Download Prostate Cancer: A Primary Care Perspective

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Prostate Cancer: A Primary Care Perspective
Dr Jon Rees
Tackle Conference, June 2015
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Current Activities
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Current Activities
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The state of UK Primary Care
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A system under strain…
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24% increase in GP consultations since 1998 – now
340million per annum in UK
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Average person sees their GP 6x per year – double the
number of the previous decade
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Accompanied by huge increase in bureaucracy & box ticking
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6/10 GP’s considering retiring early due to workload, 3/10
actively planning this
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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)
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Rising Demand in Primary Care
Change in the average number of primary care consultations per patient per year,
1995-2008
'The 2022 GP – Compendium of Evidence' - RCGP 2013
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The Perfect Storm!
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Surge of retirements
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Recruitment crisis
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Rising demand & expectations
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Unrealistic government
promises (7 day, 8 til 8)
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Poor media image
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Demoralised workforce
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And yet….
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2012/2013 GP patient survey:
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87% of patients described
their overall experience with
their GP as good
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86% were able to get an
appointment the last time they
called their practice
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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
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The Future for Primary Care?
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Horizontal & Vertical Integration
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Multispecialty Community
Provider
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Practices already merging &
federating to work towards this
goal
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What will this mean for prostate
cancer patients?
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Ideas – how could we improve
community prostate cancer care in
the future?
+ Why isn’t prostate cancer a
higher priority for primary
care?
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Prostate Cancer – a low priority in
primary care?
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Lack of under-graduate and post-graduate training in
Urology1
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Only 42% medical students had compulsory attachment in
Urology – typically for 1 week
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Very little urology in GP training – 2 hours?
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2/3 of GP’s are female
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Other clinical priorities – driven by QOF & Enhanced
Services
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An average of 4 new clinical guidelines per week
1. J Clin Urol 2012; 5: 4-10
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How many new cases of prostate
cancer does a typical GP diagnose per
year?
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40,975 new cases of
prostate cancer in
20101
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41,349 working GP’s
in UK in 20102
1.Prostate Cancer Incidence Statistics: http://www.cancerresearchuk.org/cancerinfo/cancerstats
2. BMA briefing paper 2010:
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What does a GP think of when asked
about prostate cancer?
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PSA
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Over-diagnosis
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Over-treatment
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Cost of long term treatment:
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GnRH analogues
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PDE5 inhibitors
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Unnecessary follow up
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‘The disease you die with, rather than from’
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Rank these causes of male death
England & Wales 2013
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Land Transport Accidents
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Assault
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Testicular Cancer
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Breast Cancer
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Prostate Cancer
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Myocardial Infarction
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Suicide
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Skin Cancer
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Bowel Cancer
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Lung Cancer
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Lung cancer 16,806
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MI 13,533
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Prostate Cancer 9,726
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Bowel Cancer 7,578
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Suicide 3,163
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Skin Cancer 1,516
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Land transport accidents 1,174
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Assault 215
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Breast Cancer 86
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Testicular Cancer 57
Data from Office of National Statistics 2014:
www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-327590
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The Top 10
Leading Causes Male Death UK 2012
40000
35000
30000
25000
20000
15000
10000
5000
0
www.ons.gov.uk/ons/rel/vsob1/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2012/sty-causes-of-death.html
No. of men
Prostate Cancer (C61): 2010-2012
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: http://info.cancerresearchuk.org/cancerstats/faqs/#How
Prepared by Cancer Research UK
Original data sources:
1. Office for National Statistics, Mortality Statistics: Deaths registered in England and Wales
http://www.ons.gov.uk/ons/search/index.html?newquery=series+dr
2. General Register Office for Scotland, Deaths Time Series Data, Deaths in Scotland
http://www.gro-scotland.gov.uk/statistics/theme/vital-events/deaths/time-series.html
3. Northern Ireland Statistics and Research Agency, Deaths by cause
http://www.nisra.gov.uk/demography/default.asp14.htm
+ Causes of male death
UK 2010
+ Years of Life Lost (by cause)
Males 2010
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Primary Care:
Roles in patient pathway
Reality
Ideal
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PSA testing & the decision to refer
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PSA testing & the decision to refer
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Decision to biopsy
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Decision to biopsy
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Decision to treat
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Decision to treat
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Short to medium term follow up after
treatment
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Short to medium term follow up after
treatment
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Administration of hormonal therapy
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Administration of hormonal therapy
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Long term follow up of low risk patients
with stable PSA
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Long term follow up of low risk
patients with stable PSA
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Managing side effects of treatment
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Managing side effects of treatment
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Survivorship
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Survivorship
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Survivorship
Prostate Cancer dominates
cancer survivorship for primary
care (in men!)
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Male cancer survivors by site –
USA 2012
887810, 14%
167740, 3%
185240, 3%
189080, 3%
2778630, 43%
279500, 4%
481040, 7%
595210, 9%
437180, 7%
213000, 3%
230910, 4%
Prostate
Bladder
Testis
Renal
Colorectal
Melanoma
NH-Lymphoma
Lung
Oropharynx
Leukaemia
Other
American Cancer Society. Cancer Treatment and Survivorship Facts & Figures 2012-2013. Atlanta: American Cancer Society; 2012
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Male cancer survivors by site –
USA 2022
1259700, 14%
220010, 2%
232330, 3%
231380, 3%
3922600, 45%
371980, 4%
661980, 8%
751590, 9%
548870, 6%
300800, 3%
295590, 3%
Prostate
Bladder
Testis
Renal
Colorectal
Melanoma
NH-Lymphoma
Lung
Oropharynx
Leukaemia
Other
American Cancer Society. Cancer Treatment and Survivorship Facts & Figures 2012-2013. Atlanta: American Cancer Society; 2012
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Male cancer survivors in UK
(as proportion of population per 100,000)
Colorectal
Lung
Prostate
Other
3000
2500
2306
2000
2.3% of total male
population in 2040 will
be a prostate cancer
survivor
1771
1500
1264
1000
835
500
0
2010
2020
Projections of cancer prevalence in the UK 2010-2040. Br J Cancer 2012; 107: 1195 - 1202
2030
2040
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Survivorship
Prostate Cancer as a ‘Chronic Disease’
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Survivorship issues for Primary
Care
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Living with prostate cancer as a ‘chronic disease’
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Sexual function
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Continence
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Bowel function
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Cardiovascular health
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Metabolic Syndrome
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Bone Health
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Psychological wellbeing
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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”.
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Delivery of Survivorship / Wellbeing
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Who is going to deliver this??
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Primary Care – GP’s: Capacity? Skills?
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Secondary Care – Urologists: Capacity? Interest? Skills?
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CNS?
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Charity sector?
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Penny Brohn: ‘Living well with the impact of prostate cancer’ courses
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Prostate Cancer UK / Movember: ‘A Survivorship Action Partnership’
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Questions?
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NICE Quality Standard
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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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The gold standard prostate cancer
journey: a patient perspective
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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.
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Men referred with suspected prostate cancer are offered the
full range and access to the most up to date and clinically
effective diagnostic technologies.
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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.
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The gold standard prostate cancer
journey: a patient perspective
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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.
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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.
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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.
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The gold standard prostate cancer
journey: a patient perspective
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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.
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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.
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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.
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Reflections on the Quality Standard
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Is the NICE QS useful?
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Did NICE get the quality statements right?
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What did they leave off?
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Other thoughts?
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PSA Consensus Project
Prostate Cancer UK 2015
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PSA Consensus Project
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Lack of comprehensive, clear guidance for primary health care
professionals on:
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Men under 50 – what is the threshold for referral to secondary care?
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Baseline testing – either for initial risk stratification and/or to enable
later assessment of PSA dynamics
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Men at higher than average risk – how should this vary for black men,
those with a strong family history etc
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Chaired by Peter Kirkbride, Oncologist
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Broad membership including Tackle representation
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Delphi survey of 335 HCP’s, 3 focus groups with men with
prostate cancer: Glasgow, Cardiff & Birmingham
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Risk Assessment Project
Prostate Cancer UK 2014-
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Inconsistency
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“The days of using 1 PSA threshold to trigger a biopsy for all
men are over” – BJU Editorial 2015
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“having a PSA test is consenting to having a biopsy if the result
is abnormal” – Local Urologist
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‘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
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‘I do a PSA on everyone’ – GP
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“PSA is essentially useless” - GP
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Trends in PSA Utilisation by PCP’s:
Impact of the USPSTF Recommendation
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Most significant decrease in PSA testing in 50-70 year old
age group – from 19.3% to 8.2%
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No significant difference in PSA testing frequency for men
aged 40-49 (4.2 vs 4.4%) or >70 years (10.2 vs 9.3%)
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Only 36% of men diagnosed with BPH had a PSA test
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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
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The GP & PSA screening decisions
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NICE Referral Guidelines for
Suspected Cancer – 2015 update
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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]
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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]
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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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‘A prostate cancer risk prediction
tool for primary care practice’
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Led by Chris Parker, Institute of Cancer Research & Royal Marsden
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Team includes:
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Mike Kattan, Cleveland Clinic
Robert Nam, Sunnybrook, Toronto
Monique Roobol, Erasmus
Ewout Steyerberg, Erasmus
Initial planning meeting also involved:
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Freddie Hamdy, Oxford
Jan Adolfsson, Karolinska, Stockholm
Henrik Gronberg, Karolinska, Stockholm
Sunil Jain, Queens, Belfast
Peter Albertsen, Connecticut
Plus a GP from the UK!
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“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.”
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Help GP’s interpret PSA results & make decisions re referral /
follow up interval
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Reduce numbers of ‘unnecessary biopsies’
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Identify men at higher risk for aggressive forms of prostate
cancer
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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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Feedback from meeting on 12th
June 2015
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Other Issues
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Other issues
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Intermittent Hormone Therapy
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Prostate Cancer Care Review – a practical guide for GP’s
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PSA informed decision making proposal