the Network DES offers an opportunity to deliver this. We are piloting ways to support PCNs to deliver the DES, including using text messages and digital informed choice counselling followed by straight to PSA test. We are happy to talk to areas about how we can help – contact Professionals@prostatecanceruk.org
By Amy Rylance, Prostate Cancer UK’s Head of Improving Care
Focusing on prostate cancer, and informed by data provided by the local Cancer Alliance, develop and implement a plan to increase the proactive and opportunistic assessment of patients for a potential cancer diagnosis in population cohorts where referral rates have not recovered to their pre-pandemic baseline.
The prostate pathway remains particularly challenged as a result of the pandemic; treatment numbers for prostate cancer have been the slowest to recover, and prostate cancer referrals have had the slowest recovery of any tumour group other than lung. It is likely that some men with high risk early stage prostate cancer will progress to advanced stage disease if their diagnosis is further delayed, thereby losing the opportunity for curative treatment.
PCNs should review the data provided by their local Cancer Alliance on cumulative shortfalls in urological cancer referrals and treatments over the course of the pandemic and develop an action plan.
It is recommended that PCNs focus on men who are most at risk (target cohort):
• those aged 50 or older
• those with a family history of prostate cancer aged over 45
• black men aged over 45
In delivering this requirement, supported by their local Cancer Alliance, a PCN’s plan may include the following:
• In order to understand the scale of intervention required, initially establish how many men per practice have risk factors that classify them to be high risk for prostate cancer (target cohort)
• Providing prostate cancer awareness information materials directly to the target cohort, either electronically via SMS, email, or through leaflets
• Practices to establish via the PCN a local plan to raise awareness of prostate cancer in men identified as higher risk. If subsequently there is a consultation which identifies symptoms suggestive of prostate cancer, a shared decision-making discussion takes place to offer a PSA test if appropriate in line with NICE guidance and supporting tools e.g. NICE prostate cancer overview, PSA decision making tool, and PSA testing information
• Consider supporting allied clinical professionals (Advanced Nurse Practitioners and Practice Nurses) to undertake prostate health discussions with the target cohort