Prostate Cancer: A Primary Care Perspective

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1 + Prostate Cancer: A Primary Care Perspective Dr Jon Rees Tackle Conference, June 2015

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3 + Current Activities

4 + Current Activities

5 + The state of UK Primary Care

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7 + A system under strain 24% increase in GP consultations since 1998 now 340million per annum in UK Average person sees their GP 6x per year double the number of the previous decade Accompanied by huge increase in bureaucracy & box ticking 6/10 GP s considering retiring early due to workload, 3/10 actively planning this Large number of vacancies on GP training schemes June 2014 estimated at 451 some areas especially bad (East Midlands only 62% of training posts filled)

8 + Rising Demand in Primary Care Change in the average number of primary care consultations per patient per year, 'The 2022 GP Compendium of Evidence' - RCGP 2013

9 + The Perfect Storm! Surge of retirements Recruitment crisis Rising demand & expectations Unrealistic government promises (7 day, 8 til 8) Poor media image Demoralised workforce

10 + And yet. 2012/2013 GP patient survey: 87% of patients described their overall experience with their GP as good 86% were able to get an appointment the last time they called their practice

11 + The Future Computers in the future may weigh no more than 1.5 tons Popular Mechanics, 1949 I think there is a world market for maybe 5 computers Thomas Watson, Chairman of IBM, 1943

12 + The Future for Primary Care? Horizontal & Vertical Integration Multispecialty Community Provider Practices already merging & federating to work towards this goal What will this mean for prostate cancer patients?

13 + Ideas how could we improve community prostate cancer care in the future?

14 + Why isn t prostate cancer a higher priority for primary care?

15 + Prostate Cancer a low priority in primary care? Lack of under-graduate and post-graduate training in Urology 1 Only 42% medical students had compulsory attachment in Urology typically for 1 week Very little urology in GP training 2 hours? 2/3 of GP s are female Other clinical priorities driven by QOF & Enhanced Services An average of 4 new clinical guidelines per week 1. J Clin Urol 2012; 5: 4-10

16 + How many new cases of prostate cancer does a typical GP diagnose per year? 40,975 new cases of prostate cancer in ,349 working GP s in UK in Prostate Cancer Incidence Statistics: 2. BMA briefing paper 2010:

17 + What does a GP think of when asked about prostate cancer? PSA Over-diagnosis Over-treatment Cost of long term treatment: GnRH analogues PDE5 inhibitors Unnecessary follow up The disease you die with, rather than from

18 + Rank these causes of male death England & Wales 2013 Land Transport Accidents Assault Testicular Cancer Breast Cancer Prostate Cancer Myocardial Infarction Suicide Skin Cancer Bowel Cancer Lung Cancer

19 + Lung cancer 16,806 MI 13,533 Prostate Cancer 9,726 Bowel Cancer 7,578 Suicide 3,163 Skin Cancer 1,516 Land transport accidents 1,174 Assault 215 Breast Cancer 86 Testicular Cancer 57 Data from Office of National Statistics 2014:

20 + The Top Leading Causes Male Death UK No. of men

21 Prostate Cancer (C61): Average Number of Deaths per Year and Age-Specific Mortality Rates per 100,000 Population, UK Please include the citation provided in our Frequently Asked Questions when reproducing this chart: Prepared by Cancer Research UK Original data sources: 1. Office for National Statistics, Mortality Statistics: Deaths registered in England and Wales 2. General Register Office for Scotland, Deaths Time Series Data, Deaths in Scotland 3. Northern Ireland Statistics and Research Agency, Deaths by cause

22 + Causes of male death UK 2010

23 + Years of Life Lost (by cause) Males 2010

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25 + Primary Care: Roles in patient pathway PSA testing & the decision to refer Decision to biopsy Decision to treat Short to medium term follow up after treatment Administration of hormonal therapy Long term follow up of low risk patients with stable PSA Managing side effects of treatment Survivorship Reality PSA testing & the decision to refer Decision to biopsy Decision to treat Short to medium term follow up after treatment Administration of hormonal therapy Long term follow up of low risk patients with stable PSA Managing side effects of treatment Survivorship Ideal

26 + Survivorship Prostate Cancer dominates cancer survivorship for primary care (in men!)

27 + Male cancer survivors by site USA , 14% , 3% , 3% , 3% , 43% , 4% , 7% , 9% , 7% , 3% , 4% Prostate Bladder Testis Renal Colorectal Melanoma NH-Lymphoma Lung Oropharynx Leukaemia Other American Cancer Society. Cancer Treatment and Survivorship Facts & Figures Atlanta: American Cancer Society; 2012

28 + Male cancer survivors by site USA , 14% , 2% , 3% , 3% , 4% , 45% , 8% , 9% , 3% , 3% , 6% Prostate Bladder Testis Renal Colorectal Melanoma NH-Lymphoma Lung Oropharynx Leukaemia Other American Cancer Society. Cancer Treatment and Survivorship Facts & Figures Atlanta: American Cancer Society; 2012

29 + Male cancer survivors in UK (as proportion of population per 100,000) 3000 Colorectal Lung Prostate Other % of total male population in 2040 will be a prostate cancer survivor Projections of cancer prevalence in the UK Br J Cancer 2012; 107:

30 + Survivorship Prostate Cancer as a Chronic Disease

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32 + Survivorship issues for Primary Care Living with prostate cancer as a chronic disease Sexual function Continence Bowel function Cardiovascular health Metabolic Syndrome Bone Health Psychological wellbeing

33 + Primary & Secondary Care Perspectives Reports that say there's -- that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things that we know that we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns, the ones we don't know we don't know.

34 + Delivery of Survivorship / Wellbeing Who is going to deliver this?? Primary Care GP s: Capacity? Skills? Secondary Care Urologists: Capacity? Interest? Skills? CNS? Charity sector? Penny Brohn: Living well with the impact of prostate cancer courses Prostate Cancer UK / Movember: A Survivorship Action Partnership

35 + Questions?

36 + NICE Quality Standard

37 + Quality Statements Statement 1. Men with prostate cancer have a discussion about treatment options and adverse effects with a named nurse specialist. Statement 2. Men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable are also offered the option of active surveillance. Statement 3. Men with intermediate or high-risk localised prostate cancer who choose radical radiotherapy or androgen deprivation therapy, receive them only in combination with each other. Statement 4. Men with adverse effects of prostate cancer treatment are referred to specialist services. Statement 5. Men with hormone-relapsed metastatic prostate cancer have their treatment options discussed by the urological cancer multidisciplinary team (MDT). NICE Quality Standard for Prostate Cancer, June 2015

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40 + The gold standard prostate cancer journey: a patient perspective Men over 50 or (or black men over 45) requesting a PSA test or presenting in primary care with symptoms suggesting prostate cancer are risk assessed, counselled and offered a PSA test. If considered appropriate they should be referred to a specialist centre. Men referred with suspected prostate cancer are offered the full range and access to the most up to date and clinically effective diagnostic technologies. Men with prostate cancer have the opportunity to talk through all available treatment options and are provided with comprehensive information on the risks and benefits by members of their multi-disciplinary team (MDT) in order to make an informed decision.

41 + The gold standard prostate cancer journey: a patient perspective Men with prostate cancer (regardless of stage of disease) have access to their treatment of choice, including clinical trials if deemed clinically appropriate, regardless of geographical location. Men with prostate cancer are provided with a written personalised care plan that is regularly reviewed by their assigned clinical nurse specialist. They are signposted or referred to support groups and specialist services that are appropriate to their stage of disease to manage their physical, emotional, psychological and sexual health. All men with prostate cancer (and where relevant their partner/carer) have access to specialists to support the prevention and management of their complications arising from their disease, whether physical, social, emotional or psychological, arising from the disease and its treatment.

42 + The gold standard prostate cancer journey: a patient perspective Men with prostate cancer receive guidance and a package of care to support self-management of the side effects from their treatment, if they wish to do so. Men living with prostate cancer benefit from an integrated and seamless approach to their care and wellbeing appropriate to their stage of disease for the rest of their lives. This will include clear accountability and responsibility across primary and secondary care. All men receive and benefit from non-curative care at the appropriate stage of their disease, which is not limited to end of life care or restricted to being associated with hospice care.

43 + Reflections on the Quality Standard Is the NICE QS useful? Did NICE get the quality statements right? What did they leave off? Other thoughts?

44 + PSA Consensus Project Prostate Cancer UK 2015

45 + PSA Consensus Project Lack of comprehensive, clear guidance for primary health care professionals on: Men under 50 what is the threshold for referral to secondary care? Baseline testing either for initial risk stratification and/or to enable later assessment of PSA dynamics Men at higher than average risk how should this vary for black men, those with a strong family history etc Chaired by Peter Kirkbride, Oncologist Broad membership including Tackle representation Delphi survey of 335 HCP s, 3 focus groups with men with prostate cancer: Glasgow, Cardiff & Birmingham

46 + Risk Assessment Project Prostate Cancer UK 2014-

47 + Inconsistency The days of using 1 PSA threshold to trigger a biopsy for all men are over BJU Editorial 2015 having a PSA test is consenting to having a biopsy if the result is abnormal Local Urologist my PSA was 9 2 years ago, 12 last year and now it is 18 my GP says now it is a little concerning so they decided to refer me Patient I do a PSA on everyone GP PSA is essentially useless - GP

48 + Trends in PSA Utilisation by PCP s: Impact of the USPSTF Recommendation Most significant decrease in PSA testing in year old age group from 19.3% to 8.2% No significant difference in PSA testing frequency for men aged (4.2 vs 4.4%) or >70 years (10.2 vs 9.3%) Only 36% of men diagnosed with BPH had a PSA test 75% of PCP s had changed practice as a result of USPSTF with majority believing PSA testing does more harm than good AUA May 2015

49 + The GP & PSA screening decisions

50 + NICE Referral Guidelines for Suspected Cancer 2015 update Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their prostate feels malignant on digital rectal examination. [new 2015] Consider a prostate-specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in men with: any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or erectile dysfunction or visible haematuria. [new 2015] Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA levels are above the age-specific reference range. [new 2015]

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52 + A prostate cancer risk prediction tool for primary care practice Led by Chris Parker, Institute of Cancer Research & Royal Marsden Team includes: Mike Kattan, Cleveland Clinic Robert Nam, Sunnybrook, Toronto Monique Roobol, Erasmus Ewout Steyerberg, Erasmus Initial planning meeting also involved: Freddie Hamdy, Oxford Jan Adolfsson, Karolinska, Stockholm Henrik Gronberg, Karolinska, Stockholm Sunil Jain, Queens, Belfast Peter Albertsen, Connecticut Plus a GP from the UK!

53 + Aim is to produce a risk prediction tool that is applicable to the UK population and acceptable to men in the UK, their doctors and the NHS, when delivered through primary care, forming the basis for future international adoption. Help GP s interpret PSA results & make decisions re referral / follow up interval Reduce numbers of unnecessary biopsies Identify men at higher risk for aggressive forms of prostate cancer

54 + Stages of the process 1. Build simple models for pilot testing on European cohort 2. Validation & assessment of incremental value of additional predictors (routinely available to a UK GP) using other datasets 3. Estimation of long-term life expectancy 4. Combine PC risk with overall survival to produce online, personalised risk tool

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57 + Feedback from meeting on 12 th June 2015

58 + Other Issues

59 + Other issues Intermittent Hormone Therapy Prostate Cancer Care Review a practical guide for GP s PSA informed decision making proposal

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