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2013/14 NHS STANDARD CONTRACT
PARTICULARS
SCHEDULE 2 – THE SERVICES
A.
Service Specification
Service Specification No.
2.4
Service
MANANGEMENT OF STABLE PROSTATE CANCER
PATIENTS IN PRIMARY CARE SERVICE SPECIFICATION
Commissioner Lead
NHS Herts Valleys Clinical Commissioning Group
Provider Lead
General Practice
Period
2015/16
Date of Review
Version
Version 6 (11/3/2015) FINAL VERSION
1. Population Needs
1.1
National/local context and evidence base
Within cancer services in Herts Valleys there is a strategic direction to move towards developing
new approaches to cancer follow up in line with the National Cancer Survivorship Initiative.
A review of current UK service provision following cancer treatment identified wide variation in
practice, from no follow-up with rapid access, to lifelong follow-up visits combined with or without
surveillance tests (NHS Improvement, rapid Review of Follow Up 2009). Furthermore a
systematic review to evaluate the clinical effectiveness and cost effectiveness of follow up after
cancer treatment (CRD, 2007) concluded there was a poor evidence base and no consensus as
to the intensity, duration, setting or type of follow up required for most common forms cancer.
One in eight men in the UK will develop prostate cancer, it is the most common cancer in men
and mainly affects the over 50’s. The average age of men to be diagnosed with prostate cancer is
between 70-74 years. The incidence is rising. Secondary Care currently struggling to manage
FU’s and there is a need to redesign current pathway.
Guidelines recommend men with stable PSA who have no significant treatment complications,
should be offered follow up outside hospital (for example in primary care) by telephone or secure
electronic communications, unless they are taking part in a clinical trial that requires formal
clinical based follow up. Direct access to the urological MDT should be offered and explained. In
addition NICE guidelines on Prostate Cancer state:
Men with prostate cancer who have chosen a watchful waiting regimen with no curative intent
should normally be followed up in primary care in accordance to protocols agreed by the local
urological cancer Multidisciplinary Team (MDT) and relevant primary care organisations. Their
PSA (prostate specific antigen) should be measured at least once a year.
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2. Outcomes
2.1
2.2
NHS Outcomes Framework Domains & Indicators
Domain 1 Preventing people from dying prematurely
Domain 2 Enhancing quality of life for people with long-term conditions
Domain 3 Helping people to recover from episodes of ill-health or following
injury
Domain 4 Ensuring people have a positive experience of care
Domain 5 Treating and caring for people in safe environment and protecting
them from avoidable harm
YES
YES
NO
YES
YES
Local defined outcomes
It is intended the following outcomes will be achieved via commissioning of a Primary Care
Prostate FU Service
 Reduce follow up and reviews in hospital
 Provide a local cost-effective service
 Improved patient experience – monitored through patient surveys
 Improved professional satisfaction both primary and secondary care
 Patient experience and quality of life is improved through goal setting and through
health and wellbeing course
3. Scope
3.1
Aims and objectives of service
Aims
The aims of this service are to move care of prostate cancer patients stable on treatment out of the
acute hospital setting and into primary care. The aims support the strategic objectives of moving care
closer to home and delivery of productivity savings.
Objective
 Provide routine follow up management of patients with prostate cancer with stable PSA and who
have no significant, or stable, complications and who are registered with a General Practitioner
(GP) in the catchment areas of Herts Valleys Clinical Commissioning Group. Service provision to
be aimed at adults registered with a general practice in Herts Valleys CCG.
 Improve the first to follow up ratio in the acute which will lead to releasing consultant and
specialist nurses to focus on new appointments including improvement in RTT (referral to
treatment target) and delivering holistic care assessments in patients with advanced disease
 To identify patients whose disease has progressed and ensure rapid referral back into secondary
care for review (see appendix 2 for referral triggers)
 The service will provide a high quality, responsive, cost effective GP-practice based service.
 Ensure care is tailored to patient’s holistic needs and access to services is available and
equitable.
 To bring care closer to patients home through safe and comprehensive follow up delivered by
up-skilled/trained primary care staff
 Improve patient outcomes through promotion and access to health and wellbeing support clinics
in the community
 Improve the patient experience
HVCCG will contract on registered list base with the general practice. Where surgeries wish to provide
this collaboratively for their registered population, they can make local arrangements to manage this
between themselves as the contract will be with individual practice.
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3.2
Service description/care pathway
The service is to provide a follow up consultation for patients with established prostate cancer with stable
PSA and who have no significant or at least stable treatment complications. The Consultation FU
timeframe (ie 3,6 months/weeks) will vary according to the protocol used (see appendix 2). The
consultation is to include a review of the patient PSA test, symptoms and side effects of treatment.
Patients in secondary care with prostate cancer with stable PSA and who have no significant
complications will be identified and discharged from acute hospital care with a patient specific “End of
Treatment Summary” (see appendix 1) to patient and their GP. Upon receipt of the End of Treatment
Summary the patients care is transferred to the primary care provider who will take formal responsibility
and accountability for the ongoing care of the patient.
The primary care provider will ensure :
 A register is kept of all patients with prostate cancer that have been discharged from secondary
care to be followed up in the community
 Each patient on the register for FU in Primary Care is contacted to arrange a review consultation
within primary care with a 3/6 monthly/weekly frequency (As per protocol appendix 2)
 Any patient failing to make an appointment or failing to attend for the review consultation will be
followed up. Should a patient decline to follow up, this should be documented clearly in the
patients’ record and reason stated and should be re-invited at least annually.
 The responsibility for managing the care of the patient on the prostate cancer register will be
deemed to be their registered GP although the service may be delivered by another clinician in
the practice. The agreed protocols for management of patients with prostate cancer stable on
treatment will be adhered to for the management of every patient. It is the provider’s
responsibility to ensure that the protocols used reflect the most up to date version.
 That patients are aware of the Health and Well-being clinic and signposted to that service if they
have not been previously referred. The wellbeing course is part of the wider Back in the Driving
Seat project which is a collaborative project between the Hospice of St Francis and Peace
Hospice Care as well as being supported by Prostate cancer UK. Details of Health and Well
Being Clinic (See Appendix 6)
 Specialist advice will be sought wherever required
 Results are made available to patients. It is good practice to inform patients of their results even
if normal. Please note PSA levels will need to be checked against patient specific “normal
“ranges as per their end of treatment summary. Lab normal ranges may not reflect patient
specific threshold.
Other requirements for providers to adhere to are as follows:
 The service needs to be patient-centred and accessible
 Services will be provided by trained and qualified practitioners with appropriate equipment.
 Provider will not discriminate between or against patients/carers on the grounds of age, ethnicity,
disability, religion, or any other non-medical characteristics
 Reasonable adjustments and variations in service must be made for those with a disability – this
may include reserving beginning or end of session appointments where suitable.
 Any significant issues relating to this service should be reported to the CCG and any complaints
into the service will be investigated as outlined under quality contract.
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9.1.1
Process for managing stable prostate cancer patients in primary Care
Secondary Care to identify patient suitable for
follow up in Primary Care
If GP wants to opt out of accepting to follow up
patient please write back to the clinic with
your refusal
CCG will be informed and payment reduced
accordingly
Patient discharged from secondary care clinic and
transferred back to Primary care for follow up (End of
Treatment Summary) Patient to be provided with PSA
Diary
Refer To
Health Well
and Well
Being Clinics
GP Practice organizes follow up
Primary Care to:
PSA blood taken
Patient consultation (as per protocol - template attached)
If PSA in line with
protocol
Continue to Monitor in
Primary Care
If PSA NOT in line
with protocol
Refer back to
Secondary care as per
protocol
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3.2.1 Data Collection

Any procedure carried out under the contract will be recorded in the electronic patient record
using the appropriate Read Code for patients where the surgery providing routine follow up
management of stable prostate cancer patients is also their own surgery. Brief intervention
advice should be offered as and when appropriate and any significant events to be managed in
line with practice protocol.

Annual Data to include:
o
Total number of patients listed on GP register with prostate cancer
Appropriate Read Codes have been provided. (See Appendix 5)
3.2.3 Education & Training
There is an expectation that all practices delivering the service send a clinical representative to attend
HVCCG updates on cancer when invited.
Review & Quality Assurance


3.3
Practices must use appropriate escalation procedures within their surgeries to ensure any
escalation is properly undertaken and properly recorded.
Where necessary and appropriate escalation will be made to HVCCG and in any event on a
quarterly basis (as above) providers will provide HVCCG with an exceptions report of all
escalations for this service.
Population covered, Location and timing of services
The service is available at GP Practices and is for service users who are registered with a General
Practitioner (GP) in the Herts Valleys CCG catchment area, who have been identified within acute
hospital care with locally advanced prostate cancer who are stable and are appropriate for management
within a primary care setting.
3.4
Acceptance and exclusion criteria
The service provision is for those patients identified within acute hospital care with locally advanced
prostate cancer who are stable and appropriate for management in primary care. All service users must
be registered with a GP in the Herts Valleys CCG.
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Exclusion Criteria

Men on active surveillance will be monitored by the WHHT nurse led active surveillance
programme and will not be transferred back for follow-up in primary care. Some men that are
initially managed in the active surveillance programme may eventually be transferred to watchful
waiting. This will occur if radical therapy would not be possible or appropriate in the event of
progressive disease. In this situation transfer to follow-up in the primary care setting will be
offered.

Men with a significant volume of spinal disease should not be considered for community followup

Patients that have received any other type of prostate radiotherapy will remain under oncological
follow-up and will not be transferred back for follow-up in primary care (eg clinical trial patients,
salvage patients etc
The expected activity levels for the service are based on estimates of 2000 patients for the
population of Herts Valley CCG (600,000). It is expected that the majority of patients
discharged to community follow up will be seen once a year on average. We estimate that
at least half of prostate cancer FU will continue in secondary care.
3.5



Interdependencies with other services
Acute WHHT Provider. The provider will determine the patients that are stable and can be
managed in primary care
The referring GPs – Both those specifically commissioned to provide dedicated
medical cover and the patients’ own GP;
Hospices – St Frances and Peace Hospice will be delivering the Well-being Course .The
Wellbeing course is part of the wider Back in the Driving Seat project which is a collaborative
project between the Hospice of St Francis and Peace Hospice Care as well as being supported
by Prostate cancer UK. (see appendix 6 for more detail)
4. Applicable Service Standards
The service will be delivered according to best practice and in line with the relevant local and national
guidance
4.1
Applicable national standards
Compliance with relevant guidance and policy
The service must comply with the guidelines produced by the following
organisations (where applicable):
Rules of Professional Conduct
http://www.gmc-uk.org/guidance/index.asp
NICE Guidance and recommended pathways http://guidance.nice.org.uk/
All practices should be aware of the NICE end of life care for adults Quality
standards and adhere to them in their practice. http://publications.nice.org.uk/qualitystandardfor-end-of-life-care-for-adults-qs13
.
Care Quality Commission registration requirements
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4.2
Applicable local standards
As referred to in this document and as developed by providers to ensure that there is an operational
level for self-certified protocols.
5. Key Service Outcomes & Tariffs
5.1
Tariff description
Providers to be paid £35 per prostate cancer patient on practice list per annum however Practices will be
given half of that amount (£17.50) per prostate cancer patient upfront. (This includes patients that
receive follow up in secondary care and those diagnosed years ago)
This upfront payment will be deducted from their total claim at the end of the year (April 2016)
There is an expectation that all practices delivering the service send a clinical representative to attend an
annual HVCCG updates on cancer when invited.
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Appendix 1
End of Treatment Summary
XX/XX/XXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
RE:
Mr Xxxxxxx Xxxxxxxx
Address
DOB
Diagnosis:
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
Dear Dr XXXXXXX,
Your patient Mr Xxxxxxx Xxxxxxxx has now completed his treatment for prostate cancer. He received treatment
with external beam radiotherapy followed by a high dose rate brachytherapy boost and the treatment was
completed on XX/XX/XXXX. He was subsequently reviewed in the oncology clinic on XX/XX/XX and has been
considered suitable for ongoing follow up in the primary care setting.
Mr XXXXX remains on LHRH agonist therapy. The LHRH agonist therapy must continue until XX/XX/XXXX at
which point the treatment can be stopped.
Mr XXXXX’s current PSA reading is X.Xng/ml
The PSA must be checked every 6 months for the first 2 years and then annually thereafter.
Please refer the patient back to the oncology clinic if the PSA rises above X.Xng/ml (PSA nadir +2ng/ml).
If any significant symptoms develop that may be attributable to the prostate cancer or its treatment then refer back
to oncology clinic by contacting the uro-oncology CNS.
A follow-up patient information leaflet given and a PSA diary has been given to the patient.
Mr XXXXXX’s Keyworker is XXXXXX XXXXXXX (uro-oncology clinical nurse specialist) contact 01923 XXXXXX
or bleep XXXX at Watford General Hospital.
Yours sincerely,
Signature
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REFUSAL TO FOLLOW UP IN PRIMARY CARE FORM
I wish to OPT OUT of accepting to follow up Mr ………………………………………… in Primary Care. I
understand HVCCG payment will be reduced accordingly.
Please continue to follow-up in hospital clinic
☐
(please tick box)
Please state reason for OPT OUT to follow up in Primary Care
…….……………………………..………………………………………………………………………..
…………………………………………………………………………………………………………….
Patient Address: ……………………………………..
…………………………………….
……………………………………..
DOB: ……………………………
GP Name: …………………………..
Practice: …………………………………
GP Signature: …………………………….
Secondary Care Use Only
Dear Colleague
Please could you file this letter and the GP Lead will be collecting this at the end of the year
(April 2016) for audit purposes.
If GP has refused to Follow up patient, payment to practice can be reduced accordingly.
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Appendix 2
Protocols for community based follow-up for patients previously treated for
prostate cancer in West Hertfordshire
Follow-up after Radical Prostatectomy Surgery

All radical prostatectomy surgery for Hertfordshire is performed at the Lister Hospital in
Stevenage. Initial post-operative care will be provided there. This will include catheter removal,
initial management of post-operative symptoms and continence advice.

In all cases, the histopathology from the surgical specimen is reviewed at the regional specialist
multi-disciplinary meeting to determine whether there is a requirement for adjuvant therapy.

Once the patient requires no further surgical input they will be referred back to the uro-oncology
clinic at WHHT. The PSA will be checked at this appointment.
If the PSA is undetectable AND there are no ongoing clinical issues then the patient will be
considered suitable for continued follow-up in Primary Care:
 Follow-up patient information leaflet given to the patient and a copy sent to the GP
 PSA diary given to the patient
 Contact details of the uro-oncology CNS given to the patient and sent to the GP
 PSA check 3 monthly for 1st 2 years
 PSA check 6 monthly for years 2-5
 PSA check annually thereafter

If PSA becomes detectable at any point then repeat the PSA after 6 weeks
If still detectable then refer back to urology clinic by contacting the uro-oncology CNS
If symptoms develop then refer back to urology clinic by contacting the uro-oncology CNS
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Follow-up after Radiotherapy
General Principles:







Patients will only be transferred back to primary care follow-up once all radiotherapy related side
effects have resolved or stabilised and require no further intervention.
Referral back to the oncology clinic can be triggered by new / returning symptoms or because of
PSA failure. The referral should be to the uro-oncology nurse specialist who will determine
which is the most appropriate clinic in which to see the patient.
There is an internationally recognised definition of PSA failure that must be used to determine
whether to refer patients back to the oncology clinic – this is the PSA nadir plus 2ng/ml:
If the PSA ever rises to 2ng/ml above the PSA nadir then repeat the PSA after 6 weeks
If still 2ng/ml above the PSA nadir then refer back to urology clinic by contacting uro-oncology
CNS
For example, if the PSA falls to 0.2ng/ml as the lowest recorded value after radiotherapy then
refer back if the PSA reaches 2.2ng/ml
Radiotherapy techniques vary depending upon the oncological risk category, co-morbidities and
patient choice. The various types of radiotherapy require different follow-up procedures:
1) Follow-up after External Beam Radiotherapy at Mt Vernon Cancer Centre (without
brachytherapy):
a. Low to Intermediate Risk patients treated with external-beam radiotherapy in combination with short
course (6 months) of androgen deprivation (no brachytherapy)






Patients will remain under telephone follow-up by the Clinic Review Radiographers from Mt
Vernon Cancer Centre with regular PSA evaluations for a total of 5 years.
At the end of 5 years patients will be discharged from oncological follow-up and returned to
follow-up in primary care.
Follow-up patient information leaflet given to the patient and a copy sent to the GP
PSA diary given to the patient
Contact details of uro-oncology CNS given to the patient and sent to the GP
PSA to be checked annually
If the PSA ever rises to 2ng/ml above the PSA nadir then repeat the PSA after 6 weeks
If still 2ng/ml above the PSA nadir then refer back to the oncology clinic by contacting the urooncology CNS

For example, if the PSA falls to 0.2ng/ml as the lowest recorded value after radiotherapy then
refer back if the PSA reaches 2.2ng/ml
If symptoms develop then refer back to oncology clinic by contacting the uro-oncology CNS
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b. Intermediate to High Risk patients treated with external-beam radiotherapy in combination with long
course (2-3 years) of androgen deprivation (no brachytherapy)

Patients will remain under telephone follow-up by the Clinic Review Radiographers from Mt
Vernon Cancer Centre with regular PSA evaluations for a total of 6 months.
 At 6 months the patient will be seen again in the oncology clinic. At that stage:
If PSA <1.0ng/ml AND no ongoing clinical issues then the patient can be transferred to primary
care follow-up:
 The duration and end date of androgen deprivation will be clearly stated in the GP letter
 Follow-up patient information leaflet given to the patient and a copy sent to the GP
 PSA diary given to the patient
 Contact details of the uro-oncology CNS given to the patient and sent to the GP
 PSA check 6 monthly up to the 5 year stage post radiotherapy
 PSA check annually thereafter
If the PSA ever rises to 2ng/ml above the PSA nadir then repeat PSA after 6 weeks
If still 2ng/ml above the PSA nadir then refer back to oncology clinic by contacting the uro-oncology
CNS

For example, if the PSA falls to 0.2ng/ml as the lowest recorded value after radiotherapy then
refer back if the PSA reaches 2.2ng/ml
If symptoms develop then refer back to oncology clinic by contacting the uro-oncology CNS
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2) Follow-up after external beam radiotherapy plus a High-Dose-Rate (HDR) Brachytherapy
Boost:


Patients will remain under telephone follow-up by the Clinic Review Radiographers from Mt
Vernon Cancer Centre with regular PSA evaluations for a total of 6 months.
At 6 months the patient will be seen again in the oncology clinic. At that stage:
If PSA <1.0ng/ml AND no ongoing clinical issues then the patient can be transferred to primary
care follow-up:
 The duration and end date of androgen deprivation will be clearly stated in the GP letter
 Follow-up patient information leaflet given to the patient and a copy sent to the GP
 PSA diary given to the patient
 Contact details of the uro-oncology CNS given to patient and sent to the GP
 PSA check 6 monthly up to the 2 year stage post radiotherapy
 PSA check annually thereafter
If the PSA ever rises to 2ng/ml above the PSA nadir then repeat the PSA after 6 weeks
If still 2ng/ml above the PSA nadir then refer back to the oncology clinic by contacting the urooncology CNS

For example, if the PSA falls to 0.2ng/ml as the lowest recorded value after radiotherapy then
refer back if the PSA reaches 2.2ng/ml
If symptoms develop then refer back to oncology clinic by contacting the uro-oncology CNS
Transforming Primary / Community Care follow ups for patients with Prostate Cancer Follow up
protocols. Version 1.2, 4th September 2014
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Follow-up after Iodine Seed Brachytherapy (I125 seeds):








Patients will have a CT and MRI scan at Mt Vernon Cancer Centre 4 weeks after the procedure
to check the post-implant dosimetry and to determine whether the implant was technically
successful.
All men will be seen in the oncology clinic 6 weeks after the implant.
Patients will then remain under telephone follow-up by the Clinic Review Radiographers from Mt
Vernon Cancer Centre with regular PSA evaluations for a total of 5 years.
At the end of 5 years patients will be discharged from oncological follow-up and returned to
follow-up in primary care.
Follow-up patient information leaflet given to the patient and a copy sent to the GP
PSA diary given to the patient
Contact details of the uro-oncology CNS given to patient and sent to the GP
PSA to be checked annually
If the PSA ever rises to 2ng/ml above the PSA nadir then repeat PSA after 6 weeks
If still 2ng/ml above the PSA nadir then refer back to the oncology clinic by contacting the urooncology CNS
o For example, if the PSA falls to 0.2ng/ml as the lowest recorded value after radiotherapy then refer
back if the PSA reaches 2.2ng/ml
If symptoms develop then refer back to oncology clinic by contacting the uro-oncology CNS
4) Patients that have received any other type of prostate radiotherapy will remain under
oncological follow-up and will not be transferred back for follow-up in primary care (eg clinical
trial patients, salvage patients etc.)
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3) Active Surveillance and Watchful Waiting
These are 2 very distinct processes for monitoring men with prostate cancer and must not be confused.
Active Surveillance is applied to men who have low to intermediate risk disease and are suitable for
curative therapy. Active surveillance is applied in order to safely defer radical treatment. Some men
may never need active treatment at all.
Watchful waiting applies to men who have disease that is not curable either because of the pattern and
stage of disease or because of co-morbidities. The monitoring process is applied to determine when the
patient requires palliative androgen deprivation therapy (which may never occur).
Active surveillance
 Men on active surveillance will be monitored by the WHHT nurse led active surveillance
programme and will not be transferred back for follow-up in primary care.
 Some men that are initially managed in the active surveillance programme may eventually be
transferred to watchful waiting. This will occur if radical therapy would not be possible or
appropriate in the event of progressive disease. In this situation transfer to follow-up in the
primary care setting will be offered.
 Other men on active surveillance will develop progressive disease and require radical treatment.
They will then be followed up in accordance with that treatment protocol.
Watchful Waiting
 Men on watchful waiting can be transferred directly back for follow-up in primary care.
The PSA should be checked every 6 months
If the PSA doubling time ever falls below 6 months then the patient should be referred back to the
oncology clinic but only if treatment with androgen deprivation therapy is still considered appropriate
and considered acceptable by the patient.
If symptoms develop then refer back to oncology clinic by contacting the uro-oncology CNS.
Transforming Primary / Community Care follow ups for patients with Prostate Cancer Follow up
protocols. Version 1.2, 4th September 2014
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Metastatic Disease (including incurable Locally Advanced or Regional disease)
In general, most men with advanced disease will be kept under oncological follow-up at WHHT or Mt
Vernon Cancer Centre. However, in certain circumstances it may be more appropriate for follow up in
the community. Men with asymptomatic disease that is being managed with long-term androgen
suppression, without any immediate intention for more aggressive systemic anti-cancer therapy, can be
followed up in Primary Care. Men with a significant volume of spinal disease should not be considered
for community follow-up:
 Patients will remain under the care of the oncology clinic until response to androgen deprivation
has been established and the treatment related side effects have been managed and stabilised.
 Patients will only be considered suitable for primary care follow-up if the PSA falls below 4ng/ml
and have no disease related symptoms.
PSA should be checked every 4 months
If the PSA rises from its previous value then reduce the interval between PSA tests to 2 months.
In the event of 3 consecutive PSA rises the patient should be referred back to the oncology clinic
by contacting the uro-oncology CNS.
If symptoms develop then refer back to oncology clinic by contacting the uro-oncology CNS.
Any symptoms of weakness or sensory loss in the legs in a patient with known metastatic
disease must be considered as suspicious for spinal cord compression and must be treated as
an emergency.
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Appendix 3
Prostate Cancer Annual Activity Data Return Template
GP Practice
Date
Total number of patients listed on GP
register with prostate cancer
Please indicate number of patients that
were discharged from secondary Care
but practice refused to follow up in GP
Practice
Total Payable to Practice
Initial Payment made in Quarter 1
To be deducted from total payable at end
of year.
Outstanding Balance
Practice to submit completed form to [email protected] by 31st March 2016
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Appendix 4 Prostate Cancer Annual Audit Template
Unique Patient
Identifier
Prostate Date of discharge to
Diagnosis Primary
Code
Care Follow up (IF
(B46..)
APPLICABLE)
Date of PSA (should
be within last 12
months) or exception
code
(411..)
Result or
reason for
exception
code
Date of
Holistic
needs
assessment
Date of death if in
year
April 2015/March
2016
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Please state % of prostate cancer patients with PSA or exception coded in last year (15/16) This
includes all patients with prostate cancer regardless of location of follow -up
Please state % of prostate cancer patients having holistic needs assessment in last year (15/16) )
This includes all patients with prostate cancer regardless of location of follow -up
Practice to submit completed form to [email protected] by 31st March 2016. Practice to be paid in April 2016
NB: SEARCHES WILL BE PROVIDED BY PRIMARY CARE IT SUPPORT FACILITATOR TEAM
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Appendix 5 - Prostate Cancer Read Codes
As outlined in the services specification, the minimum data to be collected annually includes
a) Total number of patients listed on GP register with locally advanced prostate cancer
stable on treatment
BELOW ARE SUGGESTED NATIONAL READ CODES
Emis/Vision
Malignant neoplasm of prostate
Carcinoma in situ of prostate
Read Code
B46..
B834
Holistic Needs Assessment
(If patient is offered and declines holistic needs assessment then enter
the read code with declined in the free text box.)
- 389H
Lab test not necessary (where PSA testing is not appropriate)
411..
Prostate Specific Antigen
43Z2
Read Code
SystmOne
Cancer of Prostate
Carcinoma in situ of prostate
Carcinoma of Prostate
B46..
B834
X78Y6
Holistic Needs Assessment
(If patient is offered and declines holistic needs assessment then enter
the read code with declined in the free text box.)
Lab test not necessary (where PSA testing is not appropriate)
Prostate Specific Antigen Level
XabVD
411..
XE25C
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Holistic Needs Assessment Protocol for Prostate Cancer Follow-up
(Annual)
PROSTATE CANCER
ACTION
Introduction:
Practice Nurse to introduce her/himself to patient, review patients End of Treatment Summary & Follow Up
Protocol and confirm that it is the correct patient. Offer partner or carer to be present at consultation
Discuss patients immediate concerns
Discuss and explain PSA and any other relevant blood test results and action as per patient protocol.
Assess for specific prostate cancer disease or treatment related issues:
Lower Urinary Tract Symptoms (LUTS): Treatments for prostate cancer may cause problems which affect the
lower urinary tract. These symptoms can vary in severity and frequency and for some men they will be very
troublesome. Access to self-management strategies and specialist continence services when necessary are
available. when assessing the patient please consider the following:

Using the International Prostate Symptom Score (IPSS) to identify and monitor LUTS

Exclude symptoms of urinary tract infection (UTI), if a UTI is indicated then send a mid-stream urine
sample for analysis and treat appropriately

Encourage regular pelvic floor exercises, re-educate and offer factsheet

Discuss lifestyle changes - Maintaining a healthy weight, avoiding constipation and avoiding heavy
lifting will reduce the pressure on the pelvic floor. If the patient smokes, encourage them to stop as
coughing puts pressure on the pelvic floor
RATIONALE
To ensure that the patient is fully
aware of the purpose, duration and
frequency of follow up
To ensure that follow up care is
patient centred which takes into
account the individual needs of
the patient and his partner/carer
To monitor PSA in accordance with
End of Treatment Summary &
Follow Up Protocol
To ensure that troublesome
symptoms related to disease or
treatment are assessed, diagnosed
and treated appropriately
Advise to drink plenty of fluids and avoid or reduce fizzy drinks, caffeine and alcohol as these may
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also irritate the bladder

Discuss pharmacological management with GP and/or Prostate Cancer Specialist Nurse

Consider referral onto to the Hertfordshire Community NHS Trust Adult Bladder and Bowel Care
Services
Adult Bladder & Bowel Care Service
Park Drive Health Centre
Park Drive
Baldock
SG7 6EN
Phone: 01462 492502
Fax No: 01462 491052
A referral form, patient and healthcare professional information can be downloaded from their
website by visiting:
www.hertschs.nhs.uk
Bowel symptoms: Radiotherapy and brachytherapy can cause the lining of the bowel to become inflamed,
which can lead to symptoms such as loose stools, frequency, urgency and bloating. These symptoms usually
settle down after a few months but can return years later. When assessing the patient please consider the
following:
 Eating less fibre in the diet for a short while may be of benefit. The patient may need guidance on
types of food to eat; suggest white bread, white pasta, white rice, potatoes without skin and lean
white meat
 The men would have been given a diet sheet from their Cancer Centre prior to their treatment, if they
follow this again for a short while symptoms are likely to improve
 If symptoms persisting or rectal bleeding is present discuss with GP and/or Prostate Cancer Specialist
Nurse and consider further investigations with specialist teams with expertise in radiation induced
enteropathy
Sexual dysfunction: Prior to treatment men and their partner’s would have been made aware of the potential
difficulties they may encounter following treatment. They may experience a reduction in or loss of erectile
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function, loss of libido, pain on orgasm. There are various treatments and support available, please consider
the following when assessing the patient:





Explore with the patient whether sexual dysfunction is an issue for him or his partner
Men with prostate cancer get free medical treatment for problems with erections and sexual function
Phosphodiesterase type 5 (PDE5) inhibitors should be considered first. However, there are other
ways to manage erectile dysfunction which include intraurethral inserts, penile injections, vacuum
devices and penile prostheses.
Offer patient appointment with GP to discuss treatments for erectile dysfunction and consider referral
to the Erectile Dysfunction Clinic within West Herts NHS Trust. This can be done through the GP or
through the Prostate cancer Specialist Nurse
Offer psychological support with the Prostate Cancer Specialist Nurse at the Spring and Starlight
Wellbeing Centres or in complex cases refer for Psychosexual Counselling at West Herts NHS Trust:
Jan Tarrant
Clinical Administrator
Psychosexual Service
St Albans Sexual Health Centre
St Albans City Hospital
Waverly Road
St Albans
AL1 5PN
Tel: St Albans 01727 897333 or Watford 01923 217206
www.sexualhealthwestherts.co.uk
Hot Flushes: Hot flushes are a common side effect for men who are on hormone deprivation; they will differ in
frequency and severity. If troublesome then please consider the following:



Patients may recognise a trigger to the hot flushes
Lifestyle changes - stopping smoking, maintaining a healthy weight, drink 1 – 1.5 litres of water a day,
reduce caffeine, reduce spicy food
Wear cotton cloths and use cotton sheets
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

Consider herbal remedies such as Sage Tea or Evening Primrose Oil. Acupuncture may also help,
this can be accessed through the Prostate Cancer Specialist Nurse at the Spring and Starlight
Wellbeing Centres
Offer the PCUK booklet ` Living with hormone therapy, a guide for men with prostate cancer`
Fatigue: Fatigue is a common side effect following a diagnosis of cancer and its treatment. It is not usually
relieved by resting and it is recognised that fatigue can impact on the physical, emotional and social aspects
of an individual’s wellbeing. Regardless of the cause there is help and support available. Please consider the
following:
 Explore with the patient the impact fatigue is having on his day to day life
 Things which may help – taking regular exercise, prioritise and plan activities, eat a regular well
balanced diet
 Offer Macmillan Fatigue booklet
 Consider referral to the Wellbeing Services at the Spring and Starlight Wellbeing Centres; Fatigue
Workshop and Physiotherapy sessions
Promote supported self-management and wellbeing services and refer as applicable to:
 Prostate Cancer Wellbeing Service – Prostate Cancer Wellbeing Clinic and Prostate Cancer
Wellbeing Course
Tina Smith, Prostate Cancer Specialist Nurse, 07921 388795 [email protected]
 Hertfordshire smoking cessation service. Tel: 0800 389 3998. www.smokefreehertfordshire.nhs.uk
 Local prostate cancer support group:
Friends of Prostate Sufferers , Chorleywood, Tel: 01923 282105, www.thefops.org.uk
Aylesbury Vale Prostate Cancer Support Group, Tel: 01442 822161, www. goo.gl/Ge5LRO
 National Support Services:
Metro Walnut Support provides support for gay and bisexual men with prostate cancer
Simon Faulkner on 07947 826 853 (Mon to Thurs 10-4), [email protected],
www.metrocentreonline.org
www.prostatecancer.org
www.bladderandbowelfoundation.org
www.rada.org.uk
www.macmillan.org.uk
To promote an empowerment and
self-management model of care
with the overall aim of improving
health, independence and
confidence
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Carer Support – Carers play an important role in supporting men with prostate cancer, there are numerous
individual and groups sessions available within the Spring and Starlight Wellbeing Centres which may be of
benefit. Carers will also be offered an assessment using the Carer Support Needs Assessment Tool
(CSNAT). The assessment tool has been developed to identify the support that is most appropriate to the
individual in their role as a carer.
Document consultation and update patient held record as appropriate
Arrange next appointment and ask patient to have PSA blood test 2 weeks before next appointment
Offer open access and support as required
To ensure that individual carers
needs are identified and
To ensure that individualised
Code this review as: Holistic Needs Assessment – Vision/Emis - 389H & SystmOne - XabVD
Note: For purposes of audit and service claims if PSA testing not indicated (e.g. End of life stage) please code - Lab test
not necessary – Vision/Emis & SystmOne - 411.. and enter details including reason in the free text
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Appendix 6 Health and Well Being Clinic leaflet
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