Download clinic name - London Cancer Alliance

Prostate – Active
Surveillance
Patient Name
Dear Patient Name
TREATMENT SUMMARY
You have now completed your initial treatment for cancer. This Treatment Summary provides a
summary of your diagnosis, treatment and on-going management plan. It includes information on the
symptoms you should be aware of, and who to contact. Your GP will also receive a copy of this
summary.
Diagnosis:
Prostate Cancer
Date of Diagnosis:
Organ/Staging
Local/Distant
Summary of Treatment and relevant dates:
Active Surveillance
Possible Consequences of Continued Surveillance:

Urinary symptoms (frequency, urgency, night time voiding)

Erectile dysfunction

Psychological issues
Treatment Aim:
You are on active surveillance because you have
localised prostate cancer and may never need
treatment unless your prostate cancer
progresses
Advise entry onto primary care palliative or
supportive care register
Yes / No
DS 1500 application completed
Yes/No
Prescription Charge exemption arranged
Yes/No
Alert Symptoms that require referral back to specialist team:
Contacts for re referrals or queries:
In relation to post biopsy complications please attend your local A&E:

Passing large blood clots or the feeling of being unable to pass
urine.

A high temperature/shivering/shaking
In Hours:
Other symptoms to seek advice about:
 A change in your urinary symptoms
 Pain in your lower back
 A sudden onset of weakness in your legs - URGENT
 Unintended weight loss (more than 3kg)
 Loss of appetite
Secondary Care Ongoing Management Plan: (tests, appointments etc)
Out of hours:
Other service referrals made: (delete as nec)
District Nurse
AHP
Social Worker
Dietitian
Clinical Nurse Specialist
Psychologist
Benefits/Advice Service
Other
Your urology consultant or nurse specialist will manage any other incidental
symptoms e.g. urinary symptoms and erectile dysfunction
Please get a PSA test taken with your GP every 6 months. It is your
responsibility to ensure you have these PSA checks.

If your PSA is more than __________please contact us on
email____________________ or call us on XXXX
patient name | date of birth | hospital number

Your next MRI scan is due______________________.

Your next biopsy will be considered_______________.

You will be referred to our post treatment seminar session if you
require any intervention for symptom control or support.
Always have a PSA done at least one week prior to your outpatient
appointment – please contact your GP to organise your PSA and
bring the results with you to your appointment.
Required GP actions in addition to GP Cancer Care Review (e.g. ongoing medication, osteoporosis and cardiac screening)
Your urology consultant or nurse specialist will manage any other incidental symptoms e.g. urinary symptoms and erectile
dysfunction
Summary of information given to the patient about their cancer and future progress:
Normal working hours: 9-5:
Prostate Cancer Nurse Specialist: XXXXX
Prostate Clinic Appointments: XXXXX
Out of hours/emergencies:
XXXX hospital switch board and ask for the on-call urology registrar
Additional information including issues relating to lifestyle and support needs:
Post treatment seminars on living & keeping well: eating well, keeping active, relationship counselling, psychologist (holistic needs).
Managing the after effects of treatment: urinary symptoms, erectile dysfunction & hot flushes
Support group (last Friday of the month 14:00 – 15:30) No referral required
Other:
Yours sincerely
Electronically Approved By:
PRIVATE AND CONFIDENTIAL
cc.
Patient GP Name
Patient GP Address
Patient GP Post Code
Supporting Documents that may help – Please delete this section before giving to the patient


Sexual Consequences for Men Prompt Tool
(http://www.londoncanceralliance.nhs.uk/media/118596/lca-hna-male-sexual-consequencesjanuary-2016.pdf)
Fatigue Prompt Tool
(http://www.londoncanceralliance.nhs.uk/media/122127/lca-hna-fatigue-prompt-sheetjanuary-2016.pdf)
Name | Date of birth | Hospital Number

Pain Prompt Tool (http://www.londoncanceralliance.nhs.uk/media/122133/lca-hna-painprompt-sheet-january-2016.pdf)
Name | Date of birth | Hospital Number
GP READ CODES FOR COMMON CANCERS (For GP Use only). Other codes available if required.
(Note: System codes are case sensitive so always ensure codes are transcribed exactly as below)
System 1
Diagnosis:
Lung Malignant Tumour
Carcinoma of Prostate
Malignant tumour of rectum
Bowel Intestine
Large Bowel
Female Malignant Neoplasia
Male Malignant Neoplasia
Histology/Staging/Grade:
Histology Abnormal
Tumour grade
Dukes/Gleason tumour stage
Recurrent tumour
Local Tumour Spread
Mets from 1°
Treatment
Palliative Radiotherapy
Curative Radiotherapy
Chemotherapy
Radiotherapy
Treatment Aim:
Curative procedure
Palliative procedure
Treatment toxicities/late effects:
Osteoporotic #
Osteoporosis
Infection
Ongoing Management Plan
Follow up arranged (<1yr)
Follow up arranged (>1yr)
No FU
Referral PRN
Referrals made to other services:
District Nurse
Social Worker
Nurse Specialist
SALT
Actions required by the GP
Tumour marker monitoring
PSA
Osteoporosis monitoring
Referral for specialist opinion
Advised to apply for free prescriptions
Cancer Care Review
Palliative Care Review
Medication:
New medication started by specialist
Medication changed by specialist
Advice to GP to start medication
Advice to GP to stop medication
Information to patient:
DS1500 form claim
Benefits counselling
Cancer information offered
Cancer diagnosis discussed
Aware of diagnosis
Unaware of prognosis
Carer aware of diagnosis
Miscellaneous:
On GSF palliative care framework
GP OOH service notified
Carers details
(5 digit
codes)
XaOKG
X78Y6
XE1vW
X78gK
X78gN
B34..
B35..
4K14.
X7A6m
XaOLF
XaOR3
X7818
XaFr.
5149.
XalpH
x71bL
Xa851
Xallm
XaiL3
Xa1TO
XaELC
Xa9ua
8H8..
XaL..
8HA1.
8HAZ.
XaBsn
XaBsr
XaAgq
XaBT6
Xalqg
Xalqh
XalSd
Xalst
9D05
Xalyc
XalG1
XEOhn
8B316
XaKbF
XaJC2
All other systems
Version 3 five byte
codes
(October 2010
release)
Diagnosis
Malignant neoplasm of bronchus or lung
Malignant neoplasm of prostate
Malignant neoplasm of Rectum
Malignant neoplasm of Colon
Malignant neoplasm of female breast
Malignant neoplasm of male breast
B22z.
B46..
B141.
B13..
B34..
B35..
Histology/Staging/Grade:
Histology Abnormal
Tumour staging
Gleason grading of prostate Ca
Recurrence of tumour
4K14.
4M…
4M0..
4M6..
Metastatic NOS
Treatment
Radiotherapy tumour palliation
Radiotherapy
Chemotherapy
BB13.
5149.
7M371
8BAD.
Treatment Aim:
Curative treatment
Palliative treatment
8BJ0.
8BJ1.
At risk of osteoporosis
Osteoporosis
1409.
N330.
Ongoing Management Plan
Follow up arranged
8H8..
No follow up arranged
8HA..
Referrals made to other services:
Refer to District Nurse
Refer to Social Worker
8H72.
8H75.
Actions required by the GP
Tumour marker monitoring
PSA
Osteoporosis monitoring
8A9..
43Z2.
66a..
Entitled to free prescription
Cancer Care Review
Palliative Care Plan Review
Medication:
Medication given
Medication changed
6616.
8BAV.
8CM3.
8BC2.
8B316
Information to patient:
DS1500 completed
Benefits counselling
Cancer information offered
Cancer diagnosis discussed
9EB5.
6743.
677H.
8CL0.
XaJv2
Xaltp
Miscellaneous:
On GSF Palliative Care Framework
GP OOH service notified
8CM1.
9e0..
9180.
Carer details
9180.
XaCDx
6743.
XalmL
XalpL
XaQly
XaVzE
XaVzA
National Cancer Survivorship Initiative
Name | Date of birth | Hospital Number
December 2010