Like last week’s blog about mental health support for men with prostate cancer, this week’s is about how an already variable and, for many, unsatisfactory situation has been exacerbated by Covid. We’re talking primary care – the services you receive through your local GP surgery.
Covid has changed the rules of access to GPs and there is evidence people are not going as often as they would otherwise. For men at risk of prostate cancer, this is a real problem.
The Daily Mail reported last September that GP referrals for prostate cancer dropped by 50% during last year’s lockdown. This was based on data from Prostate Cancer UK. Current figures are only slightly improved with considerable regional variation.
There has been a vocal, celebrity-backed campaign from the NHS and Cancer organisations that “the NHS is still open” and to contact your GP if you are worried. We enthusiastically support these campaigns, and urge all men who are concerned about prostate cancer to contact their GP and request a PSA test.
This is also an ideal time to think about best practice in primary care, and address what men should expect from their GP in supporting their prostate health. We have a wealth of comments and feedback from our patents about their experience and expectations with their GP, which we’ve consolidated and summarised below.1.PSA test
As there is no national screening programme for prostate cancer in the UK, men’s experience with the PSA test is highly variable in terms of when, where and under what conditions it is available. So many men tell us the PSA test was offered to them only as part of other investigations and their gratitude for what was a serendipitous event is powerfully felt. Some men tell us they asked for a PSA test and were refused. For clarity, Public Health England’s Prostate Cancer Risk Management Programme says that every man over the age of 50 has the right to a PSA test after a discussion of the pros and cons with a doctor.
Prostate Cancer UK provides guidelines for GPs and patients on receiving a PSA test. Our advice is to ask your GP for a PSA test if it is not offered to you, but before you do, understand what it means and what you want to happen next if its result causes concern.2.Knowledge about the range of treatments
. Few if any of our patients were advised of focal therapy from their GP, and learned about it through their own, mainly online research. While this is not unusual, what is concerning is the limited information shared about Quality of Life impacts from the various treatment options that were presented. Many of our patients felt they were not adequately counselled on the sexual and urinary functional outcomes they potentially faced, and how these could be managed from a physical and mental health perspective.3.Knowledge about resources to investigate and learn more.
While it is easy to tell men to go online and find out more, most men are in shock when they hear they might have prostate cancer and are compromised, initially, in their capacity to process new information. That’s why it’s crucial to give men effective and digestible information immediately so they can build their knowledge and develop the confidence to access more. Predict Prostate is a tool provided by the NHS that shows how different initial management strategies affect the percentage of men that survive ten and fifteen years after diagnosis. Non-individualised data is also shown on the potential harms of each treatment type. It’s the perfect platform for discussion and further investigation, and we’d like to see it used more at the GP level.4.Knowledge of specialists and variations in diagnostic
procedures and urological practice. Many of our patients tell us they are referred to a specialist without discussion of the variation in practice that continues across the UK, which can be considerable in the stages of the diagnostic pathway and ultimate treatment. Men need to be pointed in the right direction in terms of understanding the importance of imaging, imaging reporting and biopsy approach, each of which will determine his treatment choices, and is essential to making his choice of specialist and asking the right questions about his care.5.Active Surveillance support
For men that are referred to a specialist, diagnosed and put on an Active Surveillance programme, the GP becomes an important part of his life as his PSA levels are regularly tested. Many men find this stressful, often struggling between their continued status as a “cancer patient” and the mutual responsibilities that go with it. GPs might consider engaging AS patients more at each visit through broader monitoring of changes in mental health and lifestyle.
Sam Merriel, a GP and a Clinical Research Fellow at the College of Medicine and Health, University of Exeter, has been working with GP practices on approaches to support men with suspected and diagnosed prostate cancer. Writing recently in the British Journal of General Practice, he says
“Most patients place a high level of trust in their GP – it is one of the privileges of our profession that we build relationships through continuity of care, and some patients seek their GP’s opinion on big treatment decisions for conditions such as cancer. Continuity of care increases our understanding of the complexities and nuances of the patient’s medical history, their preferences for treatment, their social circumstances, and their quality of life”
“Men value receiving clear information about their treatment choices for prostate cancer. Discussions with a specialist are important, but prostate cancer patients also want to be able to talk to a healthcare professional about any questions or concerns that arise prior to or during their treatment. GPs can play a role here, and can use their knowledge of the patient regarding their personal priorities and communication style to give information in a manner the patient is more likely to understand.”
What has your experience been with your GP? What changes have you seen during Covid? We’d like to hear.