Guidance and resources to support the commissioning and implementation of a holistic, primary care follow up pathway for men with stable prostate cancer.

Primary care led follow up for men with stable prostate cancer – the case for change

In 2019, the National Institute of Clinical Excellence committee (NICE Prostate Cancer: NG131) agreed that the 2-year follow-up recommended in the previous prostate cancer guideline was conservative and, based on their expertise, people with no complications and with a stable PSA could be cared for outside of the hospital environment.

NG131 specifies that for people who have a raised PSA and MRI Likert score of 1 or 2, and who have not had a prostate biopsy, PSA blood tests should be repeated at 3 to 6 months and:

• offered prostate biopsy if there is a strong suspicion of prostate cancer, taking into account their life expectancy and comorbidities
• discharged to primary care if the level of suspicion is low; advise PSA follow-up at 6 months and then every year, and set a PSA level for primary care at which to re-refer based on PSA density or velocity.

The guidance also states that complex cases might need longer contact with hospital-based services (NG 131, 2019).

Between 2014-16, TCST and Croydon CCG worked in partnership to develop and test a holistic follow-up service that is catered to the physical and emotional well-being of patients. Following the pilot, a London pathway was endorsed by the London Cancer Commissioning Board in 2016. Evaluation of the adapted London pathway shows that:

• Practice based care is integrated with the holistic management of other long term conditions
• It offers high levels of patient satisfaction, with care delivered closer to home
• There is reduced personal cost to patients associated with outpatient appointments
• There is a high level of patient safety
• There is improved uptake and access to rehabilitation
• There is reduced specialist input and no virtual management of test results
• There is a significant freeing up of outpatient capacity compared with traditional hospital led face to face follow up.
• The cost per patient is significantly reduced, in comparison to the national secondary care tariff (at the time of the pilot).

Guidance and resources

• Business Case for the London pathway (2016)
• Frequently Asked Questions on the pathway (2015)
• Qualitative evaluation report – Croydon pilot with pan London recommendations (2016)
• Independent economic analysis report – Croydon pilot (2016)
• Operational Flowchart – Croydon pilot (2015)
• Desktop review of Prostate Cancer UK funded projects in London (2016)

Conferences, awards and publications

TCST’s pan London primary care pathway has received much attention from across England and overseas since 2015. The team has presented at conferences, a finalist in 2018 Health Services Journal Awards and has published journal articles. These include:

• Brodie H and Price L (2019), “Personalised stratified follow up: an integrated pathway for men with prostate cancer”, Prostate Cancer UK Conference, Birmingham, UK – co-designed and facilitated conference with Healthy London Partnership (Transforming Cancer Services Team), Southampton University (True NTH) and Prostate Cancer UK.
• Yaganti S and Price L (2018), “Designing and implementing a primary care led pathway for stable prostate cancer patients”, Multinational Association of Supportive Care in Cancer, Vienna, Austria
• 2018 HSJ Awards Finalist: Community or Primary Care Services Redesign – London and the South
• Dyer S et al (2016), “Stratified follow-up care for people with prostate cancer”, Primary Health Care, Vol 26:2, pp24-30,UK
• Dyer S and Yaganti S (2016), “Long-term support in primary care for men with prostate cancer, Independent Nursing, 18 October 2016, UK
• Transforming Cancer Services Team (2016) Enhanced primary care-led prostate cancer follow-up, Prostate Cancer UK
• 2015 General Practice Awards Finalist: Clinical team of the year for long term conditions