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
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. An information leaflet for GP practices was developed 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).
During the evaluation period, there was a slight increase in the median interval times from point of referral to first appointment and onto diagnosis. The evaluation team is confident that the intervention did not lead to the rise in median waits because this coincided with a wider change. NHS Forth Valley was receiving more referrals than usual to help reduce waiting times in other areas.
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 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.
- Consideration needs to be given to how this should be implemented in areas with different levels of literacy and knowledge of English.
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'.
- 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'.
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
We are pleased to have successfully implemented and evaluated an MRI-first suspected prostate cancer pathway in Hywel Dda, using gold standard imaging and biopsy techniques. We demonstrated that the PROSTAD pathway can save patients an average of 28 days in their wait time from referral to diagnosis compared to the standard pathway. Importantly, we received positive feedback from both patients and staff but must continue to be mindful of patients who require more time to make significant decisions about their progression through the pathway.
Implementation of the pathway came with its challenges, particularly surrounding obtaining the required radiology capacity to administer mpMRI scans. However, identifying the barriers and enablers to implementation is crucial learning that we can apply and share to better support successful implementation and equitable adoption of cancer innovations across Wales.
Rachel Gemine, Evaluation Lead at TriTech Institute, Hywel Dda University Health Board
Summary of Findings
Pathway Redesign:
The PROSTAD project implemented an optimal prostate cancer diagnostic pathway Hywel Dda University Health Board by introducing straight to MRI testing, with workforce reorganisations to allow for next day MRI reporting and consultant clinics. The pathway used gold-standard techniques, such as mpMRI to improve scan quality, and local anaesthetic trans-perineal (LATP) biopsies to reduce patient discomfort and the risk of infection. Additionally, a pathway navigator supported patients through diagnostic testing.
Between July 2023 and June 2024, 127 patients went through the PROSTAD pathway. This was implemented in parallel to the standard pathway, which 112 patients went through during the same period.
Evaluation:
A mixed methods evaluation of the PROSTAD pathway was conducted through multiple work packages. These included:
- A realist evaluation of staff and patient interviews to understand their experiences, the outcomes of the pathway, and its clinical impact.
- An implementation and service review that identified delays within the pathway and active solutions to reduce unnecessary activities and improve efficiency.
- An economic evaluation, including a cost-consequence analysis, to consider resource use and cost difference between the PROSTAD and standard pathway in relation to patient outcomes.
The PROSTAD project also actively engaged patients and the public throughout their project design and evaluation by involving a local PPI group.
Impact on the Pathway:
During the implementation period, the time from referral to diagnosis was 98 days in the standard pathway, but 70 days in the PROSTAD pathway, meaning the new pathway provided a saving of 28 days on average. Whilst the average cost per patient on the PROSTAD pathway was £145 more than the standard pathway, the PROSTAD pathway was found to be cost-effective when all patients on either pathway receive an LATP biopsy. However, an expected reduction in biopsies when using mpMRI compared to bi-parametric MRI was not observed during the project. The pathway was received positively by staff interviewed about their experience.
Patient Experience:
The PROSTAD pathway and it’s decrease in waiting times was viewed positively by many patients, who emphasised the emotional impact of longer waiting times to diagnosis and how this was reduced by PROSTAD:
It was just the speed at which it was that they were able to give me that information truthfully and it basically pushed me/that up the process rather than, you know, wait anxiously for a week or fortnight.
I had a concern, and I was basically sent to hospital to have a scan within a week or so, so I was quite impressed by it to be honest.
Some patients reported finding the speed of the pathway to be overwhelming, highlighting the importance of acknowledging patients who would like more time to consider their options. Some patients also mistook the speed of the pathways as being in relation to the seriousness of their condition, demonstrating the need for clear communication. However, the Patient Coordinator supported patients in making decisions, helped to reduce concerns, and was a consistent point of contact for patients throughout the pathway. Patients also felt that receiving their MRI results by telephone consultation was convenient.
Implementation Learning and Key Considerations:
- Providing and protecting more prostate MRI scanning time: Throughout the period of implementation, the PROSTAD pathway experienced limited radiology capacity, resulting in the project being unable to secure a second dedicated MRI session which would have allowed more patients to pass through the pathway. This is exacerbated by mpMRI scans requiring more scanning time and specialist reporting. It is therefore recommended that additional radiology capacity and specialist reporting upskilling should be supported.
- Increasing LATP biopsy capacity: Similarly to mpMRI scans, LATP biopsies require specialist equipment and training for staff to conduct them. Investing in biopsy machines that are accessible to patients across the region and the training of doctors to conduct these biopsies will increase capacity.
- Investing in Pathway Coordinators: It was observed that the patient’s experience on the pathway benefited from improved communication and support, provided by the Pathway Coordinator. Increasing the availability of Pathway Coordinators can reduce organisational challenges by providing administrative support with appointments and coordination between teams, whilst also helping patients and their families navigate the difficulties of the diagnostic process.
Project outputs
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’.
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
“We were delighted that patients reported a good experience of the nurse-led pathway after they had been referred with prostate cancer symptoms. Although our model, which ran nurse-led clinics alongside a consultant-led pathway, didn’t result in patients being diagnosed faster, we did show that for a selected group of patients, this pathway could save the NHS money compared to them being seen in consultant-led clinics.
The team did encounter some challenges accessing all the data we needed to fully compare the new model to what we had before, or to directly compare what happened to patients seen in nurse-led vs consultant-led clinics, so we do need to be cautious with interpreting these results. But we generated a lot of important learning that could be used to further improve the experience and care of patients with urgent suspected prostate cancer when going through the diagnostic process. For example, we learnt about clinical vetting of referrals to make sure that the right patients were seen in the right clinics, at the right time. Through additional training we transformed the role of the Advanced Clinical Nurse Specialist within the diagnostic service and developed a rapid access diagnostic pathway. We also learned about additional administrative support necessary to run a nurse led service.”
Jane Thomson, Advanced Clinical Nurse Specialist at NHS Fife
Project design
A nurse-led model for prostate cancer diagnosis was developed and implemented in NHS Fife for the assessment and management of a sub-set of people with suspected prostate cancer.
In a 12-month period, 315 patients were seen in nurse-led clinics (between one and three clinics per week) by an Advanced Clinical Nurse Specialist, supported by Patient Navigators. Consultant led-clinics ran alongside the nurse-led model. Patients were eligible for the nurse-led clinic if they met certain vetting criteria for age and levels of prostate-specific antigen (a marker of potential prostate cancer).
A mixed-methods hybrid effectiveness-implementation design evaluation was conducted, assessing a range of implementation, service and clinical outcomes. A cost-consequence methodology was used to examine resources and cost associated with the new pathway.
Obtaining the necessary routine data for this evaluation was challenging. Matching patients in terms of vetting criteria pre- and post-implementation reduced the pre-implementation groups to 16 patients from 149, reducing sample size considerably. The contemporaneous data comparing the nurse-led pathway against the consultant-led pathway was not accessible, meaning that external influences specific to the implementation period (e.g. increased waits for biopsies) could not be excluded.
Impact on the pathway
When patients (matched against a vetting criteria) went through the nurse-led pathway they waited longer on average between referral and attending clinic (10 days rather than 6.5 days) and had to wait longer for a diagnosis (49 days rather than 39 days) compared to similar patients going through the service before the nurse-led pathway was implemented. However, the data did not indicate that the time to make a treatment decision was significantly different for patients in the nurse-led pathway.
When looking at the cost of the nurse-led pathway (up to the first multidisciplinary team meeting), the results revealed that seeing a subset of patients with suspected prostate cancer in a nurse-led pathway cost less than via the traditional consultant led-pathway resulting in a saving of £368 per patient (£1049.00 versus £1417.00, using resource associated with initial vetting, first outpatient attendance, diagnostic imaging and multidisciplinary team meeting).
Patient Experience
Patients had a positive experience going through the nurse-led pathway, reporting their care to be patient-centred and professional. However, due to a lack of access to routine data for the consultant-led clinics it was not possible to directly compare the patient experience or the time to diagnosis and treatment between these pathways. Patient feedback can be grouped into three themes:
1. Being informed - "It was all explained to me in detail what’d be going on and how it’d be happening, and what they’re looking for.”
2. Having a patient-centred experience - “Whereas the approach and the speed that the clinics going, does a lot to put your mind at rest. Although you’ve still got the cancer etc, it does alleviate some of the, a lot of the worry.”
3. Efficiency and coordination - “I have no problem with it. Nurses I know can specialise to a high degree in a variety of disciplines.”
Implementation learning and key considerations
- Ensuring robust referral vetting: There were varied descriptions of how the vetting process worked in practice. This process was unclear and potentially resulted in an inconsistent application of the new clinic criteria. This may have reduced potential efficiencies due to too few patients being referred to the nurse-led clinics (leaving empty slots), or inappropriate referrals (potential over investigation).
- Addressing staffing, training and administrative needs: The pathway required adequate investment in advanced specialist nurse training and resources (including secretarial and pathway navigator support) to ensure effectiveness and sustainability. In addition to this evaluation, it is necessary to understand whether this staff cohort are currently available or whether this would require additional investment if wider roll-out is pursued.
- Whole pathway: This study examined changes in one part of the pathway. This means that it did not assess the impact of these changes in later parts of the pathway, so potential unintended consequences that emerge later in the pathway cannot be excluded.
Health System Context
The Clinical Management Pathway for Prostate Cancer is currently being developed by the Scottish Cancer Network and is not yet published; this may affect how the Fife nurse-led model is continued or expanded in the future.
Publications and Media Coverage:
- Piotr Teodorowski, Erica Gadsby, Melanie McInnes et al. JMIR Cancer. ‘Public Involvement in Cancer Research: Collaborative Evaluation Using Photovoice(link is external)’
- 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'.
- 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'.
Contact us
If you have any questions about the TET programme, please contact us at TET@cancer.org.uk.