A ‘One Stop’ Prostate Clinic for rural and remote men: a report on the first 200 patients

Distance Traveled by Patients Globally to Access Radiation Therapy: A Systematic Review

PURPOSE

This study aimed to systematically review the literature on the travel patterns of patients seeking radiation therapy globally. It examined the distance patients travel for radiation therapy as well as secondary outcomes, including travel time.

METHODS AND MATERIALS

A comprehensive search of 4 databases was conducted from June 2022 to August 2022. Studies were included in the review if they were observational, retrospective, randomized/nonrandomized, published between June 2000 and June 2022, and if they reported on the global distance traveled for radiation therapy in the treatment of malignant or benign disease. Studies were excluded if they did not report travel distance or were not written in English.

RESULTS

Of the 168 studies, most were conducted in North America (76.3%), with 90.7% based in the United States. Radiation therapy studies for treating patients with breast cancer were the most common (26.6%), while external beam radiation therapy was the most prevalent treatment modality (16.6%). Forty-six studies reported the mean distance traveled for radiation therapy, with the shortest being 4.8 miles in the United States and the longest being 276.5 miles in Iran. It was observed that patients outside of the United States traveled greater distances than those living within the United States. Geographic location, urban versus rural residence, and patient population characteristics affected the distance patients traveled for radiation therapy.

CONCLUSIONS

This systematic review provides the most extensive summary to date of the travel patterns of patients seeking radiation therapy globally. The results suggest that various factors may contribute to the variability in travel distance patterns, including treatment center location, patient residence, and treatment modality. Overall, the study highlights the need for more research to explore these factors and to develop effective strategies for improving radiation therapy access and reducing travel burden.

Analysis of the financial impact and efficiency of the One Stop Prostate Clinic: A same day prostate cancer diagnostic clinic in the Australian public health system

Background

Access to prostate cancer diagnostic clinics are challenging for rural men in Western Australia due to remoteness and long travel distances. The One Stop Prostate Clinic (OSPC) provided same day assessment and diagnosis for prostate cancer in a public tertiary hospital to reduce access barriers for rural men. The objective of this study was to determine the financial and resource utilisation impact of the OSPC compared to a usual care pathway (UCP).

Design and methods

Study design: Cost minimisation analysis of the OSPC model (assuming 100% new referrals) compared with a UCP, including impact on the Patient Assisted Transport Scheme (PATS) for rural men. An estimate of total cost comparison of OSPC and UCP pathways of outpatient and diagnostic costs was calculated based on journey mapping of attendance and follow up.

Methods

Prospective data collection between August 2011 and November 2017 of referral, attendance and follow up outcomes. Journey mapping to identify time from referral to diagnosis, number of outpatient appointment (OPA) and travel savings.

Results

A total of 1000 men attended - 466 (47%) rural and 534 (53%) metro. Mean time from referral to diagnosis was 57 days (rural) versus 63 (metro; p = 0.034)). The OSPC saved 543 travel episodes (distance of 1.5M km) and 658 OPA's. Total episode of care costs for the OSPC (100% new) pathway estimated as $2237.34, compared to $2847.00 for a UCP, generating savings of $609.66 per attendance ($609,658.22 overall).

Conclusion

The OSPC was more cost effective and efficient in comparison to a UCP.

Nurse-led telephone notification of a prostate cancer diagnosis: Prospective analysis of men's preferences for and experiences of a same-day assessment and diagnostic clinic

OBJECTIVE

The 'One Stop Prostate Clinic' (OSPC) was a same-day prostate cancer assessment and/or diagnostic clinic. Preferences and experiences of men who received initial telephone notification of their prostate biopsy results (cancer or benign) by the OSPC Clinical Nurse (CN) are reported.

METHODS

Prospective mixed methods study using survey instrument and thematic analysis of OSPC preferences and experiences.

RESULTS

One thousand men attended the OSPC between August 2011 and November 2017, 876 underwent prostate biopsies; 790/876 (90%) men consented to telephone notification of biopsy results, 5/876 (1%) declined and 79/876 (9%) were ineligible/not contacted. 220/403 men (55%) returned the OSPC questionnaire; 135/220 (61%) men received a cancer diagnosis, 119/132 (90%) would choose this method again and 7/132 (5.5%) would not and 6/132 (4.5%) were unsure; 94/135 (70%) reported no disadvantages with this notification method. Overall satisfaction rate with the OSPC was 96% (209/218) men.

CONCLUSION

Initial telephone notification of prostate biopsy results by the OSPC CN was preferred by the vast majority of eligible men. Many men with a cancer diagnosis did not experience any disadvantages. This method of results delivery can be incorporated by other tumour groups.

'Pain-free TRUS B': a phase 3 double-blind placebo-controlled randomized trial of methoxyflurane with periprostatic local anaesthesia to reduce the discomfort of transrectal ultrasonography-guided prostate biopsy (ANZUP 1501)

Objective

To determine whether the addition of inhaled methoxyflurane to periprostatic infiltration of local anaesthetic (PILA) during transrectal ultrasonography‐guided prostate biopsies (TRUSBs) improved pain and other aspects of the experience.

Patients and Methods

We conducted a multicentre, placebo‐controlled, double‐blind, randomized phase 3 trial, involving 420 men undergoing their first TRUSB. The intervention was PILA plus a patient‐controlled device containing either 3 mL methoxyflurane, or 3 mL 0.9% saline plus one drop of methoxyflurane to preserve blinding. The primary outcome was the pain score (0–10) reported by the participant after 15 min. Secondary outcomes included ratings of other aspects of the biopsy experience, willingness to undergo future biopsies, urologists’ ratings, biopsy completion, and adverse events.

Results

The mean (SE) pain scores 15 min after TRUSB were 2.51 (0.22) in those assigned methoxyflurane vs 2.82 (0.22) for placebo (difference 0.31, 95% confidence interval [CI] −0.75 to 0.14; P = 0.18). Methoxyflurane was associated with better scores for discomfort (difference −0.48, 95% CI −0.92 to −0.03; P = 0.035, adjusted [adj.] P = 0.076), whole experience (difference −0.50, 95% CI −0.92 to −0.08; P = 0.021, adj. P = 0.053), and willingness to undergo repeat biopsies (odds ratio 1.67, 95% CI 1.12–2.49; P = 0.01) than placebo. Methoxyflurane resulted in higher scores for drowsiness (difference +1.64, 95% CI 1.21–2.07; P < 0.001, adj. P < 0.001) and dizziness (difference +1.78, 95% CI 1.31–2.24; P < 0.001, adj. P < 0.001) than placebo. There was no significant difference in the number of ≥ grade 3 adverse events.

Conclusions

We found no evidence that methoxyflurane improved pain scores at 15 min, however, improvements were seen in patient‐reported discomfort, overall experience, and willingness to undergo repeat biopsies.

Transrectal ultrasound biopsy of the prostate: does it still have a role in prostate cancer diagnosis?

Transrectal ultrasound (TRUS) guided biopsy of the prostate has been a standard diagnostic approach for prostate cancer over the past thirty years. Today, the role of TRUS biopsy is being challenged by transperineal (TP) prostate biopsy due to concerns over the safety and diagnostic yield of TRUS biopsy. TRUS biopsy still offers a convenient, reliable and accessible tool for diagnosing prostate cancer in the majority of patients. It continues to play a role in prostate cancer diagnosis, especially where hospital resource allocation is limited, including the public sector. TRUS biopsy has low rates of severe complications, although there remains room for improvement in current practice to improve the tolerability and reduce the incidence of post-biopsy infection.

Ten-year outcomes of the first 'one-stop haematuria clinic' in an Australian public hospital

BACKGROUND

Urgent assessment of haematuria is critical to exclude malignancy. The utilization of haematuria clinics in Australia remains in its infancy. It is hoped that the streamlined investigative service will achieve earlier diagnosis of urological malignancy and subsequently decrease morbidity and mortality. We report the 10-year prospectively collected outcomes from Australia's first dedicated one-stop haematuria clinic (OSHC).

METHODS

Since its commencement in May 2008 through to July 2018, all consecutive patients assessed in the OSHC were included in the analysis. Data collected included demographics, presentation, wait times, investigation, assessment, initial treatment, referral and histopathology.

RESULTS

A total of 3008 patients were seen in the OSHC with non-visible haematuria (1024, 34%) and visible haematuria (1984, 66%). Three hundred and twenty-seven (10.9%) patients were diagnosed with urothelial malignancy. In all, 306 (10.2%) patients had lower tract disease and 21 (0.7%) had upper tract disease. Urothelial cases were compiled of 123 (37.6%) Ta LG, 39 (11.9%) Ta HG, 21 (6.4%) Tis, 67 (20.5%) T1 and 77 (23.6%) T2-4. Urothelial malignancy was diagnosed more often in males (odds ratio (OR) 1.74, 95% confidence interval (CI) 1.35-2.25), older patients elder than 60 years (OR 1.97, 95% CI 1.47-2.64) and patients with visible haematuria (OR 5.42, 95% CI 3.73-7.86). In all, 53.4% of patients were discharged after a single visit to the OSHC.

CONCLUSION

The OSHC has served as an effective tool for rapid, streamlined assessment of patients presenting with haematuria. This model of care has been subsequently adopted by numerous public centres across Australia. Current funding structures present a barrier to this excellent approach for rapid access diagnostics.

'One Stop Prostate Clinic': prospective analysis of 1000 men attending a public same-day prostate cancer assessment and/or diagnostic clinic

BACKGROUND

This study reported the outcomes of the first 1000 men to attend the One Stop Prostate Clinic, a consultant-led same-day prostate cancer assessment and diagnostic clinic at a tertiary public hospital.

METHODS

Prospective audit of demographic and clinical data between August 2011 and November 2017 was conducted for same-day urological assessment and/or trans-rectal ultrasound (TRUS)-guided prostate biopsies with peri-prostatic infiltration local anaesthetic (PILA) and antibiotic prophylaxis.

RESULTS

A total of 466 (47%) rural and 534 (53%) metropolitan men attended. Rural mean (range) age was 63 years (38-86) and 65 years (37-89) for metro men (P = 0.006). Rural median (range) prostate specific antigen (PSA) level was 6.7 g/mL (0.2-450) and 7.3 ng/mL (0.5-860) for metro men (P = 0.011). Twenty-five men (2.5%) refused/could not tolerate TRUS-guided biopsy using PILA. One hundred and fifty-one (15%) men had multi-parametric magnetic resonance imaging prior to TRUS biopsy and 876 (88%) men had prostate biopsies, with a new cancer diagnostic rate of 51% (443 men). Clinically significant prostate cancer was detected in 339 (34%) men. The overall infective complication rate requiring hospital admission rose from 1.4% to 2.9% after the prophylactic antibiotic regimen changed from six doses of 500 mg ciprofloxacin to a single dose of 500 mg (P = 0.398).

CONCLUSION

This is the largest single institution prospective TRUS prostate biopsy series in Australasia. Biopsies using PILA were well tolerated with low complication rates and diagnosed a high rate of clinically significant prostate cancer. The 'One Stop' pathway generates efficiencies with combined assessment and diagnostic process, lessens demand on outpatient clinic appointments and reduces travel time and costs for rural men.

General practitioner referrals to one-stop clinics for symptoms that could be indicative of cancer: a systematic review of use and clinical outcomes

BACKGROUND

One-stop clinics provide comprehensive diagnostic testing in one outpatient appointment. They could benefit patients with conditions, such as cancer, whose outcomes are improved by early diagnosis, and bring efficiency savings for health systems.

OBJECTIVE

To assess the use and outcomes of one-stop clinics for symptoms where cancer is a possible diagnosis.

DESIGN AND SETTING

Systematic review of studies reporting use and outcomes of one-stop clinics in primary care patients.

METHOD

We searched MEDLINE, Embase, and Cochrane Library for studies assessing one-stop clinics for adults referred after presenting to primary care with any symptom that could be indicative of cancer. Study selection was carried out independently in duplicate with disagreements resolved through discussion.

RESULTS

Twenty-nine studies were identified, most were conducted in the UK and observational in design. Few included a comparison arm. A pooled comparison of the cancer conversion rate of one-stop and multi-stop clinics was only possible for breast symptoms, and we found no significant difference. One-stop clinics were associated with significant reductions in the interval from referral to testing (15 versus 75 days) and more patients diagnosed on the same day (79% versus 25%) compared to multi-stop pathways. The majority of patients and GPs found one-stop clinics to be acceptable.

CONCLUSION

This review found one-stop clinics were associated with reduced time from referral to testing, increased same day diagnoses, and were acceptable to patients and GPs. Our conclusions are limited by high levels of heterogeneity, scarcity of comparator groups, and the overwhelmingly observational nature of included studies.

Transrectal prostate biopsy sepsis rate following reduced quinolone antibiotic prophylaxis from six doses to single dose

BACKGROUND

This study aimed to evaluate the rates of infective complication related to transrectal prostate biopsy (TRPB) as our centre changed its protocol from six doses over 3 days to a single pre-procedure prophylactic dose.

METHODS

This prospective cohort study identified infective complication in patients who attended and subsequently underwent TRPB at the time of their one-stop prostate clinic at our public tertiary hospital between August 2011 and April 2017. Patients who underwent TRPB between August 2011 and November 2014 received six doses of 500 mg of ciprofloxacin, taken twice daily over 3 days. This protocol was changed to a single dose of 500 mg of ciprofloxacin prior to biopsy from February 2015 to April 2017. Patients who had travelled to South East Asia in the 6 months prior to TRPB received a single dose of 1 g intravenous ertapenem prior to biopsy, and this remained unchanged throughout the study period. The rates of infective complication were recorded and compared between the groups of patients who had undergone six doses versus a single dose of prophylactic ciprofloxacin.

RESULTS

A total of 766 patients underwent TRPB from August 2011 to April 2017. Of these, 357 patients received the 3-day course of prophylaxis (Group 1) and 409 patients received the single dose prophylaxis (Group 2). Fifty-five patients were excluded from analysis. There was no significant difference in infective complications between the two groups (3.4% (11/326) Group 1 versus 4.9% (19/385) Group 2, P = 0.40).

CONCLUSION

Our study supports the use of a single dose of ciprofloxacin as sufficient antibiotic prophylaxis prior to TRPB.

The Improving Rural Cancer Outcomes Trial: a cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural cancer patients in Western Australia

Background:

Rural Australians have poorer survival for most common cancers, due partially to later diagnosis. Internationally, several initiatives to improve cancer outcomes have focused on earlier presentation to healthcare and timely diagnosis. We aimed to measure the effect of community-based symptom awareness and general practice-based educational interventions on the time to diagnosis in rural patients presenting with breast, prostate, colorectal or lung cancer in Western Australia.

Methods:

2 × 2 factorial cluster randomised controlled trial. Community Intervention: cancer symptom awareness campaign tailored for rural Australians. GP intervention: resource card with symptom risk assessment charts and local cancer referral pathways implemented through multiple academic detailing visits. Trial Area A received the community symptom awareness and Trial Area B acted as the community campaign control region. Within both Trial Areas general practices were randomised to the GP intervention or control. Primary outcome: total diagnostic interval (TDI).

Results:

1358 people with incident breast, prostate, colorectal or lung cancer were recruited. There were no significant differences in the median or ln mean TDI at either intervention level (community intervention vs control: median TDI 107.5 vs 92 days; ln mean difference 0.08 95% CI −0.06–0.23 P=0.27; GP intervention vs control: median TDI 97 vs 96.5 days; ln mean difference 0.004 95% CI −0.18–0.19 P=0.99). There were no significant differences in the TDI when analysed by factorial design, tumour group or sub-intervals of the TDI.

Conclusions:

This is the largest trial to test the effect of community campaign or GP interventions on timeliness of cancer diagnosis. We found no effect of either intervention. This may reflect limited dose of the interventions, or the limited duration of follow-up. Alternatively, these interventions do not have a measurable effect on time to cancer diagnosis.

Diagnostic and treatment factors associated with poor survival from prostate cancer are differentially distributed between regional and metropolitan Victoria, Australia

BACKGROUND

Men diagnosed with prostate cancer (PCa) in specific regional areas in Victoria, Australia have a poorer five-year survival rate compared to men living elsewhere in Victoria. This study aims to describe patterns-of- presentation and -care for men diagnosed with PCa in a specific regional Victorian area, and compare the outcomes with other Victorian regions.

METHODS

Information on consecutive men diagnosed between 2008 and 2013 was extracted from the Prostate Cancer Outcomes Registry-Victoria. Descriptive analyses summarized diagnostic and treatment patterns of the 7,204 men with PCa in the selected region (n = 373), metropolitan Melbourne (n = 2,565) and remaining areas of Victoria (n = 4,266) to compare risk factors, treatments and time-taken-to-treatment.

RESULTS

Men with PCa in the selected region were more likely to be diagnosed at older age (aged 68.6 vs 66 years in the rest of Victoria), and incidentally rather than through case-finding PSA blood tests. They were more likely to be presented with higher NCCN risk of the disease (High: 26 %, 24 % and 20.3 %; Very high/Metastasis: 11.8 %, 5.2 % and 5.7 % in the study region, metropolitan Melbourne and elsewhere in Victoria, respectively). Men in the selected region were also more likely to have a longer time from diagnosis to treatment (on average 15-30 days longer when compared to the rest of Victoria).

CONCLUSIONS

Poorer outcomes of men with PCa in this specific region might be explained by multiple factors, including clinical-, patient-, and health-system-related. This range of explanatory factors, occurring at multiple points along the pathway of diagnosis and detection, suggests that interventions to improve outcomes for PCa in regional areas such as this need to be systematic. Interventions specifically addressing any one factor in isolation are unlikely to have much effect.