Prospective cohort study of the first 200 rural or remote men to access a new OSPC at a public tertiary-level hospital in Western Australia between August 2011 and August 2014. Men attended for urological assessment, and proceeded to same-day transrectal ultrasonography-guided prostate biopsies, if appropriate. Referral criteria were either two abnormal age-related prostate-specific antigen (PSA) levels in the absence of urinary tract infection (UTI), or an abnormal digital rectal examination (DRE) regardless of PSA level.

Results

The median (range) distance travelled was 1545 (56–3229) km and median (range) time from referral to assessment was 33 (2–165) days. The median (range) age was 62 (38–85) years, PSA level was 6.7 (0.5–360) ng/mL and 39% (78/200) had a suspicious DRE. In all, 92% (184/200) of men proceeded to prostate biopsies, and 60% (111/184) of these men were diagnosed with prostate cancer. Our complication rate was 3.5% (6/172). Radical prostatectomy (46/111), active surveillance (28/111) and external beam radiation therapy (26/111) were the commonest subsequent treatment methods. A $1045 (Australian dollars) cost-saving per person was estimated based on the reduced need for travel with the OSPC model.

Conclusion

The OSPC is an effective and efficient model for assessing men suspected of having prostate cancer living in rural and remote areas of Western Australia, and this model may be applicable to other areas.

Introduction

A ‘One Stop’ Prostate Clinic (OSPC) was established in August 2011 at a public tertiary-level hospital in Perth, Western Australia. Its format is similar to the ‘One Stop’ Haematuria Clinic 1, which has now assessed >1000 patients.

The OSPC is designed primarily for men from rural and remote areas of Western Australia who have been identified by a GP as being at risk of having prostate cancer. It was introduced to remove some of the barriers that these men face in accessing prostate cancer diagnostics, by providing them with a rapid-access clinic. Previous research has shown that men with prostate cancer from rural Western Australia have prolonged time to diagnosis due to multiple visits to urologists 2, and outcomes from prostate cancer in Australia are known to be worse for men living in rural areas 3. Despite general improvements in prostate cancer outcomes over the last 15 years, this urban–rural inequality does not appear to be improving 4. The introduction of OSPCs in other countries has been shown to have positive effects on both time from referral to diagnosis 5, 6 and pathological characteristics of new prostate cancer diagnoses 7, 8. For example, one study found that the percentage of men diagnosed with Gleason 9 or 10 prostate cancer fell from 15.5% to 9.8% after the introduction of a OSPC 8.

The ‘One Stop’ model is especially suited to Western Australia (Fig. 1), which has an estimated total land area of 2.5 million km² and makes up a third of the total land area of Australia 9. About 14% of the population of Western Australia live in rural or remote areas 10. Although the Patient Assisted Travel Scheme (PATS) provides some assistance to these patients when attending medical appointments in urban areas 11, the long distances involved with travel often impose a significant burden in terms of both time and cost.

Details are in the caption following the image — **Figure 1**
Open in figure viewer PowerPoint

Map of Western Australia (numbers indicate origin of first 200 referrals).

Patients and Methods

The OSPC is conducted at a peripheral endoscopy unit that is attached to a public tertiary-level hospital in Western Australia; this service is funded by Medicare as an Ambulatory Services Initiative Clinic. The clinical team consists of the urologist who leads the service and the urology nurse who coordinates attendance and arranges the required follow-up. Data was collected from this clinic on a prospective basis by the urology nurse and outcomes from the first 200 men are reported. The OSPC healthcare model, as compared with the standard model of assessment, is shown in Figure 2.

Referral

Referral to this clinic was accepted for any man living in a rural or remote area with either two abnormal age-related PSA levels (in the absence of a UTI), or a suspicious DRE regardless of PSA level. Referral was via a pro-forma that prompts GPs to cease anti-coagulants before the appointment, so as patients can undergo biopsies if required (Fig. 2).

Attendance

Attendance at the OSPC was co-ordinated by the urology nurse. At their appointment men underwent full urological assessment by the urologist and, if clinically appropriate, proceeded to same-day TRUS-guided biopsies of the prostate. The normal practice was for the urologist to take 14 cores of prostate biopsy using an 18-G Bard^® core biopsy needle. On rare occasions a lesser number of cores were taken if clinically indicated, for example with obvious locally-advanced disease. The biopsies were taken after peri-prostatic infiltration of 10 mL 1% lignocaine local anaesthetic 12, and all biopsy samples were examined by the same specialist urology pathologist service (UroPath^®). All men who underwent biopsies were prescribed 3 days of ciprofloxacin (500 mg twice daily commencing 1 h before biopsy) 13. Although previous use of antibiotics was not considered, men who had travelled to Asia within the last 6 months received additional antibiotic prophylaxis of 1 g i.v. ertapenem 14, due to concerns of harbouring multi-resistant organisms.

Follow Up

At the end of their appointment men were given the option to receive their results from the urology nurse over the telephone, or if they preferred, by their GP. The urologist reviewed the biopsy results to determine what urological follow-up was required, with patients occasionally being discussed at a multi-disciplinary meeting if required. Men who requested telephonic follow-up were contacted with the results of their biopsies and advised of any further follow-up. If the biopsies revealed prostate cancer they were informed of this although specific details about the Gleason grade, volume of disease, and likely treatment options were not discussed. The urology nurse collected information about complications after the biopsies and was responsible for organising any follow-up appointments or staging investigations required.

Data Collection

Data was collected prospectively on the first 200 men from a rural or remote area who attended the OSPC between August 2011 and August 2014. Men were defined as coming from a rural or remote area if their home address was situated in an outer regional, remote, or very remote area based on the Australian Bureau of Statistics remoteness area classification 15.

Ethical Considerations

The study was conducted in accordance with the National Health and Medical Research Council (NHMRC) National Statement on Ethical Conduct in Human Research (2007) and was registered with local clinical governance.

Results

Referral and Attendance

The origin of the first 200 referrals within Western Australia can be seen in Figure 1; these 200 referrals were made by 100 different GPs and two other urologists. The median (range) travel distance was 1545 (56–3229) km and median (range) time from referral to biopsy was 33 (2–165) days. As a comparator, an audit of 20 men undergoing prostate biopsies via the standard pathway showed a median (range) referral to biopsy time of 188 (51–425) days. The non-attendance rate for the OPSC was 2% (four of 200). No men were lost to follow-up.

Patient Characteristics

The median (range) age was 62 (38–85) years and PSA level was 6.7 (0.5–360) ng/mL. DRE findings and the corresponding number of biopsies taken can be seen in Table 1. In all, 10 men (5%) were Aboriginal or Torres Strait Islander.

Table 1. DRE findings and number of biopsies taken

DRE finding	N (%)	Biopsies taken, n/N or n (%)	Mean number of cores taken (range)
Normal	112 (56)	98 (87.5)	14 (12–14)
Suspicious (e.g. firm, nodule)	61 (30.5)	60 (98.4)	14 (13–14)
Malignant	17 (8.5)	17 (100)	10 (5–14)
Unable to palpate prostate	6 (3)	6/6	14
Unable to tolerate	1 (0.5)	0	0
Not recorded	3 (1.5)	3/3	14
Total	200 (100)

Histopathology

The histopathology results are presented in Table 2. In all, 184 of the 200 men (92%) proceeded to prostate biopsies after initial assessment and counselling, and 111 of these 184 men (60.3%) were found to have prostate cancer. Gleason scores were recorded as the highest Gleason score assigned to any individual core biopsy. Of the 111 men diagnosed with prostate cancer, 29 (26.1%) were assigned Gleason 6 disease, 66 (59.5%) were assigned Gleason 7 disease, and 16 (14.4%) were assigned Gleason ≥8 disease. Of the 73 men not diagnosed with prostate cancer, 47 (64.4%) had high-grade prostatic intraepithelial neoplasia (HGPIN), one (1.4%) had an atypical gland suspicious for but not diagnostic of malignancy, and 25 (34.2%) had benign biopsies.

Table 2. Histopathology results

Biopsy result	N (%)
No biopsy	16 (8)
Benign	25 (12.5)
HGPIN	47 (23.5)
Atypical gland	1 (0.5)
Gleason 6	29 (14.5)
Gleason 7	66 (33)
Gleason ≥8	16 (8)
Total	200 (100)

Complications

The urology nurse contacted 93% (172/184) of the men who underwent prostate biopsies. Six of these 172 men (3.5%) reported complications related to their biopsies, all of which were infective in nature and Grade II using the Clavien-Dindo system 16. Three men were admitted to hospital for up to 5 days of i.v. antibiotics, and three men received oral antibiotics from their GP; each of these men received ciprofloxacin but not ertapenem during their biopsies. There were no cases of acute urinary retention or excessive bleeding.

Further Management

The further management of men attending the OSPC is presented in Table 3. Four men who underwent staging investigations were found to have metastatic disease at diagnosis. There were three deaths in this series, two from prostate cancer and one from an unrelated cause.

Table 3. Further management

Further management	N (%)
Radical prostatectomy	46 (23)
External-beam radiation therapy ± androgen-deprivation therapy	26 (13)
Active surveillance	28 (14)
Androgen-deprivation therapy alone	4 (2)
Watchful waiting	1 (0.5)
Re-biopsy	48 (24)
Private follow-up (outcome unknown)	3 (1.5)
No further urology follow-up	40 (20)
Cancer treatment decision pending	4 (2)
Total	200 (100)

Cost Analysis

A cost-analysis was conducted to compare the actual travel costs for the 200 men attending the OSPC to the theoretical travel costs assessment of these men would have incurred if standard assessment pathways had been used. These costs were calculated in Australian dollars based on the number of return trips to Perth each man made to receive their results and discuss further management, as well as PATS-reported travel and accommodation expenses per geographical area (email correspondence with PATS manager 11/08/2014). The assessment of costs related to infrastructure, personnel and patient expenses is complex and beyond the scope of this basic analysis.

By combining their initial assessment and prostate biopsies in one visit, all 184 men who underwent biopsies were saved one return trip to Perth resulting in an estimated cost-saving of $131 311. By delivering biopsy results telephonically and arranging local follow-up with their GP or a visiting urologist if appropriate, 109 men were saved one return trip to Perth resulting in an estimated cost-saving of $77 690. The total estimated cost savings related to travel expenses was therefore $209 001, equivalent to a saving of $1045 per person.

Discussion

We have shown that establishing a OSPC for rural and remote men is feasible, and the broad referral base to this clinic of >100 clinicians shows that this OSPC has been widely accepted. The outcomes from this clinic are comparable to OSPCs in other countries (Table 4) 5-7, 17, although longer assessment delays were experienced due to the complex travel arrangements required for attendance. Variations in pathological outcomes are likely to be pathologist dependent, and differences in subsequent treatment probably reflect institutional preference. Whilst our infective complication rate of 3.5% does not appear unduly high, further interpretation of this figure is complicated by the fact that reported rates vary from 1% to 10% 13, 14, 18, 19 depending on how these complications are defined and detected.

Table 4. Demographics and outcomes of this OSPC compared to OSPCs in other countries

Reference (Year) n	Median age, years	Median PSA level, ng/mL	Average referral–assessment time, days	Percentage undergoing biopsies	Percentage biopsied with prostate cancer	Percentage with Gleason 6, Gleason 7, Gleason ≥8	Treatment, % RP, EBRT, Other
Present study McCombie et al. (2014) n = 200	62	6.7	33	92	60	26 Gleason 6 60 Gleason 7 14 Gleason ≥8	41 RP 24 EBRT 35 Other
Kavanagh et al. 5 (2008) n = 1103	–	–	21	31.4	51	–	45 RP 20 EBRT 35 Other
Forde et al. 17 (2011) n = 215	63	7.7	13	92.5	46	13.6 Gleason 6 46.5 Gleason 7 39.8 Gleason ≥8	13 RP 56 EBRT 31 Other
O'Kelly et al. 7 (2013) n = 406	63	6.9	–	86.2	–	32 Gleason 6 43 Gleason 7 25 Gleason ≥8	25 RP 47 EBRT 28 Other
Bolton et al. 6 (2014) n = 1106	65	7.8	18	100	46	48 Gleason 6 35 Gleason 7 17 Gleason ≥8	14 RP 57 EBRT 29 Other

RP, radical prostatectomy; EBRT, external beam radiation therapy.

The alternatives to a ‘one stop’ healthcare model for men living in rural and remote areas are either the traditional assessment pathway (Fig. 2), or a visiting urology service. This OSPC model has several advantages over both of these options. The OSPC is a more streamlined healthcare model than tradition assessment pathways; it necessitates only one meeting with a urologist to arrive at a prostate cancer diagnosis as opposed to three. This reduced need for travel to and from a metropolitan centre is highly cost-effective and removes a significant barrier that rural and remote men face in accessing prostate cancer care. The OSPC model also reduces delay from referral to diagnosis compared with traditional assessment pathways 5, 6, with a five-fold reduction being noted in the present study. This OSPC model also relieves some of the outpatient burden on public tertiary-level hospitals; in this series 184 pre-biopsy appointments were avoided, and 109 post-biopsy appointments were redirected to either a visiting urology service or the man's GP. Although visiting urology services may also confer many of these advantages, the efficiency and reliability of these services is heavily dependent on the regularity of visits and availability of equipment at remote locations. One relative disadvantage of the OSPC model is that it does require a lot of organisational co-ordination, which in our present series was performed by the urology nurse.

There are several aspects of this OSPC service that warrant discussion. Firstly, only 5% of men referred being of Aboriginal or Torres Strait Islander origin may constitute an underrepresentation of this demographic; their proportion has been estimated to be as high as 26% for some remote Australian areas 20. This underrepresentation probably reflects national trends in healthcare access 20 as opposed to any specific deficiency of this clinic.

All biopsies taken at our OSPC are performed under local anaesthesia. Although this is not universal practice, this is the technique we use as it has been shown to be highly effective and it confers many advantages over alternative anaesthetic techniques 12. Our present biopsy rate of 92% is higher than most would encounter in their clinical practice. However, this biopsy rate is very similar to rates reported by other OSPCs 6, 7, 17 and may be justified considering our 60% (111/184) cancer detection rate, of whom 74% (82/111) had Gleason ≥7 disease.

Telephonic delivery of biopsy results by a urology nurse may be considered contentious; however, in the present series only one man who was offered this option declined it, suggesting that this arrangement may be acceptable to remote patients. Other benefits that we found with this arrangement included: no loss to follow-up, improved patient access to advice, familiarity with the team, and improved ability of men to prepare for subsequent appointments.

Very few men in our present cohort were discussed at a multi-disciplinary meeting before arriving at a treatment decision. Whilst the benefits of discussing new cancer diagnoses at these meetings are evident, underrepresentation of prostate cancer is not uncommon 21; this may reflect the fact that initial treatment decisions in prostate cancer are largely determined by subsequent staging and patient choice.

Finally, multi-parametric MRI (mpMRI) clearly has an emerging role in the diagnosis and management of prostate cancer 22; however, this modality is not readily available in Western Australia and was rarely used in the present cohort. Whilst pre-biopsy mpMRI may be feasible within a OSPC format, the evidence supporting pre-biopsy mpMRI is currently lacking 22 and this may add significant logistical, time, and cost barriers to prompt assessment. Additionally, the high prostate cancer detection rate in this cohort, even without mpMRI, suggests that few of our patients may benefit from this. Post-biopsy MRI on the other hand has been increasingly used for men attending this clinic, particularly in men opting for active surveillance or in those being considered for re-biopsy 22.

In conclusion, the OSPC is an efficient and effective healthcare model for men living in rural and remote areas of Western Australia suspected of having prostate cancer. It removes many of the barriers they face in accessing timely cancer diagnostics and could be applicable to other parts of Australia and the world.

Acknowledgements

We would like to thank the endoscopy staff at Kaleeya Hospital for their help and support in the delivery of the OSPC, as well as the West Australian Urologic Research Organisation. This study did not receive any external funding.

Conflict of Interest

None of the authors have any actual or potential conflict of interest to declare.

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Abbreviations

DRE: digital rectal examination
GP: General Practitioner
HGPIN: high-grade prostatic intraepithelial neoplasia
mpMRI: multi-parametric MRI
OSPC: ‘One Stop’ Prostate Clinic
PATS: Patient Assisted Travel Scheme
PSA: prostate specific antigen
UTI: urinary tract infection

Citing Literature

Volume116, IssueS3

Special Issue:Urological Society of Australia and New Zealand. The Urological Society of Australia and New Zealand and Wiley have published this supplement with no financial support

October 2015

Pages 11-17

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