Multidisciplinary care and management selection in prostate cancer

Variation in content discussed by specialty in consultations for clinically localized prostate cancer

INTRODUCTION

Multidisciplinary consultations improve decisional conflict and guideline-concordant treatment for men with prostate cancer (PC), but differences in the content discussed by specialty during consultations are unknown.

METHODS

We audiorecorded and transcribed 50 treatment consultations for localized PC across a multidisciplinary sample of urologists, radiation oncologists, and medical oncologists. Conversation was coded for narrative content using an open coding approach, grouping similar topics into major content areas. The number of words devoted to each content area per consult was used as a proxy for time spent. Multivariable Poisson regression calculated incidence rate ratios (IRR) for content-specific word count across specialties after adjustment for tumor risk and patient demographics.

RESULTS

Coders identified 8 narrative content areas: overview of PC; medical history; baseline risk; cancer prognosis; competing risks; treatment options; physician recommendations; and shared decision making (SDM). In multivariable models, specialties significantly differed in proportion of time spent on treatment options, SDM, competing risks, and cancer prognosis. Urologists spent 1.8-fold more time discussing cancer prognosis than medical oncologists (IRR1.80, 95%CI:1.14-2.83) and radiation oncologists (IRR1.84, 95%CI:1.10-3.07). Urologists (IRR11.38, 95%CI:6.62-19.56) and medical oncologists (IRR10.60, 95%CI:6.01-18.72) spent over 10-fold more time discussing competing risks than radiation oncologists. Medical oncologists (IRR2.60, 95%CI:1.65-4.10) and radiation oncologists (IRR1.77, 95%CI:1.06-2.95) spent 2.6- and 1.8-fold more time on SDM than urologists, respectively.

CONCLUSIONS

Specialists focus on different content in PC consultations. Our results suggest that urologists should spend more time on SDM and radiation oncologists on competing risks. Our results also highlight the importance of medical oncologists in facilitating SDM.

Implementation of the measure of case discussion complexity to guide selection of prostate cancer patients for multidisciplinary team meetings

BACKGROUND

Multidisciplinary team meetings (MDTMs) provide an integrated team approach to ensure individualized and evidence-based treatment recommendations and best expert advice in cancer care. A growing number of patients and more complex treatment options challenge MDTM resources and evoke needs for case prioritization. In this process, decision aids could provide streamlining and standardize evaluation of case complexity. We applied the recently developed Measure of Case Discussion Complexity, MeDiC, instrument with the aim to validate its performance in another healthcare setting and diagnostic area as a means to provide cases for full MDTM discussions.

METHODS

The 26-item MeDiC instrument evaluates case complexity and was applied to 364 men with newly diagnosed prostate cancer in Sweden. MeDiC scores were generated from individual-level health data and were correlated with clinicopathological parameters, healthcare setting, and the observed clinical case selection for MDTMs.

RESULTS

Application of the MeDiC instrument was feasible with rapid scoring based on available clinical data. Patients with high-risk prostate cancers had significantly higher MeDiC scores than patients with low or intermediate-risk cancers. In the total study, population affected lymph nodes and metastatic disease significantly influenced MDTM referral, whereas comorbidities and age did not predict MDTM referral. When individual patient MeDiC scores were compared to the clinical MDTM case selection, advanced stage, T3/T4 tumors, involved lymph nodes, presence of metastases and significant physical comorbidity were identified as key MDTM predictive factors.

CONCLUSIONS

Application of the MeDiC instrument in prostate cancer may be used to streamline case selection for MDTMs in cancer care and may complement clinical case selection.

Multi-disciplinary and shared decision-making approach in the management of organ-confined prostate cancer

Decision-making in the management of organ-confined prostate cancer is complex as it is based on multi-factorial considerations. It is complicated by a multitude of issues, which are related to the patient, treatment, disease, availability of equipment(s), expertise, and physicians. Combination of all these factors play a major role in the decision-making process and provide for an interactive decision-making preferably in the multi-disciplinary team (MDT) meeting. MDT decisions are comprehensive and are often based on all factors including patients' biological status, disease and its aggressiveness, and physician and centres' expertise. However, one important and often under rated factor is patient-related factors. There is considerable evidence that patients and physicians have different goals for treatment and physicians' understanding of their own patients' preferences is not accurate. Several patient-related key factors have been identified such as age, religious beliefs, sexual health, educational background, and cognitive impairment. We have focused on these areas and highlight some key factors that need to be taken considered whilst counselling a patient and understanding his choice of treatment, which might not always be match with the clinicians' recommendation.

Quality indicators of clinical cancer care for prostate cancer: a population-based study in southern Switzerland

Background

Quality of cancer care (QoCC) has become an important item for providers, regulators and purchasers of care worldwide. Aim of this study is to present the results of some evidence-based quality indicators (QI) for prostate cancer (PC) at the population-based level and to compare the outcomes with data available in the literature.

Methods

The study included all PC diagnosed on a three years period analysis (01.01.2011–31.12.2013) in the population of Canton Ticino (Southern Switzerland) extracted from the Ticino Cancer Registry database. 13 QI, approved through the validated Delphi methodology, were calculated using the “available case” approach: 2 for diagnosis, 4 for pathology, 6 for treatment and 1 for outcome. The selection of the computed QI was based on the availability of medical documentation. QI are presented as proportion (%) with the corresponding 95% confidence interval.

Results

700 PC were detected during the three-year period 2011–2013: 78.3% of them were diagnosed through a prostatic biopsy and for 72.5% 8 or more biopsy cores were taken. 46.5% of the low risk PC patients underwent active surveillance, while 69.2% of high risk PC underwent a radical treatment (radical prostatectomy, radiotherapy or brachytherapy) and 73.5% of patients with metastatic PC were treated with hormonal therapy. The overall 30-day postoperative mortality was 0.5%.

Conclusions

Results emerging from this study on the QoCC for PC in Canton Ticino are encouraging: the choice of treatment modalities seems to respect the international guidelines and our results are comparable to the scarce number of available international studies. Additional national and international standardisation of the QI and further QI population-based studies are needed in order to get a real picture of the PC diagnostic-therapeutic process progress through the definition of thresholds of minimal standard of care.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4604-2) contains supplementary material, which is available to authorized users.

Longitudinal regret after treatment for low- and intermediate-risk prostate cancer

BACKGROUND

Prostate cancer patients diagnosed with low- and intermediate-risk disease have several treatment options. Decisional regret after treatment is a concern, especially when poor oncologic outcomes or declines in health-related quality of life (HRQoL) occur. This study assessed determinants of longitudinal decisional regret in prostate cancer patients attending a multidisciplinary clinic and treated with radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy (BT), or active surveillance (AS).

METHODS

Patients newly diagnosed with prostate cancer at the Walter Reed National Military Medical Center who attended a multidisciplinary clinic were enrolled into a prospective study from 2006 to 2014. The Decision Regret Scale was administered at 6, 12, 24, and 36 months posttreatment. HRQoL was also assessed at regular intervals using the Expanded Prostate Cancer Index Composite and 36-item RAND Medical Outcomes Study Short Form questionnaires. Adjusted probabilities of reporting regret were estimated via multivariable logistic regression fitted with generalized estimating equations.

RESULTS

A total of 652 patients met the inclusion criteria (395 RP, 141 EBRT, 41 BT, 75 AS). Decisional regret was consistently low after all of these treatments. In multivariable models, only African American race (odds ratio, 1.67; 95% confidence interval, 1.12-2.47) was associated with greater regret across time. Age and control preference were marginally associated with regret. Regret scores were similar between RP patients who did and did not experience biochemical recurrence. Declines in HRQoL were weakly correlated with greater decisional regret.

CONCLUSION

In the context of a multidisciplinary clinic, decisional regret did not differ significantly between treatment groups but was greater in African Americans and those reporting poorer HRQoL. Cancer 2017;123:4252-4258. © 2017 American Cancer Society.

Eleven-year management of prostate cancer patients on active surveillance: what have we learned?

PURPOSE

To evaluate the outcomes of active surveillance (AS) on patients with low-risk prostate cancer (PCa) and to identify predictors of disease reclassification.

METHODS

In 2005, we defined an institutional AS protocol (Sorveglianza Attiva Istituto Nazionale Tumori [SAINT]), and we joined the Prostate Cancer Research International: Active Surveillance (PRIAS) study in 2007. Eligibility criteria included clinical stage ≤T2a, initial prostate-specific antigen (PSA) <10 ng/mL, and Gleason Pattern Score (GPS) ≤3 + 3 (both protocols); ≤25% positive cores with a maximum core length containing cancer ≤50% (SAINT); and ≤2 positive cores and PSA density <0.2 ng/mL/cm3 (PRIAS). Switching to active treatment was advised for a worsening of GPS, increased positive cores, or PSA doubling time <3 years. Active treatment-free survival (ATFS) was assessed using the Kaplan-Meier method. Factors associated with ATFS were evaluated with a multivariate Cox proportional hazards model.

RESULTS

A total of 818 patients were included: 200 in SAINT, 530 in PRIAS, and 88 in personalized AS monitoring. Active treatment-free survival was 50% after a median follow-up of 60 months. A total of 404/818 patients (49.4%) discontinued AS: 274 for biopsy-related reclassification, 121/404 (30%) for off-protocol reasons, 9/404 (2.2%) because of anxiety. Biopsy reclassification was associated with PSA density (hazard ratio [HR] 1.8), maximum percentage of core involvement (HR 1.5), positive cores at diagnostic biopsy (HR 1.6), older age (HR 1.5), and prostate volume (HR 0.6) (all p<0.01). Patients from SAINT were significantly more likely to discontinue AS than were the patients from PRIAS (HR 1.65, p<0.0001).

CONCLUSIONS

Five years after diagnosis, 50% of patients with early PCa were spared from active treatment. Wide inclusion criteria are associated with lower ATFS. However, at preliminary analysis, this does not seem to affect the probability of unfavorable pathology.

Comparison of outcomes for cancer patients discussed and not discussed at a multidisciplinary meeting

OBJECTIVES

Comparison of outcomes for cancer patients discussed and not discussed at a multidisciplinary meeting (MDM).

STUDY DESIGN

Retrospective analysis of the association of MDM discussion with survival.

METHODS

All newly diagnosed cancer patients from 2009 to 2012, presenting to a large regional cancer service in South West Victoria, Australia (620 colorectal, 657 breast, 593 lung and 511 haematological) were recorded and followed up to 5 years after diagnosis. Treatment patterns and survival of patients whose treatment was discussed at an MDM compared to those who were not, were explored.

RESULTS

The proportion of patients presented to an MDM within 60 days after diagnosis was 56% (n = 366) for breast cancer, 59% (n = 363) for colorectal cancer, 27% (n = 137) for haematological malignancies and 60% (n = 355) for lung cancer. Seventy-three percent (n = 886) of patients discussed at an MDM had their tumour stage recorded in their medical records while only 52% (n = 604) of patients not discussed had their tumour stage recorded (P < 0.01). We found for haematological and lung cancer patients that those presented to an MDM prior to treatment had a significant reduction in mortality (lung cancer hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.50-0.76, P < 0.01) (haematological cancer HR 0.58, 95% CI 0.35-0.96, P = 0.03) compared to patients whose cases were not discussed at an MDM after adjusting for the potential cofounders of age, stage, comorbidities and treatment. This was not the case for colorectal and breast cancer patients where there was no significant difference.

CONCLUSION

MDM discussion has been recommended as best practice in the management of cancer patients, however, from a public health perspective this creates potential issues around access and resources. It is likely that MDM presentation patterns and outcomes across tumour streams are linked in complex ways. We believe that our data would demonstrate that these patterns differ across tumour streams and that more detailed work is required to better allocate relatively scarce and potentially costly MDM resources to tumour streams and patient groups that may get the most benefit.

Patterns of multidisciplinary care in the management of non-metastatic invasive breast cancer in the United States Medicare patient

PURPOSE

Multidisciplinary care (MDC) in managing breast cancer is resource-intensive and growing in prevalence anecdotally, although care patterns are poorly characterized. We sought to determine MDC patterns and effects on care in the United States Medicare patient.

METHODS

Patients diagnosed with non-metastatic invasive breast cancer from 1992-2009 were reviewed using the Survival, Epidemiology, and End Results (SEER)-Medicare linked dataset. MDC was defined as a post-diagnosis, preoperative visit with a surgical, medical, and radiation oncologist. Same-day MDC (MDCSD) was the MDC subset having all three visits on one date.

RESULTS

Among 88,865 patients, MDC was utilized in 2.9 %, with 14.1 % of these having MDCSD. MDC use did not vary by stage, but MDC patients were more likely to be younger, black, receive lumpectomy, have fewer nodes examined, and receive radiotherapy. MDCSD patients were more likely than non-MDC patients to be black, receive mastectomy, and receive radiotherapy. MDC and MDCSD use increased over time and varied by geographic region, with rural patients less likely to receive MDC (OR 0.54 [95 % CI 0.45-0.65]) and MDCSD (OR 0.32 [95 % CI 0.19-0.54]). Radiotherapy after breast conserving surgery, used in 86.2 % of non-MDC patients, was administered to 90.2 % of MDC (p < 0.001) and 92.6 % of MDC(SD) (p = 0.096) patients. Post-mastectomy radiotherapy was administered in 52.0 % of non-MDC patients, 63.8 % of MDC (p = 0.050), and 89.1 % of MDC(SD) (p = 0.011) patients after propensity score adjustment.

CONCLUSION

While increasing, few Medicare patients undergo MDC and MDCSD is rare. MDC may improve quality and MDCSD should be considered for patient convenience. While not yet widespread, efforts should integrate MDC and MDCSD across the U.S.

Prostate Cancer Unit Initiative in Europe: A position paper by the European School of Oncology

The Prostate Cancer Programme of the European School of Oncology developed the concept of specialised interdisciplinary and multiprofessional prostate cancer care to be formalized in Prostate Cancer Units (PCU). After the publication in 2011 of the collaborative article "The Requirements of a Specialist Prostate Cancer Unit: A Discussion Paper from the European School of Oncology", in 2012 the PCU Initiative in Europe was launched. A multiprofessional Task Force of internationally recognized opinion leaders, among whom representatives of scientific societies, and patient advocates gathered to set standards for quality comprehensive prostate cancer care and designate care pathways in PCUs. The result was a consensus on 40 mandatory and recommended standards and items, covering several macro-areas, from general requirements to personnel to organization and case management. This position paper describes the relevant, feasible and applicable core criteria for defining PCUs in most European countries delivered by PCU Initiative in Europe Task Force.

Prospective quality-of-life outcomes for low-risk prostate cancer: Active surveillance versus radical prostatectomy

BACKGROUND

For patients with low-risk prostate cancer (PCa), active surveillance (AS) may produce oncologic outcomes comparable to those achieved with radical prostatectomy (RP). Health-related quality-of-life (HRQoL) outcomes are important to consider, yet few studies have examined HRQoL among patients with PCa who were managed with AS. In this study, the authors compared longitudinal HRQoL in a prospective, racially diverse, and contemporary cohort of patients who underwent RP or AS for low-risk PCa.

METHODS

Beginning in 2007, HRQoL data from validated questionnaires (the Expanded Prostate Cancer Index Composite and the 36-item RAND Medical Outcomes Study short-form survey) were collected by the Center for Prostate Disease Research in a multicenter national database. Patients aged ≤75 years who were diagnosed with low-risk PCa and elected RP or AS for initial disease management were followed for 3 years. Mean scores were estimated using generalized estimating equations adjusting for baseline HRQoL, demographic characteristics, and clinical patient characteristics.

RESULTS

Of the patients with low-risk PCa, 228 underwent RP, and 77 underwent AS. Multivariable analysis revealed that patients in the RP group had significantly worse sexual function, sexual bother, and urinary function at all time points compared with patients in the AS group. Differences in mental health between groups were below the threshold for clinical significance at 1 year.

CONCLUSIONS

In this study, no differences in mental health outcomes were observed, but urinary and sexual HRQoL were worse for patients who underwent RP compared with those who underwent AS for up to 3 years. These data offer support for the management of low-risk PCa with AS as a means for postponing the morbidity associated with RP without concomitant declines in mental health.

'Act on oncology' as a new comprehensive approach to assess prostate cancer centres--method description and results of a pilot study

Background

Multidisciplinary care of prostate cancer is increasingly offered in specialised cancer centres. It requires the optimisation of medical and operational processes and the integration of the different medical and non-medical stakeholders.

Objective

To develop a standardised operational process assessment tool basing on the capability maturity model integration (CMMI) able to implement multidisciplinary care and improve process quality and efficiency.

Design, Setting, and Participants

Information for model development was derived from medical experts, clinical guidelines, best practice elements of renowned cancer centres, and scientific literature. Data were organised in a hierarchically structured model, consisting of 5 categories, 30 key process areas, 172 requirements, and more than 1500 criteria. Compliance with requirements was assessed through structured on-site surveys covering all relevant clinical and management processes. Comparison with best practice standards allowed to recommend improvements. ‘Act On Oncology’(AoO) was applied in a pilot study on a prostate cancer unit in Europe.

Results and Limitations

Several best practice elements such as multidisciplinary clinics or advanced organisational measures for patient scheduling were observed. Substantial opportunities were found in other areas such as centre management and infrastructure. As first improvements the evaluated centre administration described and formalised the organisation of the prostate cancer unit with defined personnel assignments and clinical activities and a formal agreement is being worked on to have structured access to First-Aid Posts.

Conclusions

In the pilot study, the AoO approach was feasible to identify opportunities for process improvements. Measures were derived that might increase the operational process quality and efficiency.

Quality of physician-patient relationships is associated with the influence of physician treatment recommendations among patients with prostate cancer who chose active surveillance

OBJECTIVE

With growing evidence that some men with prostate cancer (PCa) may be overtreated, clinicians need greater knowledge of the factors that influence uptake of treatment recommendations in general, and specifically, uptake of active surveillance in patients for whom this is an appropriate treatment option. The objective of this study was to test the role of the quality of the physician-patient relationship in the choice to be followed by active surveillance, rather than receive definitive therapy (e.g., surgery and radiation). We hypothesized that patients would have been more influenced by their physicians' treatment recommendations to the degree that they held more positive perceptions of their relationship with their physicians, independent of treatment recommended.

METHODS AND MATERIALS

Patients with PCa (n = 120) being followed with active surveillance at a comprehensive cancer center completed self-report assessments of their treatment decision-making process. Generalized estimating equations were used to model the association between participants' perceptions of their relationships with their physicians and influence of these physicians' recommendations on their treatment decision.

RESULTS

After controlling for the type of treatment recommended, Gleason score, and education, 3 predictors, trust in the physician, perceived closeness with the physician, and the degree to which the physician shared control over treatment decision making, were associated with greater influence of physician's treatment recommendation. Receiving a recommendation for active surveillance, compared with definitive therapy, was also associated with higher perceived trust, closeness, shared control over treatment decision making, lower likelihood of having been treated poorly by a physician, and greater influence of physician's treatment recommendation.

CONCLUSIONS

There is increasing concern that patients with relatively less aggressive PCa, older age, or serious comorbidities are being unnecessarily treated with surgery or radiation, putting them at risk for side effects, and contributing to high health care costs. When active surveillance is an appropriate course of treatment, the quality of patients' relationships with their physicians may be a determinant of following a recommendation for active surveillance. Results may have implications for treatment uptake in general, indicating that the quality of the physician-patient relationship, including trust, closeness, shared decision making--all elements of patient-centered care--may be important motivators of treatment adoption and adherence.

Toward a common therapeutic framework in castration-resistant prostate cancer: a model for urologic oncology and medical oncology interaction

BACKGROUND

The rapid evolution of palliative therapeutic choices in the last few years for patients with advanced castration-resistant prostate cancer (CRPC) has resulted in a dilemma currently troubling a few other epithelial malignancies: which systemic agent to choose and at what time? In addition, which specialty specifically directs the delivery of such care--Urology or Medical Oncology--has not been clearly established.

APPROACH

Recognizing the lack of consensus, we propose a framework for Urology and Medical Oncology interactions that is founded on models that have succeeded in the past.

CONCLUSION

This approach aims to focus the care on the patient with CRPC rather than on his physicians and promises to improve patient outcomes in this disease state.

La Radioterapia Nel Trattamento Del Carcinoma Della Prostata: Indicazioni, Evoluzione Tecnologica e Approcci Integrati

Prostate cancer is a heterogeneous, indolent or sometimes aggressive tumor. Treatment options are various and without proved superiority. Radiotherapy (RT) plays a key role in the disease history. Technological evolution with Intensity Modulate Radiation Therapy (IMRT) and Image Guided Radiation Therapy (IGRT) allowed improvement, with significant results on local control and survival. Hypofractionation, Stereotactic Body RT (SBRT) and new brachytherapy approachs are still under investigation, with promising opportunities. Adjuvant vs salvage postoperative RT, hormone association, prophylactic pelvic irradiation are still under debate, but guidelines express overlapping indications.

Multidisciplinary managements will be the future for care optimization, providing the best tool for holistic and informed patients' choice.