How Can Your GP Help After a Raised PSA or Prostate Cancer Diagnosis?

Clare Delmar:

Hello and welcome to OnFocus brought to you by The Focal Therapy Clinic, where we connect you with issues facing men diagnosed with prostate cancer that are little known, less understood and often ignored. Prostate cancer is now the most commonly diagnosed cancer in the UK, and with this sombre fact comes a multitude of challenges and opportunities. I’m Clare Delmar. Joining me today is Dr Sam Merriel, a GP practising in North Somerset in southwest England. He’s also a clinical senior research fellow at the University of Exeter, investigating ways of improving the early diagnosis of cancer in primary care. Dr Merriel has published research on prostate cancer diagnosis and management and his current Cancer Research UK funded research is exploring the potential of GPs using prostate MRI to aid in the early and accurate diagnosis of prostate cancer. Sam, thanks so much for joining me.

Sam Merriel:

Thank you for having me, Clare.

Clare Delmar:

I think this is a really, really important issue, particularly during the COVID era, where we’ve seen some critical links, some connected and some may be disconnected between primary and secondary care. So I’m very interested in speaking with you about this. So if I can kick off by just mentioning that most of the public is aware that GP referrals for men with suspected prostate cancer at one point last year dropped to their lowest in over 10 years. And I think they’re recovering, but only slightly from what limited data I’ve seen. How do you think the NHS can best improve on this?

Sam Merriel:

So you raise a really important effect of the pandemic that we’re seeing acutely in primary care and in GP practices. The urgent suspected cancer referrals have dropped right off and haven’t recovered back to pre-COVID levels. If you look at referral rates prior to the pandemic arriving in the UK, GP referrals for suspected cancer were going up year on year.

We’ve certainly found in general practice, particularly early in the pandemic, that people stopped coming to see us for a lot of things that they usually would. The advice from government was to stay at home, protect the NHS. A lot of patients thought that the NHS was too busy to deal with other things right now.

But we want to put the message out there to everyone: your GP practice is open, they can see you, they want to see you. If you have any symptoms, regardless of what it relates to, please come forward and see us. We’re not a national coronavirus service — we’re a National Health Service, and if it’s a health problem, we want to see you.

For men with issues that might relate to the prostate, some might naturally think waking up three or four times a night at their age is just normal. But actually, if you’ve got symptoms related to your prostate or related to your waterworks, we still want to talk to you about it because it might be something that needs to be looked into further.

Clare Delmar:

So are online GP consultations the answer to this and if they are, how do you advise men who might be hesitant to engage that way?

Sam Merriel:

When the pandemic hit, general practice had to change the way it practised almost overnight. We went from mainly seeing patients face to face to the vast bulk being by telephone, video consultation, or online through email and web-based forms. Everyone in primary care expects this in some form to stay.

That might actually improve access for some people — if you feel more comfortable speaking to a GP about prostate symptoms by phone or video or email, those options are now available and will remain open going forward.

As GPs, we’re also very cognisant that not all of our patients are tech-savvy. Not all have access to the internet. Prostate cancer risk increases with age, and some of my older patients still don’t have a mobile phone. We still see patients face to face, still talk on the telephone, and that will remain available.

Clare Delmar:

So are online GP consultations the answer to this and if they are, how do you advise men who might be hesitant to engage that way?

Sam Merriel:

When the pandemic hit, general practice had to change the way it practised almost overnight. We went from mainly seeing patients face to face to the vast bulk being by telephone, video consultation, or online through email and web-based forms. Everyone in primary care expects this in some form to stay.

That might actually improve access for some people — if you feel more comfortable speaking to a GP about prostate symptoms by phone or video or email, those options are now available and will remain open going forward.

As GPs, we’re also very cognisant that not all of our patients are tech-savvy. Not all have access to the internet. Prostate cancer risk increases with age, and some of my older patients still don’t have a mobile phone. We still see patients face to face, still talk on the telephone, and that will remain available.

Clare Delmar:

What would you expect to be a GP’s minimal level of knowledge on further prostate diagnostics and treatments? What would be best practice in guiding a patient following a raised PSA result?

Sam Merriel:

The tests we have available in primary care are essentially the PSA or examining the prostate. In terms of further diagnostics, prostate MRI is a relatively new test not currently available to GPs — still only done by hospital specialists. GPs would be aware that these tests exist, but the awareness of prostate MRI is probably still developing amongst the GP community.

Not all GPs would know why a prostate MRI is done or what it adds. They might be aware that MRIs are now being done, but the MRI’s specific role in identifying tumours and guiding biopsies is still being disseminated.

In terms of treatments, GPs are not involved in treatment decisions — those are guided by the cancer specialist team. But GPs are involved once treatment has been started: delivering hormone therapy, organising PSA blood tests for men on active surveillance. Specialist treatments like chemotherapy for advanced prostate cancer are not something we typically get involved with.

Clare Delmar:

There have been some recent developments on prostate MRI as a potential screening device. Do you find that patients who’ve done their own research are informing the dialogue with their GP?

Sam Merriel:

That is starting to happen because the NHS is now rolling out MRI. NICE guidance says men who are able to have an MRI should be offered one before biopsy — but that guidance only changed in 2019, and hospital trusts are still rolling it out.

As that becomes standard practice, more patients and GPs will become aware. GPs will start seeing men who’ve been referred, had an MRI, but not gone further because the MRI didn’t show anything suspicious. If a patient wants to discuss prostate MRI, even if the GP doesn’t have in-depth knowledge, they would go away, look up reputable sources, and come back to have that conversation.

Clare Delmar:

You’ve advocated for a holistic approach to caring for men with prostate cancer, supported through continuity of care. How would you advise men to engage with their GP practice if this isn’t available to them?

Sam Merriel:

Having a GP who knows you as a patient and knows your full history is a challenge we’re grappling with as a profession. The traditional model of a GP available 24/7 is not feasible anymore — that would burn every GP out. We’re finding other models to deliver the best care we can.

Regardless of which GP you normally see, every patient has a named GP who is ultimately responsible for them, receives all hospital correspondence, blood test results, and prescription requests. If you don’t have a strong relationship with your current GP, think about which GPs you’ve interacted with and have a good rapport with — and ask to see them when you ring up.

With the widening options of accessing your GP through online and email consultations, non-urgent things don’t have to be dealt with on the day you ring. An email or follow-up phone call is a way to build rapport with a GP in your practice.

Clare Delmar:

Some people refer to the GP as a gatekeeper rather than an engaged practitioner. Do you think we have reason to be encouraged about a more engaged model?

Sam Merriel:

The gatekeeping role is about finding the best way to get the patient the help they need — sometimes that’s with your GP, sometimes with a community service, and sometimes it requires specialist referral. That’s bread and butter for GPs. I’m hopeful that wider access options will make it easier for people to speak to a GP that knows them and stay in touch regularly.

Clare Delmar:

One idea that’s been floated is the polyclinic idea — diagnostics available locally, for example MRI in a community clinic rather than a hospital. Is that something you’ve given thought to?

Sam Merriel:

That’s definitely one model. There’s a strong push from the NHS to make services available more in the community. Primary care networks have extra funding to bring in more diagnostics, community specialists, and extra services locally. In our practice, we now have physiotherapists who patients can book directly with.

We do need more resources if we’re going to start doing diagnostics in the community. But there’s discussion about diagnostic hubs within the NHS that might mean your GP can organise more tests for you locally rather than sending you to hospital — like an MRI.