How this practice…tackled prostate cancer screening

Chapelford Medical Centre, a GP practice in Warrington, ran a project to improve awareness and access to prostate cancer advice and screening for high-risk men registered at the practice. Carl Armstrong, advanced nurse practitioner, led the project and explains how it worked.

Prostate cancer is the most common cancer affecting men. Across the UK, more than 52,000 men are diagnosed with prostate cancer every year, according to Cancer Research UK figures. 

One in every eight men will be diagnosed with prostate cancer in their lifetime, and it accounts for around 12,000 deaths a year. That is, on average, 144 men a day diagnosed with prostate cancer, and one man dying from the disease every 45 minutes across the UK. 

There is currently no national screening programme as prostate cancer screening in asymptomatic men is contentious. Routine prostate-specific antigen (PSA) testing is ineffective; the limitations and potential risks associated with overdiagnosis and overtreatment have been well established. 

Nevertheless, catching prostate cancer early is important because that’s when it’s more likely to be curable.

As a practice, we wanted to help high-risk men decide whether testing was right for them. 

Asymptomatic 

Early prostate cancer often does not cause symptoms. But PSA testing on asymptomatic men is problematic. 

PSA can be normal even in cases of prostate cancer, resulting in false negatives. It can be elevated for reasons other than prostate cancer, which could potentially cause undue stress, increased referrals and invasive investigations that may cause harm. There is also the risk of overdiagnosis – finding a cancer that may never have caused any harm or changed life expectancy. These men then must make decisions about cancer treatments.

So, understanding and promoting the knowledge of risk factors for asymptomatic men is especially important in trying to identify prostate cancer in its early stages. 

This project, based on the Prostate Cancer UK Toolkit, proactively engaged men in making informed, personalised decisions about having a PSA test. 

Identifying patients

Using guidance from Prostate Cancer UK, we identified men at elevated risk of prostate cancer. They were men registered at our practice of 7,910, aged 50-70, or aged over 45 for black men as there is an elevated prevalence of prostate cancer within this ethnic group – one in four black men receive a prostate cancer diagnosis in their life compared to one in eight overall. We also included men who had a family history of breast cancer and/or prostate cancer. 

We excluded men who already had a diagnosis of prostate cancer as they were already under medical management or who’d had a PSA blood test within the last 12 months. We also excluded patients who were clinically unsuitable, such as those on an end-of-life pathway. 

The men were sent a text message with information about the signs and symptoms of prostate cancer,  the risks and benefits of a PSA blood test and given a link to a personalised risk checker on Prostate Cancer UK. The text also provided access to counselling resources from Prostate Cancer UK, focusing on the PSA blood test. 

Patients had the option to directly book a PSA blood test with our practice, bypassing the need for additional consultations or discussions. Alternatively, they could schedule an appointment with a clinician to seek further information, guidance or support. To reinforce engagement, we followed up with a gentle ‘nudge’ text one week later. 

All test results were reviewed in primary care, and actioned based on NICE guideline for suspected cancer, recognition, and referral.

Outcome

The project ran over a 12-week period starting in November 2023. 

We identified 689 men who met the inclusion criteria and they were contacted by the GP practice via text message. More than a third – 37% – opted to participate in the risk checker and 32% chose to have a PSA blood test. Of the 238 who opted for a test, 18 test results came back as abnormal.  

As a result of the project, two clinically significant prostate cancers were identified.

It also fostered communication between male patients and the practice, and it increased consultations for bladder and prostate health. This resulted in diagnoses of conditions like overactive bladder syndrome and benign prostatic hyperplasia, facilitating timely general practice assessments and specialist referrals. 

The project encouraged increased awareness of the risk factors, signs and symptoms of prostate cancer and facilitated informed patient decision-making. 

There was no immediate harm identified, but a possible downside to the project is that it may have inadvertently promoted local prostate cancer screening despite recognised limitations. Nevertheless, the feedback from patients was positive. No patients expressed regret at undergoing PSA testing, though not all participants provided feedback. 

Future

As a project, it was cheap to run. It incurred costs from phlebotomy and subsequent clinical time in general practice as well as urology referrals and investigations.

Although the project has now ended, the initial contact and information has continued to prompt men to arrange primary care consultations to discuss urological symptoms, prostate cancer and their options for testing. It indicated a strong interest among men for accessible information on prostate cancer, empowering them to make informed personal health decisions.

The project was led by Carl Armstrong, advanced nurse practitioner, at Chapelford Medical Centre. He was assisted by practice GP principle, Dr Dan Bunstone.