An update for General Practitioners Edgar PaezConsultant Urologist Freeman Hospital Newcastle upon Tyne and Queen Elizabeth HospitalGateshead July 2014 CCGQE AgreementProposed Pathways ID: 301742
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CCG/QEH Urology Agreements
An update for General Practitioners
-Edgar
Paez-Consultant Urologist
-Freeman
Hospital –
Newcastle upon Tyne
and Queen Elizabeth Hospital-Gateshead
July 2014Slide2
CCG/QE Agreement-Proposed Pathways
Review of agreements due
Recent NICE guidanceNew commissioning guidanceInitiate first line assessment/treatment in primary careAttempt to reduce “un-necessary” secondary care referralReduce cost of treatmentSlide3
Suspected cancer referral
Prostate
Bladder and renal -HaematuriaSlide4
SUSPECTED CANCER-PROSTATE
Men presenting with symptoms suggesting prostate cancer should have a digital rectal examination (DRE) and prostate-specific antigen (PSA) test after counselling.
Urinary tract infection (UTI) should be excluded before PSA testing. If there is a proven UTI, the PSA test should be postponed for at least 1 month ( ideally 6-8 weeks)after treatment of the infection.Slide5
Urgent referral should be made:
If a hard, irregular prostate is felt on DRE. PSA should be measured and the results sent with the referral letter.
Urgent referral is not indicated if the prostate is enlarged and the PSA is normal.If the prostate is normal on DRE, but the age-specific PSA is raised or rising.
In symptomatic men with high PSA levels. If there is doubt about whether to refer an asymptomatic man with borderline level of PSA, PSA test should be repeated after 1 to 3 months. If the second test indicates that the PSA level is rising, an urgent referral should be made.Slide6
The age-specific cut-off PSA measurements recommended by the Prostate Cancer Risk Management Programme are as follows:
50–59 years of age >= 3.0
nanograms/mL; 60–69 years of age >= 4.0 nanograms/
mL; 70 years of age and older >= 5.0 nanograms/mL. (there are no age-specific reference ranges for men over 80 years of age. Prostate cancer only needs to be diagnosed in this age group if it is likely to need palliative treatment
,
i.e
grossly abnormal DRE, suspicion of advanced disease, PSA >20.
Good performance status, life expectancy 10 years.
Screening in patients over 75 is discouraged.Slide7
SUSPECTED CANCER-RENAL AND BLADDER/
Haematuria clinic
Any adult patient with visible haematuria- check for UTI-haematuria clinic. Men 50-75 with no UTI : PSA.
Over 40’s with persistent non visible haematuria-haematuria clinicPatients under 40 with persistent non visible haematuria
-check
creatinine
and
proteinuria
, if abnormal, refer to Nephrology, if normal, non urgent referral to UrologySlide8
Haematuria
Clinic
2 stop clinicRadiology (USS + KUB in all non visible haematuria and younger patients, CTIVU in over 40’s with visible haematuria)performed first stop
Flexible cystoscopy 2nd stopReport sent to GP’s from clinic.Please perform eGFRSlide9
Shared Care
Prostate CancerSlide10
Introduction
Patient with diagnosis of prostate cancer
On A/M, hormonal manipulation or post radical treatment (surgery or radiotherapy).Care closer to homeReduce number of hospital appointmentsNo compromise in patient careFinancial implications
Hospital Doctors/Patients/GP’s have to agree. Will require written response by GP’s.Clear treatment plansGeneral guidelines + individual patients lettersReview compliance to be monitored by CCG.Slide11
Ca.Prostate
. Shared care discharge guidelines
Patient type
Discharge criteriaDischarge after
Hormone Therapy
Stable *
1 year
Watchful wait
No sign of disease progressions and stable*
1 year
Active surveillance
(suitable for radical treatments)
No sign of disease progressions and stable*
2 years
( only when no longer suitable for radical treatment)
Active surveillance
(not suitable for radical treatments)
Stable*
1 year
Low risk post radical surgery
Undetectable PSA, stable LUTS and DRE*
2 years
High risk post radical surgery
Undetectable PSA, stable LUTS and DRE*
5 years
Low risk post radiotherapy
Stable*
2 years following completion of hormones
High risk post radiotherapy
Stable*
5 years
*STABLE = No increase in LUTS, No changes in DRE & stable PSASlide12
Shared care-follow up
Patients on hormonal manipulation: PSA alone, DRE if changes on PSA or LUTS that need further assessment. Check liver function twice a year, testosterone if PSA ↑, to assure castrate levels.
Patients post radical radiotherapy: : PSA alone, DRE if changes on PSA or LUTS that need further assessment.Patients post radical prostatectomy: PSA alone, no role for DRE.Patients on active monitoring: PSA and yearly DRE.Slide13
When to refer back-following radical treatment.
After radical prostatectomy: a confirmed PSA value
>0.2 (two consecutive measurements)After radiotherapy: a confirmed PSA value 2ng/ml above nadir valueIf patients have
significant urological side effects following therapy.Slide14
When to refer back-patients on active monitoring
Letter generated on each patient with recommendation
Most patients who are discharged will be not suitable for radical treatment (in view of age, comorbidities, etc)For most patients will be signs of significant disease progression (3 significant PSA rises, PSA doubling time <6months, PSA>20, or symptoms of advanced disease).Slide15
Patients with elevated PSA and negative prostate biopsy
Patients will be discharged after investigated
Physicians satisfied that significant prostate cancer unlikely (repeat biopsies/MRI will be performed if indicated).Currently no national guideline by NICE-issue under reviewDecision aid tools
being developedSlide16
Shared care-delivery improvement
Pilot with a handful of Practices to send current forms via NHS Mail instead of post.
Working with CBC to pilot use of EMISWeb to track current Shared Care patients including a reminder system that will flag when patients are due a review appointment. Will look to run as part of EMIS QOF Template pilot being run by CBC with Practices in the Bureau.Slide17
Erectile dysfunction
As per Newcastle, North of Tyne and Gateshead guidelines for management of erectile dysfunction on adults > 18 years.
Assessment
History – medical, sexual and psychosocial. Smoking drugs and alcohol. Determine type of ED.Examination – BP and BMI. Secondary sexual characteristics abdominal and genitalia, Lower limb pulses
Bloods
Calculate CV risk
IIEF questionnaire.Slide18
Erectile Dysfunction
Referral to secondary care as per CCG Guidelines for management of erectile dysfunction
Trial of treatment in primary care .
Lifestyle change
Manage any underlying cause
Treatment if no contra-indications
If appropriate – instruct patient in use, possible side effects
First line
PDE5i is SILDENAFIL 50 – 100mgs trial of no less than 8 tablets.
Second line
- Tadalafil 20 mgs if no response to Sildenafil – no less than 8 tablets.
Vardenafil 10 -20mgs (private prescription only not on formulary)
Daily Tadalafil 5mgs (private prescription only not on formulary): consider in men with LUTS due to BPE
Refer to secondary care if above treatment fails.
Patients will be seen in secondary care until patient is established on successful treatment, then GP to continue prescribing/review.
Prescribing as per schedule 2.
Referrals that do not meet the CCG guidelines will be rejected.Slide19
Lower urinary tract symptomsSlide20
LUTS
Follow NICE guidance before referral
Initial assessment/management in community-if no evidence of this happening, referrals could be rejected or treated as advice and guidance.Normal PSA patients discharged once stable on treatmentPatients with LUTS and raised PSA discharged after successful treatment for LUTS and biopsies dealt with.Slide21
LUTS-initial assessment
History-general and urological.
Physical examination guided by symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination (DRE).urine dipstick
test.Frequency volume chart and IPSS.Discuss PSA if indicated.Slide22
LUTS-initial management
Storage symptoms (OAB): lifestyle changes, fluid intake advice (caffeine, alcohol), bladder training.
Voiding symptoms: likely bladder outflow obstruction. If mild active surveillance. If moderate or severe consider drug therapy.Slide23
LUTS-drug therapy optionsSlide24
LUTS-when to refer
Patient with uncomplicated LUTS should receive first line treatment in the community and should be referred to urology if:
LUTS not responded to conservative management or drug treatmentT
hey have:– LUTS complicated by recurrent or persistent UTI–
retention
– renal impairment you suspect is caused by lower urinary tract
dysfunction
– suspected urological cancer
– stress urinary incontinence.Slide25
Advice and Guidance Service
Patients who might not need to be seen in clinic but need advice on management
Avoid “unnecessary” appointmentAs much info as possibleE-mail service. Forwarded to consultantReply within few working daysSlide26
Thank you
Questions/comments?