Articles

Editorial

The Prostate Cancer Unit: A Multidisciplinary Approach for Which the Time Has Arrived

By: Leonard G. Gomellalowast

European Urology, Volume 60 Issue 1, December 2011, Pages 1197-1199

Published online: 01 December 2011

Abstract Full Text Full Text PDF (78 KB)

Large US-population-based studies of prostate cancer patients suggest that oncology specialist visits relate strongly to prostate cancer treatment choices for localized disease [1]. Studies also indicate that specialists tend to prefer and recommend the modality they themselves deliver. It is recognized that there is a paucity of comparative studies demonstrating superiority of one standard treatment modality, surgery or radiation, over another with regard to localized prostate cancer. Additional strategies include active surveillance and a variety of minimally invasive and focal therapies that continue to evolve and that are used in routine clinical care [2]. Therefore, prostate cancer specialists consider it essential to ensure that men have access to balanced information, including risks and benefits, before choosing a specific treatment for localized disease. Adequate pretreatment counseling can potentially reduce treatment regret and improve outcomes [3]. One approach to dealing with the complexities of prostate cancer management is the coordination of care among providers, known as the multidisciplinary model.

There are few published reports of multidisciplinary clinic outcomes for all malignancies and even less for prostate cancer. A 2010 review was unable to definitively determine a causal relationship between multidisciplinary care and outcomes such as survival [4]. However, our group now has convincing data that is discussed later in this paper.

One of the current challenges in assessing the impact of multidisciplinary care models is the lack of a formal definition of what multidisciplinary cancer care actually is. This approach can take many forms, but a true multidisciplinary care model, as described by Hong et al [4], fundamentally encompasses “collaborative patient care by a team of individuals where all diagnostic and treatment options are discussed and tailored for each patient. Although the team composition may vary by disease site and institution, independent contributors may include representatives from medical oncology, radiation oncology, surgery/surgical oncology, pathology, diagnostic imaging, palliative care, nursing, nutrition, and social work.” Another challenge is that multidisciplinary interactions between the providers and the patient can take place in different venues such as clinics, in cancer service-line programs, by defined care pathways and protocols, or through multidisciplinary tumor conferences, also known as tumor boards. It is my personal belief that true multidisciplinary care for a man with newly diagnosed prostate cancer must involve real-time interaction between the various specialists and the patient because the treatment options and decisions for this disease can be extensive and, at times, controversial.

A European policy on prostate cancer units with formal certification has been proposed recently based on a discussion by the European School of Oncology [5]. These prostate cancer units are more commonly referred to as genitourinary (GU) cancer or prostate cancer multidisciplinary clinics in the United States. This multidisciplinary model has been successfully implemented in Europe for breast care. These centers were based on a 2003 policy enacted by the European Parliament that established a network of certified multidisciplinary breast cancer units [6]. The German Oncology Society (Deutsche Krebsgesellschaft) designed a network of prostate cancer units that manages prostate cancer in a multidisciplinary manner in that country [5]. Other organizations in the United States, the United Kingdom, Asia, and Australia have had discussions to promote and establish multidisciplinary programs as a tenet of routine cancer care for most disease sites including prostate cancer [4].

Although the potential benefits of these specialized care units are generally accepted for tumors such as breast cancer, the adaptation of this model in the care of prostate cancer patients has not been widely implemented to date. The slow adaptation is likely multifactorial and includes physician, financial, and institutional barriers as well as the limited volume of published reports in this area. In a study from Milan, Italy, clinicians acknowledged that the multidisciplinary clinic has advantages in terms of patient education and data acquisition, but a clear physician preference for this multidisciplinary setting for prostate cancer did not emerge [7]. The authors reported that in one-on-one encounters, specialists feel more comfortable interacting with the patient and that the process of building trust was easier in a nonmultidisciplinary setting. In this study, clinicians recognized the value of the multidisciplinary approach in terms of effective communication with patients. The report stresses the importance of a proper organizational structure and the need for teamwork to optimize the multidisciplinary approach. Other studies have confirmed that one important outcome measure, satisfaction of patients and their families, is high in these type of programs [8] and [9].

These proposed prostate cancer units should be capable of providing optimum counseling and treatment recommendations across the spectrum of all stages of prostate cancer. In addition, the units must also provide access to support services in areas such as psychosocial counseling, rehabilitation, and management of other potential complications of treatment. Nursing navigators further support and enhance the patient care experience. Data acquisition and validation of outcome parameters should be a part of any of these programs, new or existing.

My radiation oncology colleague Dr. Richard Valicenti and I were the founding members of the Jefferson Kimmel Cancer Center GU Multidisciplinary Cancer Center in January 1996. We originally described its structure and implementation in 2000 [10]. On a weekly basis, urologists, radiation oncologists, medical oncologists, pathologists, radiologists, social workers, clinical trial coordinators, nursing navigators, and other support staff gather at one site to evaluate and counsel patients with GU malignancies in real time. Prostate cancer is the most common tumor type seen, and a conference that includes a pathology review and a brief case discussion is held just before the session. Although the majority of patients remain with us for their longitudinal care, second opinions are also provided. The change in 2008 from a preclinic conference to a postclinic conference has been the only substantive modification of the program design over the last 15 yr. Genetic counseling, integrative medicine support, and nutritional and pain management are not part of our formal clinic visit but are made available to our patients at the Kimmel Cancer Center. Participation in support groups and the opportunity to participate in the “Buddy System,” matching up similar patients by demographics and disease state, are also encouraged as part of the program. Although most men are newly diagnosed, the full spectrum of prostate patients with varying stages is also seen, and specific physician or specialty consultation is usually scheduled in advance by the navigator but can be easily modified based on the real-time nature of the clinic. I believe our Jefferson Kimmel Cancer Center GU Multidisciplinary Cancer Center is the longest continually running center of its kind at a National Cancer Institute–designated cancer center in the United States.

In the fall of 2010 we reported for the first time in prostate cancer that patient survival outcomes for high-risk men, when stratified by disease stage, are improved by our multidisciplinary clinic approach. For localized T2 disease, our 5-yr survival data approached 100%, which is to be expected based on other benchmarks such as Surveillance Epidemiology and End Results (SEER) data. However, when analyzing men with locally advanced disease, the enhanced outcome was most pronounced for T3 prostate cancer, with a statistically significant improvement in 5-yr survival of almost 90% compared to SEER, with a 78% survival probability [8].

The benefits of the prostate unit or multidisciplinary center concept include the potential to improve patient outcomes; to enhance program visibility; to provide patients with convenient, high-quality care; to enhance education of trainees and staff; to improve clinical trial accrual; to allow standardization of data collection; and to provide the host institution with downstream benefits through patient retention. The potential challenges include the fact that programmatic success is determined primarily by physician participation and enthusiasm; actual time expended may not be efficient for specialty physicians, and there is some loss of physician autonomy. The program also requires dedicated staff, space, and resources beyond the core GU oncology specialty services. It is critical that all centers collect data prospectively to establish protocols and audit criteria to benchmark their activities and validate a core principle of these centers, namely, improving patient outcome. The specific design of each multidisciplinary prostate clinic in the United States can vary greatly because there are no specific guidelines or recommendations for such activity, although the centers that have published suggest that simultaneous encounters in a real-time clinic setting are commonplace [8] and [9].

The discussion paper from the European School of Oncology by Valdagni and colleagues proposes general and specific recommendations along with mandatory requirements for prostate cancer units [5]. The long-term goal is to develop a network of certified prostate units across Europe. Our European colleagues are to be highly commended for bringing this concept forward in such an organized and defined fashion. These prostate cancer units will help ensure a uniform and, hopefully, optimum outcome for men with all stages of prostate cancer.

Conflicts of interest

The author has nothing to disclose.

References

  • [1] T.L. Jang, J.E. Bekelman, Y. Liu, et al. Physician visits prior to treatment for clinically localized prostate cancer. Arch Intern Med. 2010;170:440-450 Crossref.
  • [2] A. Heidenreich, J. Bellmunt, M. Bolla, et al. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. Eur Urol. 2011;59:61-71 Abstract, Full-text, PDF, Crossref.
  • [3] Y.H. Lin. Treatment decision regret and related factors following radical prostatectomy. Cancer Nurs. 2011;34:417-422 Crossref.
  • [4] N.J. Hong, F.C. Wright, A.R. Gagliardi, L.F. Paszat. Examining the potential relationship between multidisciplinary cancer care and patient survival: an international literature review. J Surg Oncol. 2010;102:125-134 Crossref.
  • [5] R. Valdagni, P. Albers, C. Bangma, et al. The requirements of a specialist prostate cancer unit: a discussion paper from the European School of Oncology. Eur J Cancer. 2011;47:1-7 Crossref.
  • [6] European Society of Mastology. The requirements of a specialist breast unit. Eur J Cancer 2000;36:2288.
  • [7] L. Bellardita, S. Donegani, A.L. Spatuzzi, R. Valdagni. Multidisciplinary versus one-on-one setting: a qualitative study of clinicians’ perceptions of their relationship with patients with prostate cancer. J Oncol Pract. 2011;7:e1-e5
  • [8] L.G. Gomella, J. Lin, J. Hoffman-Censits, et al. Enhancing prostate cancer care through the multidisciplinary clinic approach: a 15-year experience. J Oncol Pract. 2010;6:e5-e10 Crossref.
  • [9] J.L. Hudak, D.G. McLeod, S.A. Brassell, et al. The design and implementation of a multidisciplinary prostate cancer clinic. Urol Nurs. 2007;27:491-498
  • [10] R.K. Valicenti, L.G. Gomella, E.A. El-Gabry, et al. The multidisciplinary clinic approach to prostate cancer counseling and treatment. Semin Urol Oncol. 2000;18:188-191

Footnotes

Department of Urology, Jefferson Kimmel Cancer Center, Thomas Jefferson University, 1025 Walnut Street, 1102 Philadelphia, PA 19107, USA

lowast Tel. +1 215 955 1702; Fax: +1 215 923 1884.

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