Structured active surveillance in the Belfast Health and Social Care Trust: Moving away from a one-size-fits-all approach.

Samantha and the team are based in a regional urology unit within the city of Belfast. The Belfast Health and Social Care Trust provide services to approximately 340,000 people. Approximately 600 men are diagnosed with prostate cancer each year and they manage around 1000 men on active surveillance between two FT Band 7 CNSs and one FT Band 6 nurse. Some of the cohort have been on active surveillance for 20-years.

In 2024, Samantha, and her colleagues made the decision to implement STRATified CANcer Surveillance (STRATCANS) to help manage their active surveillance cohort.

Identifying the need for change

Samantha explains: “everyone was doing something different. But when we looked at it, we were almost risk-stratifying some of the longer-term patients but without the evidence-base to support this approach. We knew something had to be done better.”

The team started to look at patient follow-ups and identifying where they didn’t need to have annual MRI scans. There was a need to streamline and properly risk-stratify the service because some patients were being over-investigated, and others not getting the frequency of tests and follow-up they needed.

Every patient on active surveillance would have 3-monthly PSA in the first year, then 6-monthly going forwards, if it was stable (as per NICE NG131). They’d also have a biopsy at 12-months, in addition to annual MRI scans, resulting in long waiting lists.

Assessing options

“I had a brilliant one-minute conversation with a member of the Prostate Cancer UK team at their stand during the BAUN conference in 2024. They asked me if I’d seen their new toolkit for implementing personalised risk-stratified active surveillance.

I took it away with the plan to look at it when I got home. When I looked at it, I couldn’t believe it, it was sitting there, that was it, that was exactly what we needed to do. It was a moment of total clarity, this was the sensible way, a no brainer."

Samantha subsequently shared the information with the CNS team and MDT lead (Mr David Curry, Consultant Urologist). David was onboard, he’d previously seen the evidence from the STRATified CANcer Surveillance (STRATCANS) protocol and was keen on implementation. The CNS team also agreed and supported the change.

Get the toolkit

Implementing change

Samantha and David then led on the implementation with the support of the CNS team and consultants in the urology department. The aim was to implement an evidence-based active surveillance follow-up guideline that made sure men were getting the right frequency of tests based on their individual diagnosis and needs.

Recent transition to a new hospital electronic patient record system (Epic©) helped with patient management and tracking PSA results.

“Initially, there were some challenges with men still being assigned annual MRI scans when they didn’t need them. Reminders were needed to use the Epic system to assign the correct STRATCNAS group and patient follow-up schedule, so it was clear for all in urology to see.”

Implementation began in September 2024 with the new protocol being applied to all newly diagnosed patients. For existing patients, they’re onboarded to the new risk-stratified protocol at their next review. Samantha expects it to take around two years for all men to be moved to the new risk-stratified protocol.

The new follow-up protocol is based on the model and evidence published by the STRATCANS team at Cambridge University Hospitals NHS Foundation Trust [1,2].

One of the benefits of the STRATCANS model is that, even if a man is scheduled to have an MRI scan in five years, if something changes, we can spot that and put in an MRI earlier. Samantha and the team have already found the number of biopsies being done have decreased.

From the patients' perspective, some men were apprehensive with the change and the decrease in MRI scans. As they’d previously had annual scans, moving to 5-yearly was a concern for them. For a very small number of men, we’ve been flexible and continued with annual MRIs because we want them to feel confident. Others have been happy with the change, particularly the switch from 6-monthly PSA to 3-4-monthly.

Overall, patients have a much better understanding of active surveillance and can see it’s ‘active’. They know when and where their PSA follow-ups will be done. They know when their MRI scans are scheduled. And there’s an open-door policy so if men need to speak to someone before their next review, they can.

"We’ve had no complaints. We’ve also experienced a reduction in men contacting the urology department worried that their follow-up test has been missed, that feels like a success."

Lessons learned and conclusions

• The Prostate Cancer UK Toolkit provides details on how to implement personalised risk-stratified active surveillance.

• Making the initial decision to start implementation and having team support and encouragement that this was the right things to do was key.

• The implementation of the STRATCANS model was cost neutral and straight forwards.

• No additional training for CNSs was required; it was more a case of implementing and embedding changes in process and behaviour.

• A major challenge was moving established patient, particularly for men who had been on surveillance for a long time.

Samantha explains: “My take-home message is to just do it, just try. There was always a need for a structured active surveillance programme, and we knew that one-size doesn’t fit all!”

Next steps

We want to remove that postcode lottery. So, our main priority is to roll-out the protocol across the region, to make sure that every man in Northern Ireland on active surveillance has STRATCANS classification assigned to him. Samantha – “I’m fortunate to be able to help drive that as the Chair of the Cancer Nurse Forum in Northern Ireland.”   

If you’re interested in speaking to Samantha 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