Over the past 3 years, I have been dedicated to helping redesign the patient pathway for men with suspected prostate cancer at my trust. I had already undertaken elevated prostate-specific antigen (PSA) assessment and transrectal ultrasound-guided prostate biopsies, so was in a good position to lead on these changes.
Back in 2018, achieving the new faster diagnostic standard for prostate cancer by April 2020 required the communication of a cancer diagnosis, or the ruling out of cancer, to the patient within 28 days from referral from their GP (NHS England, 2018). Prostate cancer is now the most common cancer diagnosed in men in the UK. Increasing numbers of referrals presented a real challenge for most NHS trusts to achieve this new best practice pathway. Within my own trust the same patient pathway was in excess of 43 days. It was therefore identified that improvements in the current pathway would be required to meet the new diagnostic target.
Improving practice
Urology consultants, cancer managers and I met with the Clinical Commissioning Group (CCG) to identify ways in which we could work towards achieving the best practice pathway. Referrals were being made on the basis of one elevated PSA blood test. I had already undertaken a previous audit, which revealed that 20% of our referrals had a normal PSA blood test result on repeat testing. These patients did not require any further investigation; however, they were taking up valuable appointments within the clinic. The urology advanced nurse practitioners (ANPs) were already assessing these patients, as well as ordering investigations and conducting transrectal ultrasound prostate biopsies (TRUS-Bx) for others.
It was agreed that we would:
- Pilot new streamlined referral guidance for suspected prostate cancer based on two elevated PSA blood tests at least 4 weeks apart
- Introduce a nurse-led telephone triage service for the referrals
- Refer straight to test with a multi-parametric magnetic resonance imaging (mpMRI) scan
- Evaluate whether this achieved a faster pathway and improved patient experience.
The new referral criteria of two PSA tests that showed results above the age-related range were agreed with our local CCG only. Referrals received from outside our local CCG were managed as per our standard pathway. Not all patients would be suitable for telephone triage, which led to these patients continuing to be seen at a fast-track clinic appointment.
A protocol was developed, along with a patient information leaflet and a telephone triage proforma to record the consultation. The pilot ran for 6 months and data were collected prospectively for a comparison of the three referral pathways:
- Telephone triage straight to test
- Telephone triage to outpatient appointment
- Referral to appointment as per the standard pathway.
Telephone triage
Telephone triage as a new way of assessment was challenging; however, we committed to triaging referrals within 1-2 days. A detailed patient history was sometimes difficult to establish over the telephone. A full history was needed to request an MRI scan. Patients who required an interpreter or had capacity issues were always seen in a clinic appointment. The telephone triage assessment document was invaluable as a trigger to obtain all relevant information and was updated several times during the pilot. Communication of the telephone triage outcome to the fast track and multidisciplinary team (MDT) was achieved through a new dedicated triage email account, which channelled all communication through this one portal. Ensuring clear communication for this new referral pathway was the most challenging factor and for this reason the ANPs largely managed all aspects of the patient pathway for the duration of the initiative.
A patient satisfaction survey revealed that 80% of patients were highly satisfied with their experience of telephone triage straight to test. We demonstrated that the requirement of two PSA tests reduced inappropriate referrals by an average of 13.6%. This expedited the patient journey at the onset of the pathway with telephone triage patients having their mpMRI requested at a median of 3 days, compared with 11 days if attending a clinic appointment. An MRI was performed at a median of 15 days, compared with 22 days previously.
Bottlenecks with biopsy appointments resulted in the overall benefit in waiting times being less than anticipated, with a median of 48 days to communication of results for the telephone triage patients. This initiative helped the urology MDT to identify where specific improvement was required in our prostate cancer pathway. As a result, a radiology tracker post was created to expedite mpMRI appointments.
Sharing practice
The telephone triage service has been well received and has become standard practice within our organisation. As the first team in the West Midlands Cancer Alliance to introduce this, we have presented our findings to other hospitals and shared our protocols and experiences with other urology teams and specialist nurses. We submitted this project as a poster to the European Association of Urological Nurses annual conference in Amsterdam (Waymont et al, 2020a) and we were invited to present this. However, due to the global pandemic in 2020 this conference was cancelled. We have been asked to present it again this year. The results of our experience have been shared on the FutureNHS collaboration platform in the urology faster diagnosis workspace as—well as being included in a mailshot sent out by NHS England Innovation and Improvement.
This service has certainly been of benefit during the COVID-19 pandemic as telephone consultations have been the primary route of communication with patients.
Implementing this project successfully has required nurse specialists with expert knowledge of prostate cancer who are able to assess and make clinical decisions and who can also request imaging such as mpMRI scans. It is important to establish who are the important stakeholders and therefore engage with these key individuals to work together and gain support for the initiative. We have been able to present our findings to other departments responsible for different elements of the pathway and this has created a multidisciplinary approach to improving the cancer pathway.
Audit
I was co-lead author on a 5-year retrospective audit conducted to analyse the feasibility of discharging patients with a normal age-related PSA on repeat testing or an mpMRI reported as a Prostate Imaging–Reporting and Data System (PI-RADS) 2 or below.
Between 2014 and 2019, 2393 patients were seen in the nurse-led clinic for suspected prostate cancer. Some 953 patients were identified for audit inclusion who had no history of a previous prostate cancer or had a prostate biopsy at that first referral. Out of the 953 patients:
- 272 had a normal PSA on repeat testing and 137 had an MRI PI-RADS 2 (409 patients)
- Of these 409 patients, 361 were discharged back to their GP. The other patients remained under our care based on other risk factors such as a family history of digital rectal examination findings. Overall 6 (1.6%) were subsequently found to have a clinically significant prostate cancer on further referral (Gleason score of 3+4 or above). Mean referral time was 16 months
- Out of the 137 patients who had an MRI PI-RADS 2, 96 were discharged to their GP. The remaining patients stayed under our care for surveillance.
In total, 96 (10%) patients were discharged without biopsy following an mpMRI PI-RADS 2 and below, and no subsequent cancer has been found to date in this group of patients.
Of all patients discharged to primary care (361), 90 had specific advice for PSA follow-up but had no subsequent PSA testing in the community. This was fed back to the teams at the West Midlands Cancer Alliance. Discharge letters were copied to patients as well as GPs with the specific instructions for PSA testing. These data were also communicated via a local GP training day.
This innovative risk stratification and discharge to primary care of patients not requiring immediate prostate biopsy with very low re-attendance rate has redesigned this suspected prostate cancer pathway within my NHS trust. Adopting referral criteria of two raised PSA blood tests and discharging patients with mpMRI PI-RADS 2 and below may help achieve best practice pathway targets, while minimising the risk of missing clinically significant prostate cancer. A poster presentation of this audit was presented at the British Association of Urological Surgeons (BAUS) in 2020 (Waymont et al, 2020b).
Supporting black men
Black men are more likely to develop and die from prostate cancer than any other ethnic group. In the midst of my work I also developed a new support group specifically aimed at the black community. The aim of the support group was to increase awareness of prostate cancer in black men and also provide them and their families with peer support. I undertook a patient engagement exercise that led to the development of Brothers Reaching Out To/For Support in Prostate Cancer (BROS). Being able to set up BROS in a venue familiar to the black community was essential. Having speakers present with a cultural view in mind and using advertising platforms that the community were familiar with has helped to overcome barriers. This led to an increase in referrals for this cohort of men by 57% in 2019. During the current pandemic we have unfortunately been unable to meet bi-monthly; however, I have almost finished creating a website where all of the relevant and correct information can be found.
Sharing knowledge
Having a passion to share best practice, I have also been involved over the past 12 months with the following:
- Participation in audit of outcomes following a Urolift procedure, which was presented at the British Association of Urology Nurses annual conference in 2019 (Kusinski et al, 2019)
- Co-author for a further poster presentation at BAUS 2020 on trial without catheter success rates for patients treated with dual medical therapy. This showed a 50% success rate (Khela et al, 2020)
- Involvement in the development of guidelines for the West Midlands Cancer Alliance (2019) to provide a stratified follow-up pathway for stable treated prostate cancer patients.
Undertaking any project requires motivation and hard work but I would emphasise to others the rewards of improving the patient cancer journey and sharing that experience with other urology teams and specialist nurses.