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How Can GPs Best Support Men With Prostate Cancer?

Dr Sam Merriel joins OnFocus to discuss how GPs are supporting men in their prostate health and explores some avenues for improvement. Dr Merriel is a GP practicing in North Somerset in SouthWest England. He is also a clinical senior research fellow at the University of Exeter, investigating ways of improving the early diagnosis of cancer in primary care. He 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.
Please find below a written transcript of the interview.

Clare Delmar:
Hello and welcome to Unfocussed 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, really, really important effect of the pandemic that we're seeing acutely in primary care and in GP practises. So, yes, the urgent suspected cancer referrals have dropped right off and haven't recovered back to sort of pre covid levels for what we would expect. And 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. So they have dropped right off and they haven't recovered yet. We've certainly found in general practise, particularly early in the pandemic, that people stopped coming to see us for a lot of things that they usually would. And I think that's completely understandable. The advice from government was to stay at home, protect the NHS. And I think certainly my experience with my patients, it seemed like a lot of them thought that the NHS is too busy to deal with these other things right now. And I won't go and bother the GP at this time and I think people are holding back. And GPs are worried about that. We are worried that people out there have serious problems or serious symptoms or things that are building up that we would normally be picking up early that we haven't because people aren't coming to see us as much as they used to for understandable reasons. But we want to put the message out there to everyone that, you know, your GP practise 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, you know, we're not a national coronavirus service. We're a national health service and it's a health problem. We want to see you. And I can understand for men with issues that might relate to the prostate, some men might naturally think, oh, you know, waking up three or four times a night to wee at my age is just normal and everyone does it. And I shouldn't go and bother the GP to talk about it. But actually, you know, 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:
Obviously, when the pandemic hit and general practise had to change the way it practised, almost overnight, we went from mainly seeing patients face to face with a little bit of telephone consulting and some practises had started to offer online consultations. We've completely reversed that. So now the vast bulk of people we consult with is by telephone or via video consultation or online through email and other web based forms. And everyone in primary care expects this in some form or another to stay. So general practise is not going to go back to mostly face to face. We're going to have a mix of these ways of accessing your GP after the pandemic. And that might actually, in some ways for some people, improve their level of access because, as you say, some people might be hesitant to come forward to talk about symptoms such as those that could relate to the prostate face to face. But if you feel more comfortable speaking to us about that or speaking to GP about that by the phone or on a video consultation or just by email, that now is an option and those options will remain open to people going forward. So that's really good. I mean, I think as GPs, we're also very cognisant that not all of our patients are tech savvy. Not all of our patients have access to the internet. So I don't think online consultations are the solution for everyone. And something we know about prostate cancer is that age is one of the biggest risk factors. So I know some of my older patients still don't have a mobile phone, so I still have to pick up the phone to ring them. I still have to write to them with a letter. I still have to go and see them at their home and that's fine. And that will still be available. We will still be seeing patients face to face. We'll still be talking on the telephone, but yes, online consultations are here now and they will be here to stay.

Clare Delmar:
So can we talk about the PSA test? I mean, there's guidance from multiple sources, some of which seems conflicting, both to patients, I think, and possibly GPs. How do you think the GP community best responds to this?

Sam Merriel:
Yes, there are mixed and strong views about the PSA test. I think the thing to keep in mind is at the moment for GPs, the PSA test is the only test we have available to try and detect prostate cancer early. PSA and examining the prostate are the only tools the GPs have in their armoury. And so we have to do the best we can with what we've got available. And I think GPs are very cognisant about the importance of detecting cancer early, but they're also very wary of putting men through unnecessary investigations. So the PSA, it can be quite good at picking up cancers early. And there are definitely examples of men who've come and got their PSA done and it's been abnormal and we've sent them off and they've got their cancer diagnosis. But GPs are aware of the limitations of the test, too, in that some men with prostate cancer will have a normal PSA. So we're not always reassured if the PSA is normal, but a man is high risk. We still need to think about do we need to go further. And equally a man who has a raised PSA, we know that a lot of men with raised PSA is it's raised for other reasons that don't relate to prostate cancer and the diagnostic tests of having a prostate biopsy and now we've got MRI available. Those tests can take a long time. Some men find them uncomfortable and invasive, and we want to try and keep the balance. So I think there are some really good resources out there. So I know I personally use a very simple sort of one page leaflet from Public Health England that outlines the potential benefits and the potential harms of going through a PSA test. GPs often use what's called the Prostate Cancer Risk Management Programme, which has been developed over a long period of time and has quite detailed information about how to use a PSA test, how to interpret it as accurately as you can, and what other things to think about.

Clare Delmar:
What about just the simple fact of offering it to most men?

Sam Merriel:
Yeah, well, I mean, the guidance is still... Yes, the opinions vary, but the guidance in terms of for men with symptoms is very clear that in any man who comes forward with a symptom that might relate to their prostate, it might relate to prostate cancer, we should be offering a PSA test, that should be made available. The issue of screening men who don't have any symptoms,  that's a screening test, that's a bit more controversial. But I think all GPs would have the conversation with the man about, you know, OK, you want to have this test. That's fine. Let's talk about your risk. Let's talk about what the test might mean and what the consequences might be if it's a positive test. A high PSA or an abnormal PSA doesn't mean you necessarily have prostate cancer.

Clare Delmar:
Yeah, no, of course.

Sam Merriel:
It's a good way of trying to detect it early and we need to be conscious of it.

Clare Delmar:
But it does seem to put the onus on the patient to to ask. I guess that's one of the things that a lot of our patients tell us.

Sam Merriel:
I guess because the evidence says that going out and saying, well, all the men in our practise should come and get a PSA test, the evidence is that it might... There's no clear evidence it causes more benefit than harm. You know, that's still debatable. So, yes, we don't proactively go out and offer. I mean, I do know that some practises as part of a sort of the NHS health checks, if a man comes along or men who have monitoring tests for other chronic conditions, such as diabetes or high blood pressure, we might talk to them about do they have any symptoms that either relate to the prostate and should we think about adding a PSA test in. But I think a lot of GPs do feel that quite strongly, that we need to have an informed conversation with a man and not just tack it on as an extra blood test without actually informing them that this is what the test might show. And this is what the potential consequences could be if we do this test and we feel we have to have that conversation, but we're more than happy to do it.

Sam Merriel:
So what would you expect then to be a GP's minimal level of knowledge, if I can put it that way, on further prostate diagnostics and treatments? And what would be, in your opinion, best practise in guiding a patient following a raised PSA result?

Sam Merriel:
So as I said earlier, the tests we have available in primary care is essentially the PSA or examining the prostate. And GPs should know that the usage and the interpretation of that. In terms of further diagnostics, I mean, I think I touched on prostate MRI, which is a relatively new test not currently available to GPs. So that's that's still only done by hospital specialists. And obviously we don't do the prostate biopsies either. So I think the GPs would be aware that these tests exist. The awareness of prostate MRI is probably still developing amongst the GP community.


Clare Delmar:
Really?

Sam Merriel:
So I don't think all GPs would know why a prostate MRI is done or what that adds. They might be aware that they're now doing prostate MRIs. But in terms of the MRI's specific role, in terms of trying to identify tumours and guiding biopsies, that is still being disseminated amongst the GP community now. And then in terms of treatments, I mean, GPs are currently not involved in treatment decisions and recommendations that still sort of guided by the cancer specialist team. But GPs are involved for a lot of men once a treatment decision has been made and it's been started by the hospital team in terms of delivering hormone therapy, in terms of organising PSA blood tests for men on active surveillance. So we do have some role in some of the treatments. But other specialist treatments like chemotherapy for advanced prostate cancer is not something that we typically get involved with. So a GP might be aware that it's an option, but they might not know a lot more than that.


Clare Delmar:
Just speaking about prostate MRI. I mean, there's as you know, even just as recently as last week, there's been some recent developments on prostate MRI as a potential screening device. And I guess one of my questions is if, as you say, the GP community may not be as aware as prostate MRI is, we might like do you find that a lot of patients are aware that they've done their own research and the dialogue sort of between the patient and the GP informing each other has advanced?

Sam Merriel:
I think that is starting to happen because the NHS is now rolling out their MRI. So NICE guidance to say that men where they're able to have an MRI should be offered one before they get a biopsy. Now, that guidance only changed in 2019. So hospital trusts and the NHS services are still rolling that out across the board. So I think as that becomes the standard of practise across the NHS, more and more patients will become aware of it. And I think GPS will too. And they'll also start to see men who've gone been referred, come back having had an MRI, but not gone any further because the MRI didn't show anything suspicious and the decision was not to go on to biopsy. So that will evolve going forward. And I think we do have a lot of information from patients who do come and talk to us. And a lot of GPs are open to those conversations. If a patient wants to come and talk. Hey doc, do you think I should have this prostate MRI? Even if the GP doesn't have an in-depth knowledge at that point, they would go away and look up some reputable sources and come back and have that conversation.


Clare Delmar:
So in some of your research and things you've published, you've advocated for sort of a holistic approach to patient health when it comes to caring for men with prostate cancer and and that this is best supported through something called continuity of care. So how would you advise men to engage with their GP practise if this isn't available to them or it's been compromised, as it has been during covid?

So continuity of care, so having a GP, or a member of the GP team, who knows you as a patient and knows your full history and then is there for you going forward is a challenge that we are grappling with as a profession. And there are a number of factors that are affecting that. So the traditional model of having a GP available 24/7, seven days a week with the amount of workload that we have in primary care, that is not feasible anymore, that would burn every GP out in the UK. So we're finding other models of trying to deliver the best care we can and a lot of practises still really value continuity of care. So regardless of which GP you normally see, every patient will have a named GP. So someone who is ultimately responsible for that patient, will receive all the correspondence from the hospital specialists and the community care providers. They will often receive the blood test results and prescription requests and things. And then we cover for each other on the days when we're not in the practise. So if patients feel that they don't have a strong relationship with the GP they're seeing at the moment, then I mean, what I would encourage you to do is think about which GPs have you interacted with in your practise? Which ones do you feel like you've you've got along well, that you have a good rapport with and whenever you ring up ask to see that GP. It's true that we won't necessarily get to see you the day you ring up and ask for an appointment. But it's entirely possible for a lot of issues that we can arrange for the next available appointment to speak to that GP that you have a good relationship with and then take that forward. And I think with what we talked earlier about the widening options of accessing your GP through online consultations and email consultations and things. Some of those non-urgent things that don't have to be dealt with on the day that you ring the practise.You know, if you have taken up the option of an email consultation or the option of a follow up phone call, that will happen. And that will be a way to build rapport and a relationship  with a GP that in your practise.

Clare Delmar:
So some people refer to the GP as a gatekeeper as opposed to a more engaged practitioner, sort of responsible and advocating for their care. Do you think that we have every reason to be encouraged about that more engaged model moving forward?

Sam Merriel:
The gatekeeping model goes: How do we find the best way to get the patient the help they need? And then sometimes that can be delivered with your GP or with another community service, and sometimes that requires referrals to a specialist and that's bread and butter for GPs is trying to help a patient find the best available treatment for them and the right treatment. I am hopeful with these wider options for accessing your GP going forward, that it might actually make it easier for people to speak to a GP that knows them and stay in touch with them regularly.

Clare Delmar:
I mean, one idea that's been floated around from a number of various institutions are the polyclinic idea where you... Is that something that you've given any thought to?

Sam Merriel:
So when you say the polyclinic idea, did you mean in terms of having other community specialities like physiotherapists...

Clare Delmar:
And diagnostics and so for example, the MRI would be available locally in a public clinic as opposed to a hospital/

Sam Merriel:
Yeah, yeah. So that's definitely one model. And there is a strong push from the NHS to try and make services available more in the community. And there has been some rebalancing of the NHS resources to do that. So the regional initiative is what's called primary care networks. And part of the the idea behind primary care networks is that they have some some extra funding available to bring in. Yes, more diagnostics, more community specialists, more extra services into the local community. So, for instance, in our practise, we now have two physiotherapists who come and work in our practise and patients can book directly in with them if they have a problem with their back or their shoulder or something that we could assess or the physio could assess. And that's kind of increasing access to the right kind of person. We do need more resources if we're going to start doing things like diagnostics in the community. But there's discussion about diagnostic hubs in the community within the NHS that might mean going forward, your GP can organise more tests for you locally rather than having to send you up to the hospital to get the tests done like an MRI.

Clare Delmar:
Encouraging to think about. Sam, thank you so much for speaking with me today. It's been really helpful and I know our listeners will find this extremely informative. So thanks very much.

Sam Merriel:
My pleasure. Thank you very much for having me.


Clare Delmar:
A transcript of this interview is available on our website, where you can also access additional interviews, blogs and reviews of several of the issues we've discussed today. Visit The Focal Therapy Clinic at www.thefocaltherapyclinic.co.uk. Thanks for listening and from me, Clare Delmar, see you next time.


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