Prostate cancer remains the most common male cancer in Scotland, accounting for more than 20% of all cancers diagnosed in men. It is the largest cause of male cancer deaths. Although the number of cases per year of prostate cancer has largely stayed the same in the past decade, survival rates are improving, particularly where diagnosis is early. The development of new technologies and treatments has undoubtedly contributed to improvements in outcomes. Alongside this, the ability to redesign pathways in line with technological advances, patients’ needs and consumer expectations has become another critical success factor.
This has certainly been the case at Edinburgh Cancer Centre, where prostate cancer pathways have evolved considerably since our brachytherapy service was first introduced in 2001. Our infrastructure has been significantly bolstered; increased patient demand has meant the multidisciplinary team has more than doubled in size while our collaboration across disciplines and specialties has greatly improved. The latter is crucial; the diagnosis and treatment of prostate cancer touches multiple clinical specialties and departments including urology, pathology, radiology, theatre and anaesthetics. The patient journey – end-to-end – is complex.
That patient journey has extended geographically too. As national awareness of brachytherapy has increased, the footprint of our patient population – as well as our patient numbers – has expanded. Today, around half the men referred into our service are from outside the Lothian area; traveling from as far afield as the Shetlands, Highlands and Western Isles. Ten years ago, that figure was around 25%. The increase has led us to develop two pathways; one for local patients and another – which includes a comprehensive one-day pre-assessment – for patients further afield.
The uro-oncology CNS
The complexities of the journey from diagnosis-to-treatment shine a bright light on the importance of the CNS team, which fundamentally acts as the glue that binds everything together. At the Edinburgh Cancer Centre, we’re fortunate to have three CNS’s supporting our entire uro-oncology service.
The importance of the CNS, particularly in oncology settings, is widely acknowledged. Our role is primarily to support patients at every touchpoint along the pathway – providing accessible advice, information and guidance whenever it’s required. We’re also responsible for managing communication between the various internal disciplines to ensure pathways function efficiently. Our ultimate goal is to assure an optimal patient experience.
The CNS role is particularly valuable in prostate cancer care, where the evolution in treatment options presents patients with choice at a time when coherent decision-making can often be compromised by the natural stresses of a cancer diagnosis. Our job is to provide independent, unbiased advice about all the appropriate treatment options – to ensure patients choose the right treatment for them. Quality of Life studies show that if a patient is happy with the treatment they choose, their outcomes – and their ability to tolerate side-effects – are generally better.
Communication between patients and CNS is always personalised and empathetic. Patients are rarely interested in the science or the statistics – they want to know the potential side-effects, the long-term implications and the likely clinical outcomes. And they want to hear it in simple English not medical jargon.
It’s a sign of how far brachytherapy has come that it’s now a common feature of our conversations with patients. In the information age, awareness of brachytherapy has grown significantly and many of the patients we see already have a small understanding. However, the ability to build on that knowledge and hear real-world experiences from informed professionals is hugely valuable. Nevertheless, with or without prior knowledge, CNS engagement gives patients an opportunity to discuss all their treatment options.
Brachytherapy: a great option
Primarily, brachytherapy (permanent seed implant) is not suitable for everyone; there are guidelines determining its use. However, for those patients where it is appropriate, it’s a great option. The treatment is highly convenient and, because it is less invasive, generally has faster recovery times. Similarly, side-effects like incontinence or sexual dysfunction are often less severe than surgery or radiotherapy. Most importantly of all, comparative effectiveness studies show that LDR brachytherapy reports equivalent recurrence-free survival rates to RP and EBRT in both low and intermediate risk patients. All the evidence confirms that it is a very effective treatment.
It’s no surprise that more patients are choosing brachytherapy. Our own service in Edinburgh bears this out. Here, logistical challenges around the use of theatre and resources restrict our service to two slots every week – totalling between 90 and 96 slots across the year. A decade ago, some of those slots would be unused. Today, the service is at full capacity. Demand for brachytherapy, both from the local area and beyond, is such that waiting lists have increased. This is not ideal but it illustrates the level of interest in the treatment. We’re currently developing a business case in the hope of unlocking additional theatre time to reduce waiting times and treat more patients.
Whatever the outcome, one thing is for sure: brachytherapy is here to stay as a primary treatment option for prostate cancer. What’s more, as the Edinburgh Cancer Centre prepares to treat its 1000th brachytherapy patient since 2001, it’s unlikely that treating the next 1000 will take anything like 18 years. We’ve sown the seeds – now we’re bearing the fruits.