Prostate cancer remains the most common male cancer in Scotland, accounting for more than 20% of all cancers diagnosed in men (Scottish Public Health Observatory, 2019). It is the largest cause of male cancer deaths. Although the number of cases per year has largely stayed the same in the past decade (NHS National Services Scotland Information Services Division, 2016), survival rates are improving, particularly where diagnosis is early (Prostate Scotland, 2020). The development of new technologies and treatments has undoubtedly contributed to improvements in outcomes. Alongside this, the ability to redesign pathways in line with technological advances, patients' needs and consumer expectations has become another critical success factor. This has certainly been the case at Edinburgh Cancer Centre, where prostate cancer pathways have evolved considerably since our brachytherapy service was first introduced in 2001.
Our infrastructure has been significantly bolstered; increased patient demand has meant the multidisciplinary team has more than doubled in size, while our collaboration across disciplines and specialties has greatly improved. The latter is crucial; the diagnosis and treatment of prostate cancer touches multiple clinical specialties and departments, including urology, pathology, radiology, theatre and anaesthetics.
The patient journey is complex and has extended geographically. As national awareness of brachytherapy has increased, the footprint of our patient population—as well as our patient numbers—has expanded. Today, around half the men referred into our service are from outside the Lothian area, travelling from as far afield as the Shetlands, Highlands and Western Isles. Ten years ago, that figure was around 25%. The increase has led us to develop two pathways—one for local patients and another, which includes a comprehensive one-day pre-assessment, for patients from further afield.
The uro-oncology CNS
The complexities of the journey from diagnosis to treatment shine a light on the importance of the clinical nurse specialist (CNS) team, which acts as the glue that binds everything together. At the Edinburgh Cancer Centre, we are fortunate to have three CNSs supporting our entire uro-oncology service.
Our role is primarily to support patients at every point along the pathway, providing accessible advice, information and guidance whenever required. We are also responsible for managing communication between the various internal disciplines to ensure pathways function efficiently. Our ultimate goal is to ensure an optimal patient experience.
The CNS role is particularly valuable in prostate cancer care, where the evolution in treatment options presents patients with choice at a time when coherent decision-making can often be compromised by the natural stresses of a cancer diagnosis. Our job is to provide unbiased advice about all the appropriate treatment options to ensure patients choose the right treatment for them. Quality-of-life studies show that, if a patient is happy with the treatment they choose, their outcomes, and ability to tolerate side-effects, are generally better (Shrestha et al, 2019).
Communication between patients and CNSs is always personalised and empathetic. Patients are rarely interested in the science or the statistics; they want to know the potential side-effects, the long-term implications and the likely clinical outcomes. And they want to hear it in simple English, not medical jargon.
It is a sign of how far brachytherapy has come that it is now a common feature of our conversations with patients. In the information age, awareness of brachytherapy has grown significantly and many of the patients we see already have some understanding. However, the ability to build on that knowledge and hear real-world experiences from informed professionals is hugely valuable. Nevertheless, with or without prior knowledge, CNS engagement gives patients an opportunity to discuss all their treatment options.
Brachytherapy: a useful option
For those patients where brachytherapy (permanent seed implant) is appropriate, it is a useful option. The treatment is highly convenient and, because it is less invasive than surgery, generally has faster recovery times. Similarly, side-effects such as incontinence or sexual dysfunction are often less severe than after surgery or radiotherapy. Most importantly, comparative effectiveness studies show that low-dose-rate brachytherapy reports equivalent recurrence-free survival rates to radical prostatectomy and external beam radiation therapy in both low and intermediate risk patients (Prostate Cancer Results Study Group, 2016).
At our service, logistical challenges around the use of theatre and resources restrict our service to two slots every week, totalling between 90 and 96 slots across the year. A decade ago, some of those slots would be unused. Today, the service is at full capacity. Demand for brachytherapy, both from the local area and beyond, is such that waiting lists have increased. This is not ideal but it illustrates the level of interest in the treatment. We are developing a business case in the hope of unlocking additional theatre time to reduce waiting times and treat more patients.
Brachytherapy is here to stay as a primary treatment option for prostate cancer.