Implementing risk-stratified active surveillance in NHS Ayrshire and Arran

Ayr Hospital urology department serves a rural population that includes the Isle of Arran. Urology services are nurse-led, facilitating most of the prostate cancer pathway, including active surveillance. In 2024-25, the hospital diagnosed 460 new prostate cancer cases and currently manages around 400 men on active surveillance.

Identifying the need for change

Like at many other hospitals, men on active surveillance were being managed the same regardless of their Cambridge Prognostic Group (CPG). Typically, all men were having PSA levels tested every six months, and MRI scans in years 1, 3 and 7.

Lillian says: “We had variation in follow-up – phone calls, letters, clinic appointments, and frequency varied. Men were being brought back either too often or not enough and experienced delays in receiving results. This left them feeling ‘lost’ in the system and resulted in a lack of confidence in the service.

The team also lacked confidence; there was variation in approaches to care, decision-making, and inconsistency with how MRI, PSA and clinic reviews were being done.”

With increasing numbers of men being diagnosed, and starting active surveillance, capacity became an issue and this triggered a service review.

Assessing options

Lillian and the team decided to implement STRATified CANcer Surveillance (STRATCANS) to help manage their active surveillance cohort. The pathway would be re-designed on the evidence-based model created by the STRATCANS team at Cambridge University Hospitals [1, 2].

The objective was to provide risk-stratified follow-up for active surveillance patients that would help build confidence and address the issues of inconsistent practices and increasing service demand.

Implementing change

Patients in the hospital system were already categorised, making it easy to pull a list of surveillance patients to work from. Four CNSs then worked through the list – 60 patients per morning for review and consultation, checking fitness for treatment, and ensuring the men knew their treatment options.

Most of the existing surveillance cohort were having six-monthly PSA tests. They were subsequently moved to three- or four-monthly PSAs carried out remotely via community phlebotomy. PSA results are reported back to the uro-oncology nurse team, who send follow-up letters to patients. Men are routinely provided a face-to-face clinic review following their scheduled MRI scan.

Figure: Steps taken to move men from the old active surveillance protocol to the STRATCANS protocol.

Lillian explains: “It took eight months for all patients to be onboarded to the STRATCANS protocol. However, because of a previous project I’d worked where I’d categorising all patients on follow-up depending on their treatment, all active surveillance patients were recorded as ‘Category 5’, making it simple to identify them."

“Active surveillance review clinics enabled discussion between nurses if advice or support was required during the implementation phase. We ran clinics every few weeks until all patients had been reviewed. Where appropriate, patients were moved to watchful waiting, radical treatment or introduced to STRATCANS to continue with active surveillance.”

Newly diagnosed patients eligible for active surveillance were routinely onboarded and educated using the Predict Prostate and STRATCANS tools. “We use the online version of STRATCANS, introducing this to patients at the time they choose surveillance. We input the information into the tool with the patient and help them navigate the system.”

Patient feedback shows men have had a positive experience, with many saying they feel better informed and confident.

Although additional resources were needed during implementation, no additional funding was required. However, previous service development – introduction of digital follow-up for men following radical treatment – created additional capacity within the nurse-led team, which was utilised to implement STRATCANS.

Lessons learned and conclusions

• Multi-disciplinary team engagement and teamwork were crucial for getting everyone on board with the proposed changes.
• During implementation, regular team meetings were held to ensure all staff had opportunities to review the STRATCANS programme and supporting evidence.
• Ensuring resources and tools (like Predict Prostate and STRATCANS) were available from the start was vital for supporting implementation.
• Being able to identify active surveillance patients easily within the hospital system enabled the team to quickly set-up review clinics and invite patients in.
• Desire within the team to improve patient care was high, despite the initial additional workload.

Lillian explains: “It’s important to have confidence in the system that’s being implemented. I’m fortunate to work with a team who are receptive to change and recognised the benefits at an early stage. Initiating discussions with colleagues who had prior knowledge of STRATCANS was important.”

Next steps

The team at Ayr hospital have already developed and implemented a digital follow-up system for men who have completed radical treatment. Lillian is exploring the possibility of developing a similar digital system for men on active surveillance.

If you’re interested in speaking to Lillian about her work, you can reach out by emailing - [email protected] 

1. Thankapannair, Vineetha et al. “Prospective Implementation and Early Outcomes of a Risk-stratified Prostate Cancer Active Surveillance Follow-up Protocol.” European urology open science vol. 49 15-22. 24 Jan. 2023, doi:10.1016/j.euros.2022.12.013
2. Gnanapragasam VJ, et al. “The 5-year results of the Stratified Cancer Active Surveillance programme for men with prostate cancer.” BJU Int. 2025 doi.org/10.1111/bju.16666