Implementing risk-stratified active surveillance in the Royal Cornwall NHS Trust: Improving personalised care and simplifying procedures

The Royal Cornwall Hospital urology department serves an aging population, and they see a high proportion of prostate cancer cases, some of whom are on active surveillance (AS). The hospital provides a remote surveillance tracking service, allowing many of those men to be on a supported self-management pathway.

In early 2025, Claire Turner, and her colleague Nic Munro (Consultant Urologist) made the decision to implement the STRATified CANcer Surveillance (STRATCANS) approach to help manage their active surveillance cohort.

Identifying the need for change

Claire explains: “We were treating all patients who were on active surveillance the same despite their disease profiles being different.

There was uncertainty amongst the CNS team as to the frequency of MRI scans where a surveillance MRI was reported as stable. And, we had a high volume of MRI scans and re-biopsies at 12 months, when not all patients needed this.”

Some men even opted out of their annual re-biopsy because they knew what was involved. The impact on staff, clinic capacity and the men they treat was tangible. Clearer pathways for patients and staff were needed.

Assessing options

“We needed to consider a more tailored approach to our care for this group of patients. We considered STRATCANS as I had previously worked with the Cambridge team and knew of their research in this area.”

The STRATCANS approach was developed at Cambridge University Hospitals (CUH) NHS Foundation Trust. Published evidence shows that when implemented, AS follow-up can be deescalated for men at low risk of disease progression. The model demonstrates resource savings (fewer clinical appointments and MRI scans) and high patient compliance rates. Claire and the team in Cornwall didn’t need to carry out any work locally to produce evidence to support the case for change. 

Claire and Nic submitted a protocol to their Service Re-design and Business MDT for stakeholder review which was positively received and approved. Stakeholders recognised the potential benefits, such as simpler processes, clearer follow-up, fewer clinic visits and improved patient safety. Claire and Nic regularly reinforced these benefits to maintain team motivation and support the change.

Implementing change

The process began in early 2025 and took just three months from inception to roll out. Claire and Nic based the pathway redesign on the model and evidence published by the STRATCANS team at CUH NHS Foundation Trust and were supported by Professor Vincent Gnanapragasam and Vineetha Thankappan Nair, Macmillan Lead Nurse [1,2].

Figure: Steps following diagnosis to men being assigned active surveillance and their care plan communicated to them.

The wider urology team and MDT were engaged in the process, especially discussions around initial concerns that patients would be having more scans. It was explained that there would be a reduction in annual scans, but with more scans overall as surveillance patients continue to be monitored for many years. Scan reporting times were agreed and repeat scan requests would be made ahead of time to allow the radiology team to plan their capacity. 

The CNS team were educated on the agreed, tabulated protocol for risk stratification.

Claire explains that no additional funding or resources were needed to implement the change. “We already had the prostate tracker for active surveillance patients. It was just a case of developing the protocol and getting it approved for roll-out.”  

Initial qualitative data suggests patients like that now have a clear plan of when their next tests, MRI scans, and biopsies are due. It also helps when communicating the follow-up plan to the patient’s GP.

Lessons learned and conclusions

• MDT engagement was crucial for getting everyone on board with the proposed changes. Claire said this led to a “positive push to use the protocol for patients on active surveillance”.
• Support from Vincent and Vineetha in Cambridge: “We asked them all the questions you’ve asked us; it’s helped us avoid falling into traps.”
• An existing PSA tracker where patients are managed and monitored by Band 4 prostate support workers.
• A CNS team who can arrange MRI scans (‘non-medical referrers’).
• Taking time to consider how many patients we had on active surveillance and how they would be followed up in the long-term.
• One major challenge was implementing the change into the existing pathways that some patients were on, for example aligning MRI scan timings to fit with previous scan events, particularly for men who had been on surveillance for a long time.

Next steps

Claire has started working on face-to-face and video group sessions for men on active surveillance, to provide more detailed information about their prostate cancer. She hopes this will complement the existing service and offer men the support they need.

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