Non‐medical prescribing in prostate cancer care: a case study reflection

There are approximately 54 000 nurse and midwife prescribers across the United Kingdom (UK), with 19 000 nurse independent and supplementary prescribers. Prostate cancer specialist nurses are ideally suited to implement advanced levels of practice in non‐medical prescribing, but little has been detailed in the literature about the prescribing practice in this clinical context. This paper set out to critically review evidence‐based recommendations for Prostate Cancer Specialist Nurses using a case study reflection to contextualize the role of non‐medical prescribing. A structured literature review was conducted in a range of electronic databases (DARE, Cochrane, MEDLINE, BNI, PsychINFO, EMBASE and CIHAHL), and a grey literature search in google, to identify studies employing a qualitative and/or quantitative methods. National (UK) and European clinical guidelines and legislative frameworks were also included. Methodological evaluation was conducted and evidence‐based recommendations were integrated into a narrative synthesis. A multidisciplinary and proactive approach to the management of men with metastatic prostate cancer ensures safe and effective prescribing practice, and optimizes supportive care delivery. A reflective case study has illuminated the key features necessary to maximize the success of non‐medical prescribing in prostate cancer care and captures the importance of good working relationships. While different practice models will emerge, the Prostate Cancer Model of Consultation may facilitate a structured framework for safe practice, embedded in effective communication strategies. Non‐medical prescribers must be committed to continual professional development, and prescribe safely within individual competencies and scope of professional practice. There is a pressing need for further research to evaluate prescribing practices with a particular focus on the nature of influencing factors on prescribing decisions, cost‐effectiveness and a more detailed understanding of how team working and inter‐team referral affects prescribing decisions between the Multidisciplinary Team (MDT) members.     

Experiences of Unmet Need and Access to Supportive Care for Men Receiving Androgen Deprivation Therapy for Prostate Cancer: A Bi-national Study

Objective: The number of men affected by incurable prostate cancer is expected to increase worldwide. Research is needed to enable men to share their experiences of unmet supportive care needs in current care delivery. We aimed to identify the most frequently reported domains of unmet supportive care needs, levels of anxiety, depression, distress, health-related quality of life, and to identify any perceived barriers to receiving supportive care.Data Sources: Men diagnosed with prostate cancer who had received a minimum of 6 months of ADT were recruited into a cross-sectional study. Participants completed standardised questionnaires; clinical and demographic data was also collected.Conclusion: Two hundred seventy-two patients were invited, and 102 participated. No statistically significant differences were found between participant scores from Australia and UK in relation to anxiety and depression, exercise, health-related quality of life, or distress scores. Perceived barriers include service delivery related to information provision and difficulties in the navigation of complex care systems.Implications for Nursing Practice: Men affected by prostate cancer receiving ADT reported unmet supportive care needs, specifically related to sexual, informational, and psychological aspects of care. Mapping future trajectories of needs and identifying men at high risk can significantly improve timely and tailored interventions.     

A review of anemia management in the oncology setting: a focus on implementing standing orders

Standing orders serve an important role in various healthcare settings by empowering nurses to implement certain procedures and activities on behalf of physicians, enabling more immediate interventions, and ultimately improving patient care. Standing orders are based on established clinical practice guidelines and are well suited for supportive interventions. Several evidence-based clinical practice guidelines are available for the treatment of anemia in patients with cancer. The guidelines can serve as a basis for the development of standing orders for the management of treatment-related anemia in patients with cancer, which will enable the delivery of consistently high-quality care to patients. A major advantage to the implementation of standing orders is that patients with suboptimal hemoglobin levels can be treated by oncology nurses in a timely manner and receive high-quality care that is consistent with available clinical evidence.     

Monitoring cardiovascular health in men with prostate cancer treated with androgen deprivation therapy

Earlier diagnosis and improved treatments have resulted in men with prostate cancer living for many years following diagnosis. Long‐term effects of treatments are therefore important. Androgen deprivation therapy (ADT) is now commonly used to treat prostate cancer. We have estimated that, in Australia, 6500 men used ADT in 1999/2000 with a steady increase to about 21 800 men in 2009/2010 (over 300% increase), a trend similar to those in the USA and UK. ADT has a range of side‐effects that can impact on quality of life such that risks and benefits should be carefully considered before making treatment decisions. Cross‐sectional and longitudinal studies show that ADT can have cardio‐metabolic effects including increases in fat mass and reduced lean mass, possible adverse effects on lipid levels, increased insulin resistance and increased risk of type 2 diabetes. ADT may also increase the risk of incident cardiovascular events and possibly cardiovascular mortality, although the evidence is not conclusive. In the absence of high‐quality evidence to guide management, it is prudent to consider men using androgen deprivation are at higher risk of diabetes and cardiovascular disease. Maintenance of normal body weight through diet and exercise, smoking cessation, and control of blood pressure, lipid levels and blood glucose are recommended, based on guidelines for the general population. Men at significant cardiovascular risk should consider aspirin therapy. All health professionals involved in the care of men undergoing prostate cancer treatment need to be aware of the risks of ADT and ensure appropriate monitoring and management.     

The Fife hormone service for prostate cancer patients: a cost‐effective and patient‐centric model

Injectable hormone therapy is a key element of treatment for many patients with prostate cancer. In the UK, it is typically administered in primary care. In 2003, National Health Service (NHS) Fife rolled out an innovative service for these patients, in which responsibility was moved from primary care to a specialist nurse‐led service in secondary care. The initial rationale was based on cost savings, but a significant number of other advantages have subsequently been demonstrated. These include a simpler patient journey, improved continuity of care and reduced use of consultant time. Standards of care have also improved, with fewer missed appointments, better provision of patient support and rapid access to specialist physician care when needed. An audit of 377 of 542 patients currently treated within the service has provided supportive evidence for many of these advantages. The Fife service offers a cost‐effective model for locally provided nurse‐led care that could be applied to hormone therapy services for prostate cancer elsewhere in the UK, and to services for other cancers with large numbers of patients requiring long‐term management.     

A Vanguard Approach to the Design and Delivery of Nurse-Led Survivorship Care

ObjectivesSurvivorship care is an essential component of quality cancer care. Although nurses are uniquely positioned to deliver effective and efficient nurse-led survivorship care, they report that their experiences of survivorship care provision are fragmented, under-resourced, and often distressing for the patient.Data SourcesHere we report the culmination of a 4-year program of research and more than a decade of nurse-led work, to improve the survivorship care experience for men with prostate cancer comprising of: (1) the evolution of a national specialist prostate cancer nursing service; (2) a nursing Delphi study to determine prostate cancer survivorship care experiences and priorities; (3) the development of the Prostate Cancer Survivorship Essentials Framework, which provides a road map for improving quality prostate cancer survivorship care across a variety of settings; and (4) the translation of the framework into nursing practice through the development of My Personal Plan, a person-centered, evidence-informed survivorship care plan.ConclusionThrough the leadership of a national prostate cancer specialist nursing service, the provision of a coordinated, evidence-informed person-centered survivorship care service is now achievable. This program of work has demonstrated that irrespective of the setting or mode of delivery, specialist nurses involved in the care of men with prostate cancer and their families are leading best practice through the translation of evidence into everyday clinical practice.Implications for Nursing PracticeThere is an urgent need to address the significant challenges that a prostate cancer diagnosis can bring, and nurses are at the forefront and lead survivorship care delivery, which includes: (1) routine distress screening and referral to tailored evidence-based psychological care; (2) the provision of person-centered care that connects to effective symptom management; (3) self-management support; and (4) signposting to additional services which extend beyond the acute care setting.     

Prostate cancer – presentation,diagnosis and treatment: what does the literature say?

Although previously known as the Cinderella of cancers, in recent years, prostate cancer has become a significant public health problem with considerable social and economic consequences. It is currently the most commonly diagnosed male cancer in the UK and is second only to lung cancer as a cause of male cancer deaths. In this literature review, evidence‐based literature related to the anatomical, diagnostic and therapeutic perspective of prostate cancer is presented. Associated areas of controversy related to prostate cancer are also fully discussed. It is essential that urology nurses have a strong foundation in their knowledge related to these aspects of prostate cancer. Only when they have this knowledge in their armoury are they able to confidently help patients make informed choices and participate in shared decision‐making regarding their care. This should help ensure that urology nurses rise to the challenge of providing patients with prostate cancer with high quality care by helping these patients through the minefield of information associated with prostate cancer.     

Metastatic castrate‐resistant prostate cancer: a discussion of the physical and psychosocial effects

Management options for metastatic castrate‐resistant prostate cancer (mCRPC) have increased in recent years resulting in more men living for longer with the disease. The implications for patients and health care services are considered through an examination of the literature in relation to the physical and psychosocial effects of mCRPC and its treatment, looking at quality of life (QoL) and service delivery implications. QoL in advanced prostate cancer has been well documented in the literature but studies involving those with mCRPC are sparse. There is a lack of evidence regarding psychological distress and effective psychological interventions for men with mCRPC. There is a need for research to understand the impact of new treatments on QoL of men and their partners, to establish effective psychological interventions for men with mCRPC and to quantify the increased demand for services with prolonged survival. The purpose of this discussion paper is to examine the physical and psychosocial effects of both disease and treatment, alongside QoL issues and consideration of the implications for service delivery.     

The psychosocial dimensions of fatigue in men treated for prostate cancer

Prostate cancer is one of the most prevalent forms of cancer in men worldwide. Cancer‐related fatigue (CRF) is the most frequently reported side effect of all cancer treatments and occurs in up to 74% of men treated for prostate cancer, particularly those receiving combined hormone and radiation therapies. Patients report the devastating impact of CRF on their quality of life and psychosocial functioning, affecting work, social, emotional and cognitive performance. It can manifest during treatment and persist long after its completion. A diagnosis of CRF is achieved once all other treatable factors such as anaemia or anxiety and depression have been managed, but does not alleviate the fatigue. The Functional Assessment of Cancer Therapy‐Fatigue (FACT‐F) is a brief and easily administered valid and reliable tool recommended for the assessment of CRF. Non‐pharmacological interventions such as activity‐based programs and psychosocial interventions including prostate cancer specific education and cognitive behavioural therapy have shown benefits in reducing levels of CRF. A multidisciplinary approach to the management of CRF in prostate cancer patients is advocated. The NICE four‐tier model of psychological support can be used as a framework to assist nurses and other health care professionals to alleviate the psychosocial burden of CRF. More research studies using a solid methodological foundation are required in men with prostate cancer to provide robust evidence which can be applied in practice.     

Initial experience of a community‐based prostate cancer risk assessment clinic for men of black and minority ethnicity background

We designed and implemented a community‐based prostate cancer risk assessment clinic targeting men from black and minority ethnicity (BME) background. This service had the dual aims of optimizing detection of prostate cancer within a local BME population, with a secondary goal of encouraging longer‐term engagement with primary care for follow‐up prostate‐specific antigen (PSA) testing in order to facilitate early diagnosis of future disease. “Drop‐in” clinics were set up in strategic locations and, staffed by experienced urology nurses. Risk assessment was offered in the form of a PSA test, and digital rectal examination (DRE). We targeted men of BME background aged between 45 and 75 but all attending individuals were given access to counselling and assessment as appropriate. In total, 312 men attended clinics for risk assessment. We diagnosed nine prostate cancers with histological confirmation, with a further two individuals considered to have prostate cancer based on clinical/biochemical parameters. These findings were consistent with similar previously published reports. Nurse‐led, community‐based targeted risk assessment is feasible, leads to the detection of significant numbers of prostate cancers and is well received by patients.     

Responses of primary health care professionals to UK national guidelines on the management and referral of women with breast conditions

Rationale, aims and objectives To explore the responses of primary health care professionals to guidelines in general, and to the UK national guidelines on the management and referral of women with breast conditions in particular. Methods Qualitative study using practice‐based, semistructured group discussions with primary health care professionals. All practices were involved in a study evaluating the effect of the national breast symptom management guidelines on clinical practice. Discussion groups were conducted in the practice; fifteen of the 34 study practices were audio‐taped. Groups comprised the available partners and practice nurses at each practice. All members of each group were well known to one another. There was good attendance by all doctors, with 75% of male partners and 90% of female partners present at the meetings. Of the practice nurses 51% attended. In all, 86 professionals attended the meetings. Results A number of areas for comment arose consistently in each discussion. Guidelines in general were welcomed, although there was more support for evidence‐based than consensus‐based guidelines. The breast lump guideline was also welcomed, participants commenting that it was concordant with current practice. The breast pain guideline was more contentious, participants reflecting that it recommended more primary care management than was usual, and fell outside the experience and confidence of doctors or the expectations of patients. Participants felt it did not incorporate psychosocial factors into recommended management, despite this being an important part of primary care management. Conclusions There are concerns about consensus guidelines and doubts about the applicability of the breast pain guideline in this complex management area. The failure of these guidelines to address patient anxiety may limit their implementation.     

The specialist nursing workforce caring for men with prostate cancer in the UK

Prostate cancer is the most common cancer in men in the UK accounting for 25% of all new cases of cancer. It is predicted to become the most common cancer overall by 2030. A national survey of the specialist nursing workforce caring for men with prostate cancer was completed across the four countries of the UK during June and July 2014. In total 302 specialist nurses completed the survey and data from 285 was used in the analysis. This is the biggest whole population survey of this workforce in recent years. The most common job title was clinical nurse specialist (185) and the most common band was agenda for change band 7 (174). However in Scotland 50% of the respondents stated that they were paid on band 6. Over half the group (158) had worked in prostate cancer care for more than 10 years. Few (48) had come into specialist posts from a specific specialist nurse development role. There is wide geographic variation in the provision of specialist nursing for men with prostate cancer. This is reflected in available hours and caseload sizes. The respondents reported frozen and vacant posts across the UK. This equated to 58·3 full time equivalents. The work of specialist nurses caring for men with prostate cancer is clinically complex and appears to cover most key times in the cancer journey. However workload appears to be limiting the care that the nurses are able to provide with over half the respondents (163) saying that they left work undone for patients.     

Supportive care in the cancer setting: rhetoric or reality?

BACKGROUND: Since 1995, UK cancer policy has been directed at organizational changes to secure improvements in treatment outcomes and quality of supportive care for cancer patients. The substantial increase in hospital-based specialist cancer nurses (SCNs) during this time suggests they have a major role to play in the delivery of supportive care. AIM: To explore how SCNs implemented their role in the context of organizational change and newly-formed multidisciplinary teams. METHODS: Twenty-nine SCNs participated in observation and/or interviews, resulting in 135 hours of observation and in-depth semi-structured interviews with 17 SCNs. Data were collected and analysed using a grounded theory approach. RESULTS: The prominence of the treatment agenda--the process of investigating, diagnosing and treating cancer--presented the biggest challenge to the delivery of supportive care. The treatment agenda influenced how support was offered, determined professional boundaries and relegated support to a subordinate position in patient care. CONCLUSIONS: Access to supportive care is a central tenet of current cancer policy and crucial to the philosophy of patient-centred care. While SCNs are essential to the delivery of supportive care, this study highlights the challenges they encounter in organizations which prioritise treatment and improvements to treatment outcomes.     

Evaluation of a multidisciplinary allied health prostate cancer clinic

Prostate cancer is the most common male cancer, with increasingly longer survival, and many treatment options for advanced disease. Men with prostate cancer report a high level of unmet supportive care needs. To evaluate unmet needs of a small cohort of Australian men with advanced prostate cancer, and their partners, and to assess the impact of attendance at a multidisciplinary allied health clinic on meeting these needs. Fifty patients were referred to the clinic by their treating specialists. Prior to their clinic consultations patients and partners completed study questionnaires to determine their unmet needs, prostate cancer and treatment related quality of life, levels of anxiety and depression, exercise patterns and prostate cancer‐related functional status. Questionnaires were completed again 1 month post‐clinic attendance, and pre‐and post‐clinic scores were compared. Patients reported unmet needs in several domains including psychological and sexuality needs. These showed a small reduction when assessed post‐clinic. Partners also reported needs in the psychological and emotional, and information domains. Thirty‐two percent of patients reported clinical levels of distress when assessed pre‐clinic attendance, reduced to 8% reporting the same level of distress 1 month post‐clinic. The identified high levels of unmet needs and levels of distress of this group of patients and partners highlights the necessity for additional resources to assist these men. A multidisciplinary allied health care prostate clinic as described here may further assist in the comprehensive care of these men and their partners.     

Implementation of evidence‐based practice by nurses working in community settings and their strategies to mentor student nurses to develop evidence‐based practice: A qualitative study

The aim of the study was to explore how community nurses apply the best available evidence to their practice, and how they mentor student nurses to conceptualize and implement evidence‐based practice in community settings. In the UK, the expansion of health‐care provision in the community has supported the development of highly skilled community nurses. However, there is limited literature regarding the strategies used by community nurses to implement evidence‐based practice and mentor student nurses to conceptualize evidence‐based practice in community placements. An exploratory qualitative approach applying inductive reasoning to focus group data was used. As a result, nurses working for a community NHS Foundation Trust in South England with a mentor qualification were invited to participate in one of the seven focus groups, 33 nurses participated. Data were analyzed with thematic analysis. The themes discussed in this paper are: ‘our practice is evidence‐based’ as guidelines and policies provided structure, but occasionally stifled autonomous clinical decision‐making, and ‘time’ as a barrier and facilitator to mentoring student nurses in community settings. In conclusion, nurses need to develop the ability to incorporate patients' needs and wishes within evidence‐based care. Time was a facilitator for some community mentors, but protected time is required to complete the necessary practice documentation of student nurses.     

Supportive Care Needs of Patients on Surveillance and Treatment for Non-Muscle-Invasive Bladder Cancer

ObjectiveThis literature review provides an overview of non-muscle-invasive bladder cancer diagnosis (NMIBC), treatment, and surveillance. Existing evidence is reviewed to identify the NMIBC patient pathway, highlight its effect on quality of life, and identify supportive care needs of this patient group. A framework to guide nurses in the care of this underserved population is proposed.Data SourcesElectronic databases including CINAHL, Medline, PsychInfo, Cochrane, and Google Scholar were searched.ConclusionNMIBC is a chronic disease with high recurrence and progression rates with most patients requiring invasive treatment and burdensome surveillance schedules with frequent hospital visits. Treatment-related side effects may interrupt therapy and possibly result in its discontinuation. Patients’ quality of life can be negatively affected at various stages of the cancer trajectory. Specialist nurses provide holistic care throughout all stages of the patient journey to optimize supportive care, information provision, and delivery of appropriate treatment and surveillance protocols. NMIBC research is historically underfunded with a paucity of evidence identifying the supportive care needs of this population. Further research is urgently required to fill the gaps identified.Implications for Nursing PracticeThis timely paper raises the profile of unmet supportive care needs in an underserved research cancer population. Suggestions are proposed to improve the quality of nursing care through standardized practices and the development and integration of patient pathways. Evidence of the effect of NMIBC on family members or carers is absent from the literature. Future research implications and directions are proposed.     

Management of patients with metastatic prostate cancer

Prostate cancer is the most common cancer in men and is recognised as a significant health problem. Treatment of advanced or metastatic prostate cancer is challenging, and support and care should be tailored to meet the individual's needs. This article focuses on the pharmacological management of metastatic prostate cancer and the nurse's role in providing patients with information about the disease. It is hoped that this article will be used as a resource to improve patient care.     

Managing cancer‐related fatigue in men with prostate cancer: A systematic review of non‐pharmacological interventions

The aim of this systematic review was to synthesize the best available evidence informing the effectiveness of non‐pharmacological interventions for managing cancer‐related fatigue in men treated for prostate cancer. This review considered experimental studies that included men with prostate cancer (regardless of staging, previous treatment or comorbidities), aged 18 years and over who were undergoing any treatment, or had completed any treatment for prostate cancer within the previous 12 months. Three interventions were identified for the management of cancer‐related fatigue in men with prostate cancer. Evidence from five studies including 447 participants demonstrates the effectiveness of physical activity, both aerobic and resistance exercise, and from three studies including 153 participants suggesting the benefits of psychosocial interventions including education and cognitive behavioural therapy. Health professionals require knowledge of a range of effective interventions aimed at reducing cancer‐related fatigue in men with prostate cancer and should incorporate those interventions into their patient management. Although physical activity appears to show the greatest benefit, other non‐pharmacological interventions such as education and cognitive behavioural therapy have demonstrated benefit and should also be considered as a strategy in treating this debilitating side effect of cancer and its treatment.     

Supporting cancer patients with palliative care needs: district nurses' role perceptions

The aim of this study was to examine UK district nurses' perceptions of their role in supporting palliative care cancer patients. Patients with cancer are living longer with the disease. District nurses are the largest UK workforce caring for people with cancer at home, the preferred place of care. Meeting patients' supportive and palliative care needs is complex. Little is known about district nurses' supportive role in the early phase of palliative care. Semistructured interviews were conducted with 34 district nurses. Data were analyzed thematically, with assistance from Atlas/ti. A dominant theme emerging from the interviews was ambiguity in the district nurses' supportive role in early palliative care. District nurses discussed the importance of making contact early on to support cancer patients and their families but had difficulty articulating this "support." Ambiguity, lack of confidence, and perceived skill deficits presented district nurses with dilemmas that were difficult to resolve. District nurses have great potential for meeting cancer patients' supportive and palliative care needs, a potential not currently realized. Education alone is unlikely to improve practice without an understanding of the tensions faced by district nurses in their work. Recognizing and addressing dilemmas in the everyday work of district nurses is central to moving practice forward.     

The long‐term quality of life and information needs of prostate cancer survivors

What are the quality of life (QoL) and information needs of long‐term prostate cancer survivors? Numbers of prostate cancer survivors are increasing and it is vital that their QoL issues and information needs are understood. The long‐term effects of surviving prostate cancer is poorly understood. Specialist nurses play a key role in their management. A cross‐sectional survey was used. The study questionnaire [(European Organization for Research and Treatment of Cancer‐Quality of Life Questionnaire) EORTC‐QLQ‐30 and EORTC QOL‐INFO25] was posted to 398 prostate cancer survivors attending an Irish centre managed by a clinical nurse specialist and consultant. Completed questionnaires (n = 195) were returned (response rate 49%). Overall, the men demonstrated a Global Health Status/QoL score of 77·6 (SD 20·7), demonstrating a high or healthy level of functioning. Men on hormonal therapy demonstrated inferior physical function in comparison to other treatment options. Fatigue and insomnia were the most frequent symptom experienced, while age was the most significant demographic variable affecting symptom scales. Men undergoing active surveillance for prostate cancer management were least happy with information received (p = 0·019). Comparison with EORTC QLQ‐C30 international reference values suggests that this cohort report a high/healthy QoL. However, a significant proportion of men expressed a need for the receipt of further information, especially men on active surveillance. Specialist nurses are in a unique position to meet the information needs of long‐term prostate cancer patients. However, planning is needed to ensure there are enough specialist nurses to meet the information needs of a growing number of men surviving prostate cancer.