Pathways are step closer to health

At every stage of care, a man diagnosed with prostate cancer should have access to appropriate clinical expertise, writes Peter Archer

Prostate Cancer UK has prepared a Quality Checklist setting out expected standards of care.

If you are diagnosed with prostate cancer, healthcare professionals should work together in teams to ensure you receive care that is properly co-ordinated.

You should be informed of the support services available, such as financial advice and emotional support, and be given information in a format that meets your needs.

Your partner, other family members and friends should be offered information and support at every step to help them understand prostate cancer, the treatment options and their side effects.

Prostate Cancer UK’s full Quality Checklist can be downloaded from their website, but here is Raconteur’s step-by-step guide:

Diagnosis pathway

Step 1: Report symptoms to GP. You should be given balanced information about the PSA (prostate-specific antigen) blood test, digital rectal examination (DRE) and biopsies, and have the opportunity to discuss the pros and cons of the tests with a doctor or nurse.

Step 2: Take a PSA test at the GP’s surgery.

Step 3: The GP makes an assessment and, if necessary, makes a fast-track referral to hospital or a one-stop specialist clinic.

Step 4: You are offered an appointment for an MRI scan if your PSA level is raised but not too high. An MRI is not done if the PSA is high and a biopsy is performed. You may be given a bone scan if appropriate.

Step 5: Multi-disciplinary team meeting to discuss scan and biopsy results.

Step 6: You are given the results. If diagnosed with prostate cancer, you should have a face-to-face consultation with a doctor, given written information about the type of cancer you have and treatment options are discussed.

Step 7: You, your partner and family members should have access to a specialist nurse who will provide consistent support and co-ordinate your care.

Treatment pathway

If you are diagnosed with prostate cancer, you should be told about all appropriate treatment options available, including information on possible side effects.

You should have the opportunity to discuss the options with a doctor, and have access to the best treatment and drugs that your doctor recommends, regardless of where you live.

Treatment options depend on whether the cancer is localised within the prostate gland, has grown just outside or spread to other parts of the body.

The treatment also depends on factors such as general health, Gleason score (likelihood of the cancer spreading), PSA (prostate-specific antigen) level and the cancer’s rate of growth, as well as your opinion on preferred therapies.

Step 1: You should be seen by a urologist and oncologist at a hospital or specialist clinic.

Step 2: You are given a treatment plan.

Step 3: If you have a cancer that is growing very slowly, it may never cause any symptoms. With your specialist, you may decide on watchful waiting or active surveillance, to wait and see whether the cancer is getting bigger before starting treatment. This is a way of delaying or avoiding unnecessary treatment which may cause side effects that are worse than living with the disease.

If your cancer is localised within the prostate, you may be offered surgery or radiotherapy. Robotic or keyhole surgery may be available as an alternative to open surgery. If you opt for radiotherapy, you may have low-dose radioactive seeds implanted in the prostate or a high-dose source of radiation inserted temporarily, known as brachytherapy. High-intensity focused ultrasound (HIFU) and cryotherapy may also be available (in a clinical trial) which use intense heat and cold to damage the cancer. Localised prostate cancer can also be treated using hormone therapy.

If the cancer has spread just outside the prostate, you may have radiotherapy or high-dose, temporary brachytherapy with hormone medicines.

If your cancer is advanced, hormone therapy is the gold standard. If it is resistant to other treatments, you may be offered a drug, such as Jevtana.

Care pathway

Following treatment for prostate cancer, you must be given a care plan that sets out what follow-up tests and care you should expect to receive.

The care plan should be regularly reviewed and you should have regular check-ups to monitor possible side effects of your treatment. You should be referred to the most appropriate service to help manage these.

Step 1: You should be given a post-treatment consultation and follow-up appointments depending on the nature of your treatment.

Step 2: You are given a care plan.

Step 3: If your cancer is slow growing and you opted for watchful waiting, you should have a PSA (prostate-specific antigen) test every six to twelve months.

If your cancer was not aggressive and you chose active surveillance, you should have three-monthly PSA tests, a repeat biopsy and annual MRI scan for the first two years, and then PSA tests every six months.

If you had surgery or radical prostatectomy, you should have three to six-monthly reviews for the first year and six to twelve-monthly checks for a further four years.

If you underwent radiotherapy or brachytherapy (internal radiotherapy), you should have six or twelve-monthly reviews for five years.

If you received hormone therapy, you will need a check-up every three months until your condition is stable and then every six months.

Step 4: If you suffer a recurrence of the cancer or a new primary cancer, you should receive appropriate management of your condition.

Many men who have prostate cancer during their lives do not die from it. However, each year in the UK, some 10,000 men do lose their lives to the disease. If you are approaching the end of your life as a result of prostate cancer, you should be helped to manage pain and other symptoms, and made aware of the financial, emotional and support services available to you and your family.