Urology Care Pathways Cancer Care Pathways outline the steps and stages in the patient journey from referral through to diagnostics, staging, treatment, follow up, rehabilitation and if applicable onto palliative care. Timed effective care pathways are central to delivering quality and timely care to patients throughout their cancer journey and to the delivery of an equitable service. These pathways have been developed following with reference to available best practice guidance. They represent an ‘ideal’ pathway that can be adapted for local use. The timelines on the pathway are intended to facilitate the proactive management of patients within the access standards and it is to be noted that for some urological tumours, the patient will move much quicker through the pathway (e.g. testicular cancer).
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Urology Care Pathways Cancer Care Pathways outline the steps and stages in the patient journey from
referral through to diagnostics, staging, treatment, follow up, rehabilitation and if
applicable onto palliative care.
Timed effective care pathways are central to delivering quality and timely care to
patients throughout their cancer journey and to the delivery of an equitable service.
These pathways have been developed following with reference to available best
practice guidance. They represent an ‘ideal’ pathway that can be adapted for local
use. The timelines on the pathway are intended to facilitate the proactive
management of patients within the access standards and it is to be noted that for
some urological tumours, the patient will move much quicker through the pathway
(e.g. testicular cancer).
Haematuria Referral Guideline
GP referral/other point of entry
(A&E, incidental findings)
Haematuria Clinic
History / Physical Examination
Flexible cystoscopy +
Upper Tract Imaging
Red Flag
(See Guidance *)
NOTE: Please Consider Nephrology referral as well as referral to haematuria
clinic if the patient has any of the following:
Diabetes Proteinuria Hypertension
Direct Booking by primary
care
Routine
All patients aged <50 with non- visible haematuria
Young females with visible haematuria and UTI
* NICE Guideline
Patients of any age with painless visible haematuria
Patients aged >50 years who have unexplained non-visible haematuria
Patients with an abdominal mass identified clinically or on imaging that is thought to arise from urinary tract.
Appendix 3 of NICaN Urology Cancer Clinical Guidelines
One Stop Haematuria Clinic Flexible cystoscopy + Upper Tract Imaging/ History Physical
Renal Tumour
Stage tumour
Patient discussed at
MDT ∆
PT2 PT3a PT3b PT4
M1
Outpatient’s appointment Treatment options discussed Decision to treat ♦
Follow UP ♦
PT1a
B
*** Manual of Cancer Service
Standards
Oncology Protocols (to include
Letter from MDT to GP Proactive pathway management PACS Regionally agreed dataset and
d’base (NICR)
Inform MDT coordinator on receipt
of results.
Laparoscopic Treatment of choice ? Partial ? Open Surgery ? Laparoscopic
Laparoscopic ? Open
Open ? Laparoscopic
Open ? Laparoscopic Vascular Surgeon Cardiac Bypass
? Debulk + Immunotherapy Embolisation Radiotherapy Palliative Care New drugs
Renal Preservation
Partial Nephrectomy Open/ Laparoscopy Auto transplant Radio Frequency Ablation Cryotherapy
Other point of entry (A&E, Incidental Findings
GP referral
MAXIMUM WAIT PATHWAY
Pa
tient s
up
po
rt & in
form
atio
n a
t all s
tag
es; P
atie
nt d
eta
ils re
co
rde
d; P
atie
nt in
form
ed
at a
pp
rop
riate
po
ints
*****NIC
E
1/62
GOOD PRACTICE &
QUALITY PARAMETERS
See NICaN referral Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE
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Renal Tumour
♦ Indicates point of holistic assessment ∆ Inter-Trust transfer by Day 28
Appendix 3 of NICaN Urology Cancer Clinical Guidelines
GP Referral received Testicular Cancer suspected
Assessment of clinical
presentation (Lump)
Diagnostic tests
Ultrasound Equivocal
Metastatic
Oncology
MAXIMUM WAIT PATHWAY
Pa
tient s
up
po
rt & in
form
atio
n a
t all s
tag
es; P
atie
nt d
eta
ils re
co
rde
d; P
atie
nt in
form
ed
at a
pp
rop
riate
po
ints
*****NIC
E
1/62
GOOD PRACTICE &
QUALITY PARAMETERS
NICaN Referral Guidelines, 2007
Swelling or mass in body of testis
Improving Outcomes guidance
in Urological cancers, 2002
Inform MDT coordinator on receipt
of results. 7/62
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Follow UP ♦
Post Chemo
Mass/ RPLND
Orchidectomy +- Prosthesis
CXR Tumour Marker Book CT
Patient discussed at
MDT ∆
GP letter from MDT Proactive pathway
management PACS Regionally agreed dataset and
d’base (NICR)
Testicular Cancer Confirmed
Decision to treat
Oncology Outpatient’s
appointment ♦
Outpatient’s appointment ♦ CT/Histology
*** Manual of Cancer Service
Standards
Oncology Protocols (to
Sperm Bank Clinical Trial Radiation Chemotherapy Surveillance
Patient discussed at MDT
Testicular Cancer Pathway
♦ Indicates point of holistic assessment ∆ Inter-Trust transfer by Day 28
Appendix 3 of NICaN Urology Cancer Clinical Guidelines
GP referral / other point of entry
(A&E, incidental findings)
Upper
Tract
MAXIMUM WAIT PATHWAY
Pa
tient s
up
po
rt & in
form
atio
n a
t all s
tag
es; P
atie
nt d
eta
ils re
co
rde
d; P
atie
nt in
form
ed
at a
pp
rop
riate
po
ints
*****NIC
E
1/62
GOOD PRACTICE &
QUALITY PARAMETERS
See NICaN referral guidelines,
2007
Improving outcomes for
Urological cancers, 2002
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Laser
Local Excision
Nepho-
Ureterectomy
PTa Eastoscopic Follow up
Register only
One Stop Haematuria Clinic
Flexible cystoscopy + Upper
Tract Imaging/ History Physical
Bladder Tumour
Superficial Muscle Invasive
TURBT
Single shot
MitomycinC
Grade and stage tumour
Patient discussed at
MDT ∆
CT Chest,
Abdomen
? Bladder Preservation /radio/chemo
? Radical Surgery/ reconstruction
Palliation Neo-adjuvant Chemo
Outpatient’s appointment
Treatment options discussed
Superficial treatment
options
Invasive treatment
options
Follow UP ♦
PTaG3
BCG
PT1G3 Re-resect BCG
*** Manual of Cancer Service
Standards
Oncology Protocols (to include
Letter from MDT to GP Proactive pathway management PACS Regionally agreed dataset and
d’base (NICR)
Inform MDT coordinator on receipt
of results.
♦ Indicates point of holistic assessment ∆ Inter-Trust transfer by Day 28
Transitional Cell Carcinoma
Appendix 3 of NICaN Urology Cancer Clinical Guidelines
GP referral/ OP Referral
Pa
tient s
up
po
rt & in
form
atio
n a
t all s
tag
es; P
atie
nt d
eta
ils re
co
rde
d; P
atie
nt in
form
ed
at a
pp
rop
riate
po
ints
*****NIC
E
GOOD PRACTICE &
QUALITY PARAMETERS Rising PSA/New Symptoms
Inform MDT coordinator on receipt
of results.
Letter from MDT to GP Proactive pathway management PACS Regionally agreed dataset and
d’base (NICR)
Conservative Management
* MRI/Bone Scan as clinically indicated
Patient re-presented at
MDT
Outpatient’s appointment
Treatment options discussed
Follow UP ♦
*** Manual of Cancer Service
Standards
Oncology Protocols (to include
Radiotherapy Chemotherapy Hormone therapy
Bisphosphonates
Palliative Care
Staging * MRI Bone Scan
Clinical Trials
Oncology Referral
Castration Resistant Prostate Cancer
Appendix 3 of NICaN Urology Cancer Clinical Guidelines
GP Referral received Penile Cancer suspected
Biopsy/Stage Tumour CT/MRI
MAXIMUM WAIT PATHWAY
Pa
tient s
up
po
rt & in
form
atio
n a
t all s
tag
es; P
atie
nt d
eta
ils re
co
rde
d; P
atie
nt in
form
ed
at a
pp
rop
riate
po
ints
*****NIC
E
1/62
GOOD PRACTICE &
QUALITY PARAMETERS
NICaN Referral Guidelines, 2007
Improving Outcomes guidance
in Urological cancers, 2002
Inform MDT coordinator on receipt
of results.
28/62
31/62
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Surgery - Amputation - Penile preservation - Glansectomy
Permanent Prostate Brachytherapy Implant performed
(Pt discharged)
Post implant AUR management if required
4week Post implant CT scan and QA/peer review (PSA, IPSS, Dosimetry to database)
Edu
cati
on
of
pat
ien
ts r
egar
din
g P
SA m
on
ito
rin
g, a
lert
sym
pto
ms
and
acc
ess
to s
erv
ice
s
3month - Radiographer telephone review (PSA to database)
12monthly clinical review GP check PSA every 6 months
(PSA, IPSS,IIEF, EPIC to database) Discharge to GP care at 5 years if PSA <1ng/ml
& falling
6month - Consultant led clinical review (PSA, IPSS,IIEF,EPIC to database)
6monthly Consultant led clinical review. GP check PSA every 3-6months
(PSA, IPSS,IIEF,EPIC to database) Transfer to annual review at 3years if PSA
<1ng/ml & falling
Sigmoidoscopy by experienced practitioner at year 5, 10, 15 If deemed fit for procedure
GP information letter re biochemical and clinical triggers and re-referral pathway
Clinical inclusion criteria: Organ confined prostate cancer T1 or T2
Estimated life expectancy >10yrs Gleason 6 and PSA <15ng/ml Gleason 7 and PSA <15ng/ml
Livi
ng
Wit
h a
nd
Bey
on
d C
ance
r –
ww
w.n
ican
.hsc
ni.n
et
Clin
ical
Su
pp
ort
Ser
vice
s: E
du
cati
on
an
d In
form
atio
n: P
hys
ical
Act
ivit
y: O
ther
Su
pp
ort
Ser
vice
s
Ris
ing
PSA
Yea
r 0
– 3
co
uld
be
ben
ign
PSA
bo
un
ce.
PSA
3m
on
thly
wit
h c
linic
al r
evie
w.
MR
I/C
T/IB
S if
: 1
PSA
leve
l>1
0n
g/m
l
2 C
linic
ally
ind
icat
ed
Selection criteria for Permanent Prostate Brachytherapy
monotherapy
Clinical exclusion criteria for brachytherapy: Prostate volume >50ml (> 65ml prior to hormonal cytoreduction) IPSS >9. (Would consider for implant is <15 & Qmax >12ml/sec) Life expectancy <5years Large or poorly healed TURP defect Unacceptable operative risk Relative contraindications for brachytherapy: Large median lobe
Selection criteria for combined
Permanent Prostate Brachytherapy +
EBRT
Selected men with: High volume Gleason 7 or Low volume Gleason >7 or
Early T3a disease May be suitable for dose escalation
with combination therapy and should
be referred for discussion to central brachytherapy team