The PRAGMATIC pathway - PRostate cancer diAGnosis and MAnagement Triage In Clinical care.
Sharma A., Campbell T., Kanabar S., Soanes H., Sathanapally G., Bates A., John R., Adams C., Brassill A., Lennon B., Sinha S., Flaxman L., von Hasseln V., Camilleri P., Sabharwal A., Charlton P., Andrade G., Tuthill M., Protheroe A., Lamb AD., Leslie T., Leiblich A., Lopez F., Verrill C., Gleeson F., MacPherson R., Hamdy FC., Bell R., Bryant RJ.
OBJECTIVES: To investigate whether nurse navigator-led triaging of high-risk patients may reduce prostate cancer (PCa) diagnosis and treatment times using an in-house bespoke PRostate cancer diAGnosis and MAnagement Triage In the Clinial care pathway (PRAGMATIC) triaging system, as locally advanced/metastatic disease should be diagnosed and treated rapidly, and UK targets allow 28 days for diagnosis, and 62 days to commence treatment. PATIENTS AND METHODS: We reviewed diagnosis and treatment timelines for patients undergoing 28/62-day investigation for suspected PCa at a tertiary unit in a 3-month period (2022). We then introduced nurse navigator-led triaging of urgent referrals and evaluated a subsequent 3-month period (2024), with streamlining for rapid investigation and treatment based on prostate-specific antigen, magnetic resonance imaging (MRI) staging, and histology. We hypothesised nurse navigator-led triaging would improve investigation and treatment times for high-risk localised, or locally advanced, or metastatic PCa. RESULTS: A total of 165 and 327 consecutive patients were on the 28/62-day PCa pathway in the pre- (2022) and post-nurse navigator-led (2024) triaging periods, respectively. The median time from referral to first appointment (8 vs 4 days), MRI (12 vs 6 days), MRI result (26 vs 17 days), biopsy decision (25 vs 16 days), biopsy procedure (48 vs 22 days), biopsy result communication (64 vs 44 fays), and prostate-specific membrane antigen positron emission tomography computed tomography staging scan (87 vs 56 days) was reduced following nurse navigator triaging of high-risk cases (all P < 0.001). The median time from referral to treatment for Gleason Grade Group ≥3, or T3, or ≥N1, or ≥M1 disease (104 vs 70 days; 49/75 [65.3%] vs 72/128 [56.3%] patients), and for M1b disease (47 vs 27 days; 15/75 [20%] vs 32/128 [25%] patients), was reduced (P < 0.05). CONCLUSIONS: Nurse navigator-led triaging and stratification of the most clinically urgent suspected PCa cases was associated with improved imaging, biopsy diagnosis, and treatment times for the highest-risk patients.