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How can primary care better support men at risk of prostate cancer?

How can primary care better support men at risk of prostate cancer? The substantial drop in GP referrals for prostate cancer diagnostics over the last year has led to concern over a mounting cancer backlog, mainly focused on hospitals. But it also merits a look at patient’s experience in primary care and how this might be improved.

We’ve explored this a lot over recent months by talking with patients, primary care and men’s health specialists.

In terms of patients, one group that stands out is Black men.

Delroy Wright is a former patient from south London whose primary care  experience appears to be shared by several black men we spoke with. He describes this in a recent interview

“I was 56 at the time. He asked me if I had any symptoms. I said I’ve got no symptoms, I’m sleeping well, I go to the gym and stuff. And he says, well, we’ll have to go up into your passage. I said, well, you know, I said, well, nah, you can’t really do that, because being a black guy, you know, we don’t really have anybody just go up into your passage just like that. So I asked him if there’s a lady doctor on site that can do it, and he said, yeah, and he laughed because he knew, you know, because I’ve got an Indian doctor, he said he knew how black guys were regarding just going up the passage. So it wasn’t a problem getting one of the lady doctors to do a test. But even that test when she did it didn’t show up nothing. But at the same time, they said I should go and get a PSA test, blood test. What they say to you then it’s a little bit high, but leave it, don’t worry about it. know, you wait, you don’t worry about it. Even though it was about, you know, a little bit high, they said, don’t worry. Six months later, I had another PSA test and this time they wanted me to do a MRI.”

Marcus McKenzie, also from south London, felt he had to challenge his GP for a PSA test, even though as a mixed-race man he knew he was at higher risk for prostate cancer.

“Well, being a man of mixed race in terms of Asian and black, I was aware of my heightened risk. So I took it upon myself to have a PSA test on a regular basis. Ordinarily, I think it was roughly every 12 months. There are some obstacles I have encountered at the doctor’s surgery level whereby one particular doctor sort of suggested that I ought not to have a PSA test because it wasn’t particularly reliable, knowing full well that that’s the only barometer or gauge one has. So I had to challenge that particular doctor and I insisted that I have the test by virtue of the fact that I was 50 percent more likely to develop prostate cancer because of my ethnicity.”

Del and Marcus struggled to get screened for prostate cancer despite being both higher risk and proactive in managing their health. This isn’t encouraging for other black men or indeed all men.

We discussed this with Dr Sam Merriel, a practicing GP in Somerset and a clinical research fellow at the University of Exeter, where he is investigating ways of improving the early diagnosis of cancer in primary care.

He feels that despite the drop in referrals during the pandemic, some encouraging signs emerged that are most likely here to stay and can be improved further. Video and telephone consultations is an example where he has seen men who might have been more reticent about going to a GP surgery and discussing prostate-related issues are more likely to engage.

He also believes that PSA testing can be better guided by the Prostate Cancer Risk Management Programme which is aimed at helping GPs to engage with patients more substantively, and that GPs should have conversations with men who are symptomless about their prostate cancer risk.

In terms of improvement, Dr Merriel feels that GPs could do better on their knowledge of the prostate cancer diagnostic pathway. While this is the domain of hospital specialists, GPs do support patients later as they undergo treatments such as Active Surveillance and hormone therapy. He hopes that emerging Primary Care networks can connect these dots and integrate more diagnostics locally.

Another approach comes from Prof Gordon Wishart is a professor of cancer surgery at Anglia Ruskin School of Medicine and the Chief Medical Officer and CEO of Check4Cancer, a leading cancer detection and cancer prevention organisation. He’s been a leading voice in lobbying the government and NHS to address the backlog in cancer diagnoses incurred by the pandemic, and spoke to us recently about how certain aspects could be addressed through primary care.

One aspect is risk stratification – we know that age, ethnicity and family history (including BRCA gene) increase the risk of prostate cancer, and this information could be more systematically used to bring men into their local GP surgery for screening.

In terms of screening itself, Prof Wishart would like to see more use of at-home PSA testing, which he believes to be both accessible and effective, allowing more men to regularly measure and track their PSA levels.

Another leading voice in primary care focused specifically on men’s health is Dr Jeff Foster is well-known GP and men’s health specialist who is frequently featured in the media. He notes a clear difference between men and women in their GP attendance:

“For many men, the thought of going to the doctors’ fills them with deep dread, and they may only attend primary health care at the insistence of a partner or significant other who has booked the ap Women are much more likely to seek medical help than men, and there are several potential factors for this phenomenon. Firstly, the fear of receiving bad news can cause this reticence, especially if doctor google has been employed prior to the visit. The feeling that they are wasting the doctor’s time has also been found to be a cause, as well as not wanting to lose time off work for health issues. Another important factor is that not all GP’s have specialist knowledge specific to men’s health and some men feel embarrassed by discussing issues that relate to sexual or reproductive health.”

He emphasises the importance of finding a GP that understands men’s health:

“It’s long overdue that we think about men’s health issues separately rather than combining it into a generic one-size-fits-all screening that is currently available. For instance, as women produce oestrogen up until their menopause they experience greater physiological protection from diseases affecting the heart than men. In fact, many men start to experience heart issues during their thirties but these are not picked up until much later in life, by which time it is too late to correct and can only be managed at best.”

He advises all men to do their homework. “Too few men visit a doctor let alone place enough importance on their health to shop for a decent one. So, look for a doctor who will treat you comprehensively as an individual and who you feel comfortable enough to talk openly with”

As a wish list, we’d like to see GP practices supporting men in the following ways:

  • More accessible screening In future, possibly to include emerging imaging approaches such as  Prostagram
  • Campaigns to encourage black and mixed-race men to get screened for prostate cancer
  • Information hubs, signposting links to and providing information on prostate cancer, diagnostics, treatments, side effects and support groups.
  • Pre- and Post-treatment care for sexual, mental and urinary health
  • Communication on why consenting to share GP Data is so important to improving research, diagnostics, treatment and services for men with prostate cancer — For two reasons:
    • Training for healthcare professionals and tools for data-driven healthcare are growing continually and can be channelled into men’s health
    • At a time when the NHS needs funds, its data is a resource of unparalleled scale and scope
  • Accessible and effective approaches to health promotion, ideally encompassing the 4Ps – healthcare that is predictive, preventative, personalised and participatory

What has your experience been with your GP? Is there something you’d like to see improve? We’d love to hear from you.

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