Articles

Editorial

Prostate Cancer Units: Has the Time Come to Discuss This Thorny Issue and Promote their Establishment in Europe?

By: Riccardo Valdagnilowast

European Urology, Volume 60 Issue 1, December 2011, Pages 1193-1196

Published online: 01 December 2011

Abstract Full Text Full Text PDF (90 KB)

In recent years it has been universally accepted that patients with cancer should be offered the best chances of optimising their outcome in a multidisciplinary and multiprofessional setting, managed by a team of specialists and health professionals with expertise in the specific disease who become involved in care and follow-up [1] and [2]. The question of whether men with prostate cancer (PCa) should benefit from multidisciplinary and multiprofessional management, however, is still being debated. PCa is indeed an extremely complex, multifaceted disease. The opportunistic screening with the prostate-specific antigen (PSA) test, extensively used since the 1990s, has dramatically increased the number of diagnoses and has led to the detection of the slowly progressing, potentially non–life-threatening tumours that otherwise would have remained clinically undetected.

The diagnostic iter is often troublesome both for clinicians and patients. Because PSA is not a tumour marker, a prostatic biopsy is mandatory to formulate a diagnosis of cancer. However, this invasive procedure is accompanied by the well-known problem of false-negative biopsies, and the lack of clarification thus complicates both patients’ and clinicians’ lives.

Depending on the state of their disease [3], PCa patients can be advised about an observational setting or various therapies: open, laparoscopic, or robot-assisted laparoscopic prostatectomy; conformal, intensity-modulated, or image-guided external radiotherapy; low-dose-rate or high-dose-rate brachytherapy alone or combined with radiotherapy; hormonal therapy alone or combined with radical therapies; chemotherapy; an observational setting such as active surveillance and watchful waiting; or in selected cases, cryotherapy and high-intensity focussed ultrasound [4] and [5]. Although all these options appear to have a place and indication, they may cause significant side-effects that may affect patients’ physical, emotional, and sexual domains.

Considering this kaleidoscopic scenario, patients have the right to receive adequate information about the pros and cons of the screening, of their therapeutic and observational options, and of the therapy-induced complications so they can take an active part in the decision-making process on the basis of their values and priorities [6]. What really happens is this: From diagnosis to treatment or follow-up, multiple specialists—urologists, radiation oncologists, and medical oncologists—participate in the process, all with their individual education, forma mentis, relational approach to the patient, monospecialist culture, and (unfortunately, in some cases) personal interests or corporatism. If other therapeutic options are not recognised as equally effective, it may be a mission impossible to expect the specialists to switch from a prescribing to a recommending position and from a paternalistic to a deliberative attitude. What is more, in this era of rapidly evolving, sophisticated technologies, specialists are keen on focussing on their own fields of interest and, unfortunately, do not always consider referring the patient to other clinicians for opinions on other approaches. The patient, who should ultimately be asked to make the decision, may end up being scantly informed or disoriented by the different opinions and contrasting information collected.

On these premises, the European School of Oncology (ESO)—committed to its motto “Learning to Care,” to improving the skills of all health professionals dealing with cancer patients, and to improving the care of patients in a global sense—organised an ESO brainstorming meeting in February 2010 to discuss the issue of multidisciplinary, multiprofessional management of PCa. Peter Albers, Chris Bangma, Lawrence Drudge-Coates, Tiziana Magnani, Clayre Moynihan, Chris Parker, Kathy Redmond, Cora N. Sternberg, Louis Denis, Alberto Costa, and I, all with a definite position towards the multidisciplinary management of this disease, participated with the aims of (1) discussing whether PCa patients could benefit from a change from monospecialist to multiprofessional management, (2) identifying general recommendations and minimal requirements for the establishment of PCa units, and (3) writing a discussion paper and launching a debate on the organisation of PCa–focussed centres of care in Europe [7]. Table 1 shows the main requirements listed by Valdagni et al [7]; these requirements should be the backbone of disease-focussed centres.

Table 1 Prostate cancer units: main requirements*

Requirements
General recommendations Able to provide care for patients with prostate cancer at all stages
Research and teaching activities as essential interests
Setup of a European certification process based on agreed-upon requirements
Mandatory requirements
Critical mass Able to cover a population of at least 300 000 people
Able to have >100 newly diagnosed cases under its care (for treatment or observation)
Able to carry out treatments and observational strategy protocols under the guidance of the unit's multidisciplinary team
Documentation/audit Recording of basic data (including side-effects and complications)
Able to provide data for yearly audit in which quality indicators and protocols are reviewed
Able to have written protocols for diagnosis and management of prostate cancer at all stages
Core team Members with specialist training in prostate disorders, spending an agreed-upon amount of time working with prostate cancer, attending multidisciplinary meetings for case management and audit purposes, and undertaking continuing professional education on a regular basis
Clinical director Responsible for coordination
Uropathologist One or more, responsible for prostate pathology reports
Urologist Two or more, each carrying out ≥25 prostatectomies per year (≥50 prostatectomies per unit per year)
Radiation oncologist Two or more, each performing radiotherapy on ≥25 patients per year (≥50 treatments per unit per year); at least 15 brachytherapy procedures (high or low dose rate)
Medical oncologist One or more, each seeing ≥30 patients per year
Nurse specialist in prostate cancer At least one, able to provide care for patients at different stages
Data manager One or more, responsible for entering data
Documentation representative One, responsible for the documentation system, monitoring the compilation of patient data, and supporting staff in compilation
Associated services and noncore personnel Additional professional services available in the various European countries under different professional headings
Radiologist One or more, spending at minimum 20–30% time on prostate disease
Medical physicist One or more, each carrying out radiation treatment planning on ≥40 treatments per year
Radiation therapy technologist Two or more, each carrying out simulation and treatment on 25 radiotherapy treatments per year
Physiotherapist One or more, trained in rehabilitation
Palliative care specialist One or more, responsible for palliative therapy and supportive care
Professional offering psychological support Experienced in seeing prostate cancer patients to offer support after the diagnosis, during therapy, or in decision making
Sexologist/andrologist Able to provide counselling about changes in sexual function
Geriatrician Trained in the care of elderly patients with prostate cancer
Clinical trials coordinator One or more, responsible for all clinical trials and research protocols
Patient advocate and advocacy group To offer information on the disease and its multiple facets
To help improve the quality of care offered
Organisation
Multidisciplinary case management Held weekly, attended by the core personnel and possibly by the noncore personnel
Aimed at discussing ≥90% of all cases
Relation to the patient Respect of patients’ right to information and self-determination
Offer of clear and easy-to-understand written and oral information
Clinics
Multidisciplinary clinics for newly referred patients At least one clinic per week
Appointment within 10 working days of receipt of referral
Depending on risk class, urologist, radiation oncologist, and medical oncologist, synchronously or in rapid succession
Follow-up clinics Supervision by one of the prostate cancer unit core teams responsible for initial treatment
Recurrent/advanced prostate cancer clinics Held at least every 2 wk
Urologist, radiation oncologist, and medical oncologist, synchronously or in rapid succession

* Modified from Valdagni et al [7].

As director of the PCa Programme and the Division of Radiation Oncology 1 at the Milan National Cancer Institute and as coordinator of the PCa Programme of the ESO, I believe in the importance of an interdisciplinary, multiprofessional, patient-centred approach for men with PCa in all stages, from newly diagnosed to advanced and metastatic disease. The synergy among different specialists favours a holistic approach, in which the focus is on the patient's physical and psychological well-being [8]. This attitude should ensure the administration of high-quality procedures by a team of professionals with adequate expertise in treating PCa; facilitate access to specialist counselling, supportive care, and rehabilitation programmes; and help patients identify their emotional needs [9]. Furthermore, high volume should optimise outcomes and reduce therapy-induced side-effects [10].

Some European countries have already established disease-focussed centres or units in which men with PCa in all stages are managed multidisciplinarily and multiprofessionally. One of the most interesting examples is in Germany, where the Deutsche Krebsgesellschaft has set up a network of certified PCa units responsible for diagnosing and managing patients affected by this disease.

In Great Britain, the National Institute for Health and Clinical Excellence has promoted the setup of urology cancer teams. It has identified minimal requirements to become part of a multidisciplinary team and determined how work should be organised.

In the Netherlands, since the official ending of national health care insurance in 2006, the individual insurance companies have been empowered to concentrate and centralise treatments in specialised and multidisciplinary centres to increase efficacy and quality. Applying the criteria in the ESO discussion paper [7], the Prostate Centre at the Erasmus Medical Centre in Rotterdam, started in October 2010, is the first organised multidisciplinary PCa unit in The Netherlands, able to provide complete care, combining expert treatment with innovation and research.

In Italy, the minister of health is promoting a multidisciplinary approach to the oncologic diseases, and minimal criteria for establishment of PCa units were presented in Rome in June 2010. To my best knowledge, although multiple institutions and hospitals have greatly appreciated the concept, the only centres with an officially established PCa unit so far are the Milan National Cancer Institute (since January 2009) and Rome Policlinico Umberto I (since November 2010).

The PCa Programme at the Milan National Cancer Institute was activated in September 2004 to reorganise ongoing clinical and experimental activities and start new research within a disease-focussed programme. After 7 yr of experience, I am confident in stating that certified PCa units could be the solution that we all have been looking for to manage the complexity of this disease.

In March 2005, after sharing institutional diagnostic, therapeutic, and observational guidelines, we switched from monospecialist to multidisciplinary management, offering weekly multidisciplinary clinics to newly referred PCa patients with the synchronous participation, according to the state of disease, of a urologist, radiation oncologist, medical oncologist, and psychologist. Our organisational model has always been highly flexible and has changed to meet new needs. A patient-dedicated secretary and a nurse are included in the team to optimise the service. Furthermore, multidisciplinary follow-up clinics for patients on active surveillance and watchful waiting are organised biweekly. Case discussion meetings are held weekly to discuss cases seen multidisciplinarily, patients in observational settings and patients who were examined monodisciplinarily and considered complex. The meetings are open to the professionals participating in the PCa Programme (urologists, radiation oncologists, medical oncologists, psychologists, uropathologists, radiologists, experimental researchers, and data managers) to share the decisions formulated in the clinic, tailor therapeutic or observational strategies, evaluate adherence to guidelines, and check quality. It is reasonable to say that the case discussion meetings have been, and still are, the real laboratory of multidisciplinary team building and work, where different specialists offer their knowledge and learn from the interchange with other colleagues.

To assess the effectiveness of our multidisciplinary work, we analysed the data from the clinics and case discussion meetings. Fifty-nine percent of patients had received incomplete or/and incorrect prescriptions of therapies and/or observational strategies by specialists working elsewhere that we completed or changed based on scientifically based evidence. Twenty-seven percent of patients reported having being urged to treatment, regardless of their low-risk disease or comorbidities.

The establishment of PCa units necessitates a thorough reorganisation of the work flows and processes within each country and each hospital. The decision to establish these units may be hard and not particularly popular, especially considering the fact that small centres should be asked to refer PCa patients to assessed PCa units. PCa units should be certified according to a set of minimal criteria. This certification should guarantee the respect of shared concepts, such as multidisciplinary management of PCa patients and respect of their right to self-determination. We have a very long way to go, and the support of the scientific community, political leaders, and patient advocates is mandatory.

Conflicts of interest

The author has nothing to disclose.

References

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Footnotes

The European School of Oncology, Milan, Italy; Prostate Cancer Programme, Scientific Director's Office, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Division of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

lowast Prostate Cancer Programme, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy. Tel. +39 02 23903034; Fax: +39 02 23903015.

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