Integrated Care in Prostate Cancer (ICARE-P): Nonrandomized Controlled Feasibility Study of Online Holistic Needs Assessment, Linking the Patient and the Health Care Team

Exploring the experiences of patients, general practitioners and oncologists of prostate cancer follow-up: A qualitative interview study

Purpose

To examine the experiences of patients and healthcare professionals of prostate cancer follow-up in primary care and to identify areas where current policy and practice could be improved.

Methods

Semi-structured interviews with patients, GPs and oncologists explored experiences of prostate cancer follow-up. Interviews were audio recorded and transcribed verbatim. Data were analysed using thematic analysis. The three participant groups were analysed as individual datasets but the same key themes were evident across the groups.

Results

14 patients, 6 GPs and 5 oncologists were interviewed. Four main themes were identified: Experience of current practice; Knowledge and understanding of prostate cancer follow up; Disparity of processes and pathways; Unclear roles and responsibilities.

Conclusions

Findings from this study highlight the variation in the approach to prostate specific antigen monitoring and emphasise the lack of clear policies and practices. The lack of clarity around existing follow up and monitoring processes could cause delays in the diagnosis of recurrence. There is a need for a new and improved pathway for prostate cancer follow up. The pathway should include clear and concise guidance for patients, primary care and secondary care and all relevant parties need to understand what their role is within the pathway.

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There is huge variation in PSA monitoring processes and after care.

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Patients and professionals are unsure of their role.

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Lack of clarity means there is a risk that patients may not be monitored routinely.

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There is a need for a new and improved pathway for prostate cancer follow up.

A Narrative Overview of Active Surveillance for Clinically Localised Prostate Cancer

BACKGROUND

-Active surveillance (AS) is a strategy employed as an alternative to immediate standard active treatments for patients with low-risk localised prostate cancer (PCa). Active treatments such as radical prostatectomy and radiotherapy are associated with significant adverse effects which impair quality of life. The majority of patients with low-risk PCa undergo a slow and predictable course of cancer growth and do not require immediate curative treatment. AS provides a means to identify and monitor patients with low-risk PCa through regular PSA testing, imaging using MRI scans and regular repeat prostate biopsies. These measures enable the identification of progression, or increase in cancer extent or aggressiveness, which necessitates curative treatment. Alternatively, some patients may choose to leave AS to pursue curative interventions due to anxiety. The main benefit of AS is the avoidance of unnecessary radical treatments for patients at the early stages of the disease, hence avoiding over-treatment, whilst identifying those at risk of progression to be treated actively. The objective of this article is to provide a narrative summary of contemporary practice regarding AS based on a review of the available evidence base and clinical practice guidelines. Elements of discussion include the clinical effectiveness and harms of AS, what AS involves for healthcare professionals, and patient perspectives. The pitfalls and challenges for healthcare professionals are also discussed.

DATA SOURCES

We consulted international guidelines, collaborative studies and seminal prospective studies on AS in the management of clinically localised PCa.

CONCLUSION

AS is a feasible alternative to radical treatment options for low-risk PCa, primarily as a means of avoiding over-treatment, whilst identifying those who are at risk of disease progression for active treatment. There is emerging data demonstrating the long-term safety of AS as an oncological management strategy. Uncertainties remain regarding variation in definitions, criteria, thresholds and the most effective types of diagnostic interventions pertaining to patient selection, monitoring and reclassification. Efforts have been made to standardise the practice and conduct of AS. As data from high-quality prospective comparative studies mature, the practice of AS will continue to evolve.

IMPLICATIONS FOR NURSING PRACTICE

The practice of AS involves a multi-disciplinary team of healthcare professionals consisting of nurses, urologists, oncologists, pathologists and radiologists. Nurses play a prominent role in managing AS programmes, and are closely involved in patient selection and recruitment, counselling, organising and administering diagnostic interventions including prostate biopsies, and ensuring patients' needs are being met throughout the duration of AS.

"Good care" throughout the prostate cancer pathway: Perspectives of patients and health professionals

PURPOSE

Men in follow up for prostate cancer represent the largest proportion of patients with the illness. In the United Kingdom, primary care is increasingly involved in caring for these patients. Little is known however regarding the factors that determine men's evaluation of their care and primary healthcare professionals' perceptions of the care they provide. This study aimed to investigate patient and primary care based health professionals' perspectives of what constitutes 'good care' for men with prostate cancer, including limiting or facilitating factors.

METHOD

Semi-structured interviews were conducted with ten patients and eight primary care based healthcare professionals and thematically analysed in collaboration with a patient representative group.

RESULTS

Good care was identified by patient participants, with aspects of communication, including information, active participation, sensitivity of approach and context being highlighted. Healthcare professionals also prioritised communication as the basis of good care and recognised the benefits of locally based services.

CONCLUSIONS

Treatments in prostate and other cancers continue to improve with corresponding increases in survival. To further develop and sustain the good care that patients require to help them cope with diagnosis, treatment and long term adjustment, investment in resources, training and innovative communication systems between patients, generalist and specialist services are required.

Promoting integrated care in prostate cancer through online prostate cancer-specific holistic needs assessment: a feasibility study in primary care

Purpose

This study assessed the feasibility of implementing a novel model of integrated prostate cancer care involving an online prostate cancer-specific holistic needs assessment (sHNA) and shared digital communication between patients and their healthcare professionals (HCPs). The sHNA produces a semi-automated care plan that is finalised in consultation between the patient and their practice nurse.

Methods

Men living with and beyond prostate cancer were invited to participate in a 9-month non-randomised cluster controlled feasibility study. The intervention group was asked to complete the sHNA on three occasions. Data were collected using Patient Reported Outcome Measures (PROMs) at baseline, 10 and 24 weeks, and 9 months. Outcomes included recruitment, retention, acceptability, and engagement with the sHNA and PROMs.

Results

Fourteen general practices (8 intervention and 6 control), and 41 men (29 intervention and 12 control) participated. Initial patient engagement with the sHNA was high, with all but one receiving practice nurse-led follow-up and an individualised care plan. The sHNA proved useful in identifying ‘red flag’ symptoms, and helping practice nurses decide when to seek further medical care for the patients. There was a high level of acceptability for patients and HCPs. However, integration of care did not occur as intended because of problems linking hospital and general practice IT systems.

Conclusion

While the study demonstrated the feasibility of implementing the sHNA, it did not meet the a priori progression criteria; as such, undertaking a definitive randomised controlled trial is not appropriate until the identified methodological and technical issues have been addressed.

"My gut feeling is we could do more..." a qualitative study exploring staff and patient perspectives before and after the implementation of an online prostate cancer-specific holistic needs assessment

Background

Men surviving prostate cancer report a wide range of unmet needs. Holistic needs assessments (HNA) are designed to capture these, but are traditionally paper-based, generic, and only carried out in secondary care despite national initiatives advocating a “shared care” approach. We developed an online prostate cancer-specific HNA (sHNA) built into existing IT healthcare infrastructure to provide a platform for service integration. Barriers and facilitators to implementation and use of the sHNA were explored from both the patients and healthcare professionals (HCPs) perspectives.

Methods

This qualitative study consisted of two phases. Phase 1 used semi-structured interviews to explore HCPs (n = 8) and patients (n = 10) perceptions of the sHNA, prior to implementation. Findings were used to develop an implementation strategy. Phase 2 used semi-structured interviews to explore HCPs (n = 4) and patients (n = 7) experienced barriers and motivators to using the sHNA, 9 to 12 months after implementation. Interviews were audio-recorded, transcribed verbatim and thematically analysed. Themes were mapped to the Theoretical Domains Framework.

Results

HCPs and patients anticipated many benefits from using the sHNA. Barriers to implementation included: confidence to work in depth with prostate cancer patients, organisational and cultural change, and patient factors. Our implementation strategy addressed these barriers by the provision of disease specific training delivered in part by a clinical nurse specialist; and a peer-led IT supporter. Following implementation HCPs and patients perceived the sHNA as beneficial to their practice and care, respectively. However, some patients experienced barriers in using the sHNA related predominately to symptom perception and time since treatment. HCPs suggested minor software refinements.

Conclusions

This work supports the importance of identifying barriers and motivators to implementation, and using targeted action via the development of an implementation strategy to address these. Whilst this process should be on-going, undertaking this work at an early stage will help to optimise the implementation of the sHNA for future trials.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3941-4) contains supplementary material, which is available to authorized users.