CCG/QEH Urology Agreements
An update for General Practitioners
-Edgar Paez-Consultant Urologist
-Freeman Hospital –Newcastle upon Tyne and Queen
Elizabeth Hospital-Gateshead
July 2014
CCG/QE Agreement-Proposed
Pathways
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Review of agreements due
Recent NICE guidance
New commissioning guidance
Initiate first line assessment/treatment in
primary care
• Attempt to reduce “un-necessary” secondary
care referral
• Reduce cost of treatment
Suspected cancer referral
• Prostate
• Bladder and renal -Haematuria
SUSPECTED CANCER-PROSTATE
• Men presenting with symptoms suggesting
prostate cancer should have a digital rectal
examination (DRE) and prostate-specific
antigen (PSA) test after counselling.
• Urinary tract infection (UTI) should be
excluded before PSA testing. If there is a
proven UTI, the PSA test should be postponed
for at least 1 month ( ideally 6-8 weeks)after
treatment of the infection.
Urgent referral should be made:
• If a hard, irregular prostate is felt on DRE. PSA
should be measured and the results sent with the
referral letter. Urgent referral is not indicated if
the prostate is enlarged and the PSA is normal.
• If the prostate is normal on DRE, but the agespecific PSA is raised or rising.
• In symptomatic men with high PSA levels. If there
is doubt about whether to refer an asymptomatic
man with borderline level of PSA, PSA test should
be repeated after 1 to 3 months. If the second
test indicates that the PSA level is rising, an
urgent referral should be made.
• The age-specific cut-off PSA measurements
recommended by the Prostate Cancer Risk
Management Programme are as follows:
• 50–59 years of age >= 3.0 nanograms/mL;
• 60–69 years of age >= 4.0 nanograms/mL;
• 70 years of age and older >= 5.0 nanograms/mL. (there
are no age-specific reference ranges for men over 80
years of age. Prostate cancer only needs to be
diagnosed in this age group if it is likely to need
palliative treatment, i.e grossly abnormal DRE,
suspicion of advanced disease, PSA >20.
• Good performance status, life expectancy 10 years.
• Screening in patients over 75 is discouraged.
SUSPECTED CANCER-RENAL AND
BLADDER/Haematuria clinic
• Any adult patient with visible haematuriacheck for UTI-haematuria clinic. Men 50-75
with no UTI : PSA.
• Over 40’s with persistent non visible
haematuria-haematuria clinic
• Patients under 40 with persistent non visible
haematuria-check creatinine and proteinuria,
if abnormal, refer to Nephrology, if normal,
non urgent referral to Urology
Haematuria Clinic
• 2 stop clinic
• Radiology (USS + KUB in all non visible
haematuria and younger patients, CTIVU in
over 40’s with visible haematuria)performed
first stop
• Flexible cystoscopy 2nd stop
• Report sent to GP’s from clinic.
• Please perform eGFR
Shared Care
Prostate Cancer
Introduction
• Patient with diagnosis of prostate cancer
• On A/M, hormonal manipulation or post radical treatment
(surgery or radiotherapy).
• Care closer to home
• Reduce number of hospital appointments
• No compromise in patient care
• Financial implications
• Hospital Doctors/Patients/GP’s have to agree. Will require
written response by GP’s.
• Clear treatment plans
• General guidelines + individual patients letters
• Review compliance to be monitored by CCG.
Ca.Prostate. Shared care discharge guidelines
Patient type
Discharge criteria
Discharge after
Hormone Therapy
Stable *
1 year
Watchful wait
No sign of disease progressions
and stable*
1 year
Active surveillance
(suitable for radical treatments)
No sign of disease progressions
and stable*
2 years
( only when no longer suitable for
radical treatment)
Active surveillance
(not suitable for radical
treatments)
Stable*
1 year
Low risk post radical surgery
Undetectable PSA, stable LUTS and
DRE*
2 years
High risk post radical surgery
Undetectable PSA, stable LUTS and
DRE*
5 years
Low risk post radiotherapy
Stable*
2 years following completion of
hormones
High risk post radiotherapy
Stable*
5 years
*STABLE = No increase in LUTS, No changes in DRE & stable PSA
Shared care-follow up
• Patients on hormonal manipulation: PSA alone,
DRE if changes on PSA or LUTS that need further
assessment. Check liver function twice a year,
testosterone if PSA ↑, to assure castrate levels.
• Patients post radical radiotherapy: : PSA alone,
DRE if changes on PSA or LUTS that need further
assessment.
• Patients post radical prostatectomy: PSA alone,
no role for DRE.
• Patients on active monitoring: PSA and yearly
DRE.
When to refer back-following radical
treatment.
• After radical prostatectomy: a confirmed PSA
value >0.2 (two consecutive measurements)
• After radiotherapy: a confirmed PSA value
2ng/ml above nadir value
• If patients have significant urological side
effects following therapy.
When to refer back-patients on active
monitoring
• Letter generated on each patient with
recommendation
• Most patients who are discharged will be not
suitable for radical treatment (in view of age,
comorbidities, etc)
• For most patients will be signs of significant
disease progression (3 significant PSA rises,
PSA doubling time <6months, PSA>20, or
symptoms of advanced disease).
Patients with elevated PSA and
negative prostate biopsy
• Patients will be discharged after investigated
• Physicians satisfied that significant prostate
cancer unlikely (repeat biopsies/MRI will be
performed if indicated).
• Currently no national guideline by NICE-issue
under review
• Decision aid tools being developed
Shared care-delivery improvement
• Pilot with a handful of Practices to send
current forms via NHS Mail instead of post.
• Working with CBC to pilot use of EMISWeb to
track current Shared Care patients including a
reminder system that will flag when patients
are due a review appointment. Will look to
run as part of EMIS QOF Template pilot being
run by CBC with Practices in the Bureau.
Erectile dysfunction
As per Newcastle, North of Tyne and Gateshead guidelines for
management of erectile dysfunction on adults > 18 years.
Assessment
 History – medical, sexual and psychosocial. Smoking drugs and
alcohol. Determine type of ED.
 Examination – BP and BMI. Secondary sexual characteristics
abdominal and genitalia, Lower limb pulses
 Bloods
 Calculate CV risk
 IIEF questionnaire.
Erectile Dysfunction
Referral to secondary care as per CCG Guidelines for management of erectile dysfunction
Trial of treatment in primary care .
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Lifestyle change
Manage any underlying cause
Treatment if no contra-indications
If appropriate – instruct patient in use, possible side effects
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First line PDE5i is SILDENAFIL 50 – 100mgs trial of no less than 8 tablets.
Second line - Tadalafil 20 mgs if no response to Sildenafil – no less than 8 tablets.
Vardenafil 10 -20mgs (private prescription only not on formulary)
Daily Tadalafil 5mgs (private prescription only not on formulary): consider in men with
LUTS due to BPE
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Refer to secondary care if above treatment fails.
Patients will be seen in secondary care until patient is established on successful treatment, then GP to
continue prescribing/review.
Prescribing as per schedule 2.
Referrals that do not meet the CCG guidelines will be rejected.
Lower urinary tract symptoms
LUTS
• Follow NICE guidance before referral
• Initial assessment/management in community-if
no evidence of this happening, referrals could be
rejected or treated as advice and guidance.
• Normal PSA patients discharged once stable on
treatment
• Patients with LUTS and raised PSA discharged
after successful treatment for LUTS and biopsies
dealt with.
LUTS-initial assessment
• History-general and urological.
• Physical examination guided by symptoms and
other medical conditions, an examination of
the abdomen and external genitalia, and a
digital rectal examination (DRE).
• urine dipstick test.
• Frequency volume chart and IPSS.
• Discuss PSA if indicated.
LUTS-initial management
• Storage symptoms (OAB): lifestyle changes,
fluid intake advice (caffeine, alcohol), bladder
training.
• Voiding symptoms: likely bladder outflow
obstruction. If mild active surveillance. If
moderate or severe consider drug therapy.
LUTS-drug therapy options
LUTS-when to refer
• Patient with uncomplicated LUTS should receive first line
treatment in the community and should be referred to
urology if:
• LUTS not responded to conservative management or drug
treatment
• They have:
– LUTS complicated by recurrent or persistent UTI
– retention
– renal impairment you suspect is caused by lower urinary
tract dysfunction
– suspected urological cancer
– stress urinary incontinence.
Advice and Guidance Service
• Patients who might not need to be seen in
clinic but need advice on management
• Avoid “unnecessary” appointment
• As much info as possible
• E-mail service. Forwarded to consultant
• Reply within few working days
Thank you
Questions/comments?