AUA 2022: Panel Discussion: What is the Optimal Multidisciplinary Team in 2022: Drafting for the Future

(UroToday.com) The 2022 Annual Meeting of the American Urological Association was host to a panel discussion on the significance of multidisciplinary teams in the management of urologic oncology patients and the importance of a collaborative approach to optimizing patient care. This panel discussion was expertly moderated by Dr. Leonard Gomella with Drs. Neal Shore and Michael Cookson as panelists.

Dr. Gomella began his presentation by highlighting the volume of recent advances in all areas of urologic oncology, both in the localized and advanced disease spaces. There are new, emerging standards of care for all genitourinary cancers that require shared decision making and multimodal therapies. This can only be facilitated by multidisciplinary care teams with different skill sets.

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There are many different multidisciplinary team approaches:

  1. “True” multidisciplinary clinic teams: real time interaction with the specialists and the patient/family
  • Providers go to the patient in one common visit
  1. Care pathways: Agreement among specialist teams to follow predefined treatment maps
  2. Tumor board: recommendations back to care team

Decision making for multimodality treatment plans with high-risk or advanced disease often requires the input of all specialists and consideration for clinical trials. Treatment regret can be minimized if patients are given the opportunity to openly discuss treatment options with different specialists. This is perhaps of most significance in the prostate cancer disease space, where treatment regret can often be an issue. Genitourinary multidisciplinary approaches have improved care for patients by:

  • Improving outcomes
  • Improving adherence to NCCN guidelines
  • Broadening of treatment options
  • Increasing clinical trial enrolment
  • Decreasing patient regret

There has been increased interest in the multidisciplinary approach with the European School of Oncology having certified “Prostate Cancer Units” and numerous multidisciplinary centers now published in William Beaumont, Walter Reed, Duke, Hopkins, Erasmus (Netherlands), and Milan (Italy). Thomas Jefferson’s Sidney Kimmel Cancer Center GU Multidisciplinary Center was founded in 1996. It is believed to be the longest continuously running NCI-designated cancer center, with all specialists and other team members present on site at the same time. All GU tumor types are evaluated (~80% prostate). Team members include:

  • Navigators
  • Urologists
  • Radiation oncologists
  • Medical oncologists
  • Clinical trials coordinators
  • Social workers
  • Generic counsellor screening

Dr. Gomella went on to present the outcomes from the multidisciplinary team approach of his center. In 2010, his group presented outcomes from a 15-year experience at that time that demonstrated significantly improved survival outcomes for patients with locally advanced prostate cancer, when compared to national results from the SEER database.

Dr. Gomella believes that the following are core team members of any multidisciplinary team:

  • Urology/urologic oncology
  • Medical oncology
  • Radiation oncology
  • Navigator/coordinator

Optional team members are as follows:

  • Physician assistants/nurse practitioners
  • Radiology
  • Pathology
  • Nuclear medicine
  • Genetic counsellors
    • Molecular and genomic markers add further complexity to decision making  Molecular tumor boards
  • Clinical trials coordinators
  • Social workers
  • Nutritionists
  • Psychologists

Next, Dr. Gomella addressed the pros/cons of a multidisciplinary approach to prostate cancer care.

Pros:

  • Multiple studies suggest enhanced outcomes
  • Enhances program visibility
  • Facilitates care and allow for patient/family convenience
  • High patient satisfaction/retention; less treatment regret
  • Educational enhancements: students/residents/faculty/staff/families
  • Clinical trials discussions
  • Encourages dialogue about multimodality therapy

Cons:

  • Significant physician buy-in is required
  • May not be time efficient for physicians
  • Some loss of physician autonomy
  • Site of service reimbursement/billing issues
  • Requires dedicated staff, space, and resources

Next, Dr. Gomella asked Dr. Cookson to elaborate on the multidisciplinary team approach at the University of Oklahoma. Dr. Cookson commented that he agreed with all the points that Dr. Gomella made. One issue that he brought up was the possibility of patient burnout from too many visits at once and his belief that staggering appointments may be the way to go in that setting to counteract that.

Dr. Shore was next asked to elaborate on his team’s approach at Myrtle Beach in the private practice seeting. Dr. Shore emphasized the importance of the multidisciplinary approach in this era, particularly given the constant emergence of novel, approved drugs particularly in advanced prostate, kidney and bladder cancers. His practice setting allows for constant collaboration with multiple providers from other disciplines leading to a true multidisciplinary care approach.

Next, the three panel members discussed how a multidisciplinary approach might be beneficial in various disease spaces:

  • Non-muscle invasive bladder cancer (NIBC)
    • Currently less crucial, but may change with emergence of multitude of intravesical therapies
  • BCG-refractory NMIBC
    • May be relevant in consideration of novel intravesical therapies and systemic treatment with IO agents (e.g. pembrolizumab)
  • Active surveillance prostate cancer
    • Potentially for consideration of genetic counselling/screening
  • High-risk localized prostate cancer
    • May become more relevant with trials evaluating neoadjuvant use of theranostics prior to radical treatment
  • Metastatic prostate cancer and kidney cancer
    • Extremely useful given the constant emergence of novel agents that change the standards of care and increasing uptake of stereotactic ablative radiotherapy (SABR) fot treatment of oligometastatic disease

 

Dr. Gomella concluded as follows:

  • Urologic oncology care is becoming more complex
    • More novel treatment approaches for prostate, bladder and kidney cancer
  • Patient shared decision making is becoming more difficult
  • Expansion into genetic and genomic analysis guided treatment decisions needs expertise  Dedicated molecular tumor boards
  • Multidisciplinary care teams are becoming common and necessary
  • Real time MD Clinic OR treatment plans OR tumor boards
    • How these teams function depends on location, commitment and resources
  • Core: Urology, medical oncology, and radiation oncology
  • Integrated teams becoming essential to ensure high quality, consistent care, and adherence to latest guidelines

 

 

Presented By:

Dr. Leonard G. Gomella, MD, Professor and Chair, Thomas Jefferson University, Philadelphia, PA
Dr. Michael S. Cookson, MD, MHA, Professor and Chair, University of Oklahoma, Oklahoma City, OK
Dr. Neal D. Shore, MD, Carolina Urologic Research Center and Atlantic Urology Clinics, LLC, Myrtle Beach, SC

Written By: Rashid Sayyid, MD, MSc – Urology Chief Resident, Augusta University/Medical College of Georgia, @rksayyid on Twitter during the 2022 American Urological Association (AUA) Annual Meeting, New Orleans, LA, Fri, May 13 – Mon, May 16, 2022.

 

 

 

 

 

 

 

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