Prostate Cancer (PC) affects 1 in 8 men during their lifetime and accounts for the most common type of cancer diagnosed in men within the UK (Cancer research UK, 2017). 

PC follow up has traditionally been clinic based. In recent years, alternative models of care have been explored including nurse-led telephone review and patient initiated care. Alternative approaches are equivalent to clinic based follow up with regards to patient satisfaction and detection of cancer recurrence (Howell et al, 2012)

Follow up care for men following treatment for PC is predominantly provided by secondary care throughout Scotland.  Regional and National Guidelines advises PSA follow up for 10 years following completion of treatment (NICE, 2019 and MCN, 2016).  Due to a combination of the increased number of men being diagnosed with PC and the 10 year period requirement for follow up is becoming increasingly difficult to manage. These factors led to a review of follow up services for men who have completed radical treatment for PC in NHS Ayrshire and Arran.

A small working team (Appendix 1) formed to discuss alternative follow up approaches. The Prostate Cancer pathway was designed by NHSAA, and built by inHealthcare (IHC) developers.  

The primary aim of the system was to:

• Provide safe effective follow up for patients.
• Allow quick access to test results (PSA) within 24-48 hours of having a test taken.
• Encourage the patient to be involved in their care.
• Provide a system where patients can access help/support timeously.
• Create a system which can cope with increasing number of patients.
• Reduce need for patients to attend hospitals as much as possible.
• Provide a service which is suitable for all patients i.e. options of communication.
• Develop role of a Support Worker (SW) to manage IHC system with support as required from Urology Oncology CNS.

The team agreed to select patients who had completed radical treatment for PC. This patient group was selected as a satisfactory range could be determined. 

Prostatectomy – PSA <0.1

Radiotherapy +/- hormones – PSA nadir + 2.

1. Referral from consultant to support worker (SW) for IHC follow up.
2. Send written information to patient follow up phone call to discuss and questions and ascertain communication preference.
3. Request prostate-specific antigen (PSA) tests as per protocol.
4. Select pathway
   1. Radiotherapy
   2. Prostatectomy.
5. Input patient details to IHC template - this will form the treatment summary.
6. A welcome email (APP) will be sent to patient with a copy of treatment summary.

SW will populate treatment summary with details of diagnosis, treatment and PSA satisfactory range.

Information will be taken from consultant referral letter and cross checked with MDT paperwork which is available on patient portal.

PSA satisfactory range will be inserted. SW will review blood results on Result reporting site initially at time of registering patient and select the lowest PSA reading since treatment was complete, this would be the PSA Nadir.

PSA satisfactory range

Patient will receive a copy of treatment summary by APP or email. This can also be printed and sent to patients who do not have access to internet. A copy will be filed on patient portal and a copy sent to GP.

See the process algorithm.

The support worker (SW) will receive an alert from the IHC system to advice when a PSA result is outwith the predetermined range. SW is responsible for arranging an urgent appointment with the CNS within 2-3 weeks to discuss results and further management plan.

Concerns

The patient will be prompted to report any concerns regarding symptoms they may have. The APP or email will allow the patient to leave a message for the SW who would respond timeously. The patient will have a selection of common concerns to choose from. If they select a common concern they will be directed to a link from Prostate Cancer regarding helpful information. Should they require help at any stage of follow up they can contact the SW directly by email, APP or telephone who would assess and discuss with senior colleagues as required.

Concerns list

• general concerns regarding prostate cancer
• urinary symptoms
• bowel symptoms
• erectile dysfunction
• fatigue/tiredness
• hot flushes
• financial concerns
• diet and exercise
• emotional issues.

Support worker (SW) recruited for purpose of managing the IHC system with support from Urology Oncology Clinical Nurse Specialists (CNSs).

Training

The SW will be responsible for requesting PSA blood tests for all patients enrolled on IHC system. PSA bloods tests will be requested as per follow up protocol – (Appendix 2).

Phlebotomy Request Supervised Practice

The SW will require to complete 20 blood requests under the supervision of the Urology Oncology CNS. When deemed competent the SW will be able to request blood samples independently as per the protocol. A further 5 cases will be reviewed each year by the CNS.

Supervised practice – (Appendix 3).

Registering Patient to IHC system

The SW will require to register 10 patients to the IHC system as per protocol under supervised practice.  A further 5 cases will be reviewed each year by the CNS.

Supervised practice – (Appendix 4).

Development and support

A training diary will be maintained by the SW to capture all experiential learning. The SW and CNS will meet weekly to discuss progress and address any ongoing training needs.

If patients do not have blood samples taken within 2 weeks of their due date, the system will alert the SW.  The support worker will explore the reasons for blood not being checked and rectify. If the patient is non-compliant they should be referred to an alternative pathway.

During the initial 6 months a manual process will run alongside the digital pathway to ensure all results are being checked timeously and that patients are receiving notification of results.

Paper copies of PSA results will be checked against the digital pathway to ensure accuracy.  Any change of report or additional notes which may not be captured will be recorded by the support worker and highlighted to CNS who will action appropriately.  All cases of notes being applied to reports or change of results will be recorded for audit purposes and reviewed monthly.  If any issues are identified the CNS will discuss with the IHC team to work towards a solution.

Audit

Audit will take place to assess the safety of the process. 

Audit will be carried out to assess patient satisfaction.

Audit will be carried out to assess cost effectiveness of project.

Reports will be produced quarterly within year.

Robinson, Nicola
Project Manager
Turnberry Building, Ailsa Hospital
Owner

Callaghan, Sharon
Project Manager, TEC Digital Services
Turnberry Building, Ailsa

Hales, Michelle
Project Co-ordinator
Turnberry Building

Cottingham, Gillian
Digital Facilitator
Turnberry Building

Andrews, Karen
General Manager, Surgical Services
Level 1, Management Offices, University Hospital Ayr
Member

Glen, Hilary
Consultant Medical Oncologist
Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN
Member

Baillie, Marie
Clerical Officer
Ayr Hospital
Member

McGlynn, Brian
Nurse Consultant Urology Oncology
Ayr Hospital
Member

Connor, Karen
MCN & Improvement Manager
Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF
Member

Clark, Ross
Consultant Urological Surgeon
Ayr Hospital
Member

Fleming, Mark
Nurse Consultant Digital Services
Care Partner Team – Digital Services, Room 632, Ground Floor (Childsmile corridor),
Horseshoe Building, Ayrshire Central Hospital
Member

Pellowe, Alexia
GP Principal
Loudoun Medical Centre, Darvel
Member

White, Lillian
Specialist Nurse Urology Cancer
Ayr Hospital
Member

Brown, Hugh (Dalmellington Medical Practice (80202)) (Guest)
Guest

Dawson, Jillian
Oncology Clinical Nurse Specialist
Ayr Hospital
Member

MacLeod, Nicholas
Consultant in Clinical Oncology
Beatson West Of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN
Member

Lambert, Karen
Programme Manager
Ailsa Hospital
Member

Paterson, Jordan
Medical Secretary
Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF
Member

McCusker, Laura
GP
The Cathcart Street Practice

Proposed follow up schedules are in accordance with the Prostate Cancer Regional Follow up Guidelines (WOS MCN, 2016 and NICE, 2019)¹ .

Radical treatments - surgery/hormones and radiotherapy

If PSA and symptoms stable discharge to GP at 10 years - no routine PSA testing advised.

Supervised practice blood tests form

Supervised practice: registrations form

1. West of Scotland Cancer Network. Urological Cancers Managed Clinical Network Primary Care Cancer Network. Prostate cancer regional follow-up guidelines. v2.0. October 2016. Available from: https://www.woscan.scot.nhs.uk/wp-content/uploads/URO-Prostate-Cancer-Follow-up-Guidelines-v2.0-October-2016_Review-extended.pdf