TET Phase 1 - Prostate and Breast Cancer
Phase 1 of the Test Evidence Transition programme launched in April 2023 in Scotland and Wales, supporting three NHS teams collaborating with academic partners to improve breast cancer and prostate cancer pathways. These projects are:
- PROSTAD: Development of Model Prostate Cancer Diagnostic Pathway – Hywel Dda University Health Board, TriTech Institute & Swansea University, Wales
- Access to Breast Assessment Clinics without GP Appointment – NHS Forth Valley and University of Stirling, Scotland
- Rapid Access Referrals for Prostate Cancer: A Nurse-Led Model for Suspected Prostate Cancer Referrals – NHS Fife and University of Stirling, Scotland
Phase 1 has been supported by the Royal London Insurance Group as part of their commitment to tackling cancer inequalities.
Our Phase 1 projects
PROSTAD: Development of Model Prostate Cancer Diagnostic Pathway – Hywel Dda University Health Board, TriTech Institute & Swansea University, Wales
Project Leads:
- Rachel Gemine – Evaluation Lead, TriTech Institute, Hywel Dda University Health Board
- Mr Yeung Ng - Consultant Urologist, Hywel Dda University Health Board
- Jaynie Rance – Professor of Health Psychology, Swansea University
Overview:
PROSTAD aims to develop, pilot, and evaluate implementation of a model prostate cancer diagnostic pathway within NHS Wales to improve optimal cancer pathway arrangements by shortening time from referral to diagnosis. The project implements a new diagnostic pathway aiming to shorten the cancer pathway and incorporate gold standard techniques, including a two-stage diagnostic clinic for prostate MRI with next day reporting and dedicated biopsy clinics with specialist nurse support to establish joint clinics and reduce known delays. The introduction of the mpMRI may reduce the need for biopsies by increasing diagnostic accuracy, and implementing the most up to date biopsy technique will reduce discomfort for patients and the risk of infection. Project completion is due December 2024.
Media Coverage:
- Western Telegraph. 'Cancer Research UK funds Hywel Dda prostate cancer scheme'.
- Moondance Cancer Initiative. 'Moondance Cancer Awards 2024 Shortlist'.
- Swansea Bay News. ‘Local Swansea prostate cancer initiative wins national award’.
The Prostad pathway explores the role of straight to optimal test imaging (multi parametric MRI) and local anaesthetic transperineal (LATP) biopsies, enabling accurate diagnosis and reducing the need for additional tests and minimising delays in the pathway. We are very excited to be working with Cancer Research UK, as part of the TET programme to develop a streamlined, more efficient and more effective pathway for those with suspected prostate cancer.
Rachel Gemine, Evaluation Lead at TriTech Institute, Hywel Dda University Health Board
Access to Breast Cancer Assessment Clinics without GP Appointment – NHS Forth Valley & University of Stirling, Scotland
Project Leads:
- Juliette Murray – Consultant Breast Surgeon and Deputy Medical Director, NHS Forth Valley
- Erica Gadsby – Associate Professor in Public Health, University of Stirling
“We run one-stop clinics that allow patients referred by their GP to get a range of breast cancer diagnostics during a single visit, often providing reassurance that it’s not cancer.
Enabling patients who discover a breast lump to access clinics without attending an initial GP consultation has further streamlined the pathway, supporting rapid assessment and timely care.
The improved pathway has now been successfully implemented across all general practices in the Forth Valley area, demonstrating its effectiveness at our local level. It has freed up appointments in general practice and has removed a step in the process of getting patients the tests they need. This approach clearly benefits patients, GPs and the wider healthcare system. Our evaluation has identified valuable lessons for other health systems considering the adoption of a similar pathway."
Juliette Murray, Consultant Breast Surgeon and Deputy Medical Director at NHS Forth Valley
Pathway redesign
A direct pathway to the one-stop breast assessment clinic was implemented in NHS Forth Valley for patients who present to GP practices with a breast lump.
Patients who contacted their GP practice with a breast lump were triaged by receptionists, using three standard questions. If indicated, they were referred directly to the breast assessment clinic at Forth Valley Royal Hospital, bypassing the need for an initial GP consultation.
Breast clinicians worked with lead GPs to develop referral protocols, and a project manager partnered with practice managers to ensure GP practice reception staff were fully trained and supported in implementing the new procedures.
Breast clinicians developed an information leaflet for GP practices to share with patients, outlining what to expect at the breast assessment clinic. Receptionists provided this information verbally during the screening process, and the leaflet was designed for flexible distribution, via text message, email, or as a hard copy.
During interactions with eligible patients, receptionists made it clear they still had the option to consult with a GP or nurse prior to the referral if that was their preference. This patient-centred communication helped to address any concerns and fostered trust in the new system.
In a 9-month implementation period, 393 patients attended the breast assessment clinic following a direct referral from a GP practice in Forth Valley (August 2023 – April 2024).
Evaluation
A mixed-methods hybrid effectiveness-implementation design evaluation was conducted by the University of Stirling, assessing a range of implementation, service and clinical outcomes, drawing on comparable data from pre-and post-implementation periods. A cost-consequence methodology was used to examine resources and cost of the new pathway. A reflective thematic analysis was used to analyse qualitative data.
Impact on the pathway
The direct pathway for eligible patients was implemented successfully and created both efficiencies (eliminating the need for an initial GP consultation) and positive experiences. Importantly, the pathway is safe and has not adversely impacted the process or outcomes of cancer diagnosis.
Local implementation demonstrated the pathway, enabled by a simple screening questionnaire, has the potential to reduce demand on GP services, free up GP appointments for patients who require them and improve patient convenience, important when patients face difficulties in accessing their GP practice (e.g., due to geographical distance, transportation issues, mobility limitations, or appointment availability).
Clinical outcomes, cancer conversion rates and tumour staging were all comparable to those in pre-implementation patient cohorts. Eliminating the initial GP consultation reduced overall costs (average differences per patient ranged from £15.81 to £41.68).
Evaluation of the quantitative data indicated a slight increase in the median interval times from point of referral to first appointment and onto diagnosis. Since the intervention did not change the pathway from the point of referral, this is likely due to changes in demand overall, in particular because of concurrent increases in patients being referred to the NHS Forth Valley breast assessment clinic from other areas in Scotland.
Patient Experience
To understand and learn from the patient experience of the pathway, qualitative data was collected through an online survey (N = 155), and semi-structured interviews (N = 9).
Most participants (99.3%) reported feeling happy to receive a direct referral, with 95.6% feeling comfortable in sharing symptomatic details of their condition with a GP receptionist. A minority (7.7%) reported they would have preferred to see the GP first. Reasons for this varied - concerns about wasting a hospital appointment if it were deemed unnecessary, wanting to see the GP for ‘reassurance,’ or a perception that their condition would have been dealt with quicker.
Patients emphasised the importance of clear, timely communication about the referral process, which played a crucial role in fostering confidence in the pathway:
“The GP receptionist was very empathetic…… she went on to explain how they would refer me straight away and I wouldn’t need to see the GP. She clarified my understanding and ensured I was happy. They were happy for me to book and see a GP if that would make me happier, which I thought was good, which I didn’t need, though some people might. I was very impressed.”
Some women felt more confident about going directly to the breast assessment clinic and reported feeling more empowered - they were being taken seriously, knew their own body and something was concerning:
“I didn’t feel I needed a GP appointment; I could feel the lump. I don’t need someone else to say it’s there, I know it’s there.”
Some patients appreciated the removal of an unnecessary step in the pathway, benefiting both their own experience and the efficiency of NHS services:
“I thought, miss out the middleman – for want of a better way of putting it – and just go straight through that rather than waste maybe a week to get the appointment with the doctor.”
Implementation learning and key considerations
The evaluation highlighted some considerations for others who might want to adopt the direct pathway:
- Before implementation, ensure strong engagement and commitment across the local health system. Clearly communicate the rationale, emphasising anticipated benefits and addressing any concerns to build trust and support.
- Identify leads from both local primary care and the breast clinical team to champion and oversee the change—this should include GPs, breast consultant, surgical care practitioner, or advanced nurse practitioner.
- Secure dedicated project management support to lead and oversee the implementation across the primary–secondary care interface, ensuring regular feedback is gathered from both patients and staff to guide ongoing improvements.
- GPs and practice managers should determine the most effective way to integrate the breast lump direct pathway, identify the appropriate staff to manage the process, and ensure they receive adequate training and support.
- To support informed attendance, all patients referred to the breast assessment clinic must receive clear, accessible information about what to expect at their appointment. This should be available in multiple formats and provided in advance, regardless of how soon the appointment is scheduled.
Project Outputs:
Publications and Media Coverage:
- Piotr Teodorowski, Erica Gadsby, Melanie McInnes et al. JMIR Cancer. ‘Public Involvement in Cancer Research: Collaborative Evaluation Using Photovoice’.
- University of Stirling. ‘New cancer screening pathway prevents treatment delays and eases pressure on GPs’.
- Erica Gadsby, Jane Thomson, Juliette Murray et al. BMC Cancer. 'Test, evidence, transition projects in Scotland: developing the evidence needed for transition of effective interventions in cancer care from innovation into mainstream practice'.
- NHS Forth Valley. 'New Breast Cancer Fast-Track Diagnosis Scheme Launched'.
- Alloa Advertiser. 'NHS Forth Valley: Scheme launched to cut breast cancer waiting times'.
- The Scotsman. 'GPs bypassed in new Scottish pilot to speed up cancer diagnosis'.
- University of Stirling. 'Health experts to evaluate new fast-track cancer diagnosis scheme'.
- The Times. 'Scottish trials for faster NHS diagnosis of breast and prostate cancer'.
- Daily Mail. 'Receptionists refer patients for treatment in bid to cut cancer waiting times'.
Rapid Access Referrals for Prostate Cancer: A Nurse-Led Model for Suspected Prostate Cancer Referrals – NHS Fife & University of Stirling, Scotland
Project Leads:
- Jane Thomson – Advanced Clinical Nurse Specialist, NHS Fife
- Erica Gadsby – Associate Professor in Public Health, University of Stirling
Overview:
NHS Fife are collaborating with the University of Stirling to implement a nurse-led, rapid access diagnostic clinic for suspected prostate cancer referrals. This model will support patients from referral to diagnosis, providing daily referral triage and a one-stop diagnostic investigation service. Once patients have been referred to the nurse-led team, patient navigators will support the Advanced Clinical Nurse Specialist (ACNS) in assessing patients, arranging scans, booking tests. The ACNS will interpret the results, discuss them with the patient, and present them to the multidisciplinary team to consider treatment options. This approach aims to improve the patients’ experience, reduce patient waiting times and enable clinical consultants to focus on the specialist diagnostic and treatment phases of the pathway. Project completion is due in February 2025.
Publications and Media Coverage:
- Erica Gadsby, Jane Thomson, Juliette Murray et al. BMC Cancer. 'Test, evidence, transition projects in Scotland: developing the evidence needed for transition of effective interventions in cancer care from innovation into mainstream practice'.
- NHS Fife. 'New initiative aims to fast-track cancer diagnosis'.
- The Scotsman. 'GPs bypassed in new Scottish pilot to speed up cancer diagnosis'.
- University of Stirling. 'Health experts to evaluate new fast-track cancer diagnosis scheme'.
- The Times. 'Scottish trials for faster NHS diagnosis of breast and prostate cancer'.
- Daily Mail. 'Receptionists refer patients for treatment in bid to cut cancer waiting times'.
- NHS Fife. 'Awards Ceremony Recognises Fife’s Healthcare Heroes'.
The development of a new advanced clinical nurse specialist rapid access diagnostic clinic for people with an urgent suspected prostate cancer has the potential to allow quicker access to diagnostic appointments, diagnostic tests, as well as earlier treatment decisions and management. This initiative also supports our aim to ensure that people with an urgent suspicion of prostate cancer receive the right care, at the right time, every time, and addresses what matters most to people.
Jane Thomson, Advanced Clinical Nurse Specialist at NHS Fife
Contact us
If you have any questions about the TET programme, please contact us at TET@cancer.org.uk.