- Published in Everyday Urology - Oncology Insights: Volume 2, Issue 2
When patients receive a diagnosis of cancer it can be devastating. Suddenly their world is turned upside down, populated by doctors, diagnostic tests, and treatments.
The standard process for newly diagnosed patients with prostate cancer is a chronologically linear and often one-dimensional process managed by urologists.3 If the patient’s diagnosis is based on biopsy results, the urologist discusses treatment options with the patient and his family. This may be followed by referral to another specialist such as a medical and/or radiation oncologist depending on their risk stratification.4
Sometimes patients immediately choose to have surgery without learning about radiation therapy options. Compounding the patients’ anxiety about their cancer diagnosis is the burden of making a treatment decision and dealing with the complexities of the health care system. Some patients are uncomfortable with the responsibility of choosing a treatment and would prefer that the physician tell them what to do. Many patients have a sense of inadequacy to understand the terminology, treatment options, and associated long-term ramifications. Recommendations to meet with the nurse educator for educational counseling and support are not consistently offered to patients. Difficulties getting immediate appointments further contribute to the anxiety in decision making. Patients from out-of-state, and particularly out-of-country, often experience additional anxiety managing this process long distance. 5,6
Physicians may also feel challenged to meet the demands to stay current with the rapidly changing science and expanding number of treatment options as research has allowed more treatment modalities to move from the research laboratory to the clinical setting. Increasing specialization has ledmanycancer treating physicians to limit their practice to specific cancer types. This is a benefit care for specific patient problems, but may lead to narrow-minded tendencies. Thus there is a growing need to coordinate care among providers, ensuring that patients successfully negotiate the complexities of cancer care. 3,7
MULTIDISCIPLINARY APPROACH FOR CANCER CARE
As early as the 1990s it was becoming clear that multidisciplinary care clinics provide an effective way to deploy expertise while simultaneously being more cost efficient.8 Theoretically, a multidisciplinary approach provides a rational and coordinated way to evaluate and treat patients with complex diseases by bringing health care providers in the surgical, medical, and radiation oncology disciplines together. In reality, each discipline functions in a different environment with different requirements and incentives that can undermine seamless coordination. For the most part the practice of medicine relies on consulting different specialty services concerning individual patient problems, however there has been a growing movement towards integrating multiple specialties into a multidisciplinary care center (MDCC). The MDCC has been playing an increasingly prominent role in cancer care, both in the community and in academic cancer centers. It is becoming more common in the practice of many oncological disciplines including prostate cancer.8,9,10,11,12
MULTI-DISCIPLINARY CLINICS IN NON-UROLOGICAL CANCERS
A cancer center tends to be organized into distinct disease centers. Each center may have its own disease-based multidisciplinary clinic, the needs of which differ from another center. This is particularly true in large academic centers where specialized providers treat patients with a single disease.13
Multidisciplinary clinics play a prominent role in many cancer centers but their structures differ by institution. When two different structures were compared, one in which patients are seen sequentially by physicians from each discipline, and a second in which patients are seen concurrently by physicians from each discipline, more than 90% of providers enjoyed working in an MDCC and more than 75% preferred to see new patients in an MDCC. Additionally, 90% believed that patients perceived the clinics to be valuable for comprehensive, coordinated, and appropriate care. However, satisfaction differed between patients and physicians. One third of the physicians thought the clinics were not an efficient use of their time, whereas patients seen in each clinic model uniformly expressed high satisfaction with the coordination of care.13
For patients diagnosed with cancer, coordinated disease management among physicians in different specialties at a single location makes multidisciplinary care clinics an indispensable resource. They provide patients the opportunity to receive individualized treatment plans in the broad context of multiple specialists all within a single encounter. MDCC models are important decision-making forums in current oncology practice.9 An MDCC forum can foster physician coordination to generate comprehensive patient care plans, but it may also have medicolegal implications.10
Measurements of success are principally by patient and physician satisfaction surveys, and downstream revenue, calculated by determining revenue generated by surgery, pathology, clinical laboratory, imaging, chemotherapy, radiation therapy, and in-patient services.3 Although an MDCC is purported to offer benefits to patients, there is little evidence about the benefit to individuals receiving care at community cancer centers in the United States. Among community cancer centers serving patients diagnosed with colon, rectal, or lung cancer the relationship between the level of implementation of an MDCC and various processes of cancer care such as time to treatment receipt or evaluation for enrollment onto a clinical trial is notably limited.9
The rigorous study of the use of multidisciplinary cancer care is scant despite the overall observations of its use. One such objective study showed the benefit of an MDCC to improve the use of standardization and adherence to evidence based medicine to provide better care was demonstrated in an Australian study of 335 patients with non-small-cell lung cancer.11
Gradually multidisciplinary care clinics have been shown to improve cancer specific survival in brain, breast, lung, colorectal, and head and neck.7,14,15,16, 17 An increase in the number of patients screened for and enrolled in clinical trials has also been demonstrated after implementation of a MDCC in a gynecologic oncology center.15 Improved patient access to consultations and shorter time to initial treatment was observed in a study of MDCC in pancreatic cancer following the establishment of a multidisciplinary pancreas tumor clinic.14 This same report also cited that one group has reported that after establishing a multidisciplinary pancreatic cancer clinic, 23.6% of their patients had a change in their recommended management and 77.8% of patients enrolled in the National Familial Pancreas Tumor Registry.18 After three decades MDCs are able to show not only improved patient and provider satisfaction, but improved patient access to care.14
MULTI-DISCIPLINARY CLINICS IN UROLOGICAL CANCERS
Our literature review of MDCCs for urological cancer revealed remarkably few. We found no studies specifically for testicular cancer or renal cancer and only one related publication specifically for bladder cancer.19 One prospective study of a multidisciplinary approach to urological malignancies reported 38% of newly diagnosed patients had a change in diagnosis or treatment. Changes in treatment were most common in bladder cancer (44%), followed by kidney (36%), testicular (29%), then prostate (22%) cancers. 20
Figure 1: Patient flow through the multidisciplinary genitourinary cancer clinic based on the current model.
MULTI-DISCIPLINARY CLINICS IN PROSTATE CANCERS
Publications for prostate cancer are the most extensive, nevertheless they too are limited. One Canadian study reported on a large, in depth assessment of their diagnostic assessment program for newly diagnosed prostate cancer within an MDCC.21 In this report, more than 80% of patients had timely multidisciplinary consultation which was associated with different management decisions.
A few years ago an Italian study reported on management changes following 6 years after the establishment of multidisciplinary prostate cancer clinic.6 Not unexpectedly, results showed that patients with prostate cancer should be comprehensively informed about the disease, the therapeutic and observational strategies available, the therapy-induced adverse effects, and the rehabilitation programs, and should be accompanied in the decision-making process. They should be able to understand the pros and cons of their options, the therapy-induced adverse effects, and the available rehabilitation programs, thus becoming active participants in the decision-making process. Realistically, this is frequently not the scenario. The report delivered a rap on the wrist with the finding to consumers and to the marketing industry. Sophisticated technologies and therapies and the amount of information available in the press and on the internet, combined with the consumer’s demand for the ‘best treatment’ available and their inability to distinguish between evidence-based medicine and marketing strategies.22
Although the multidisciplinary setting is often viewed as an “inefficient” use of time in terms of the numbers of patients that can be seen by an individual clinician, a retrospective study demonstrated potential outcome benefit to many patients. This study at Duke University Medical Center compared a prostate cancer multidisciplinary clinic against their standard urology clinic model. Neither a difference in outcomes over a 4-year period, despite higher risk disease in the MDC population, nor any delay in time to radical prostatectomy was found. 23 On the other hand, a report of an evaluation of 15 years of data from a prostate cancer MDCC reported a 10 year survival data for stage 3 and 4 prostate cancer had an institutional survival rate that exceeded the government SEER (Surveillance, Epidemiology and End Results) data together with high patient satisfaction. This study also underscored the importance of interdisciplinary educational aspects and patient satisfaction.7
The options for the management of localized prostate cancer include active surveillance, surgery, radiotherapy, cryotherapy, or other investigational methods and each option has many subsets. Patients and physicians need to be informed of the risks and benefits of each option.24 The impact of multi-disciplinary meetings was the subject of a systematic review of the literature. The reviewers found that patients discussed at meetings were more likely to receive more accurate and complete pre-operative staging, and neo-adjuvant/adjuvant treatment. In prospective studies, between 4% and 35% of patients discussed had changes in assessment and diagnosis following the meeting.25 Of the only two urological oncology studies reviewed, one study 26 found no changes in management, whereas the second study 27 found changes to the original treatment plan in 26.7% of all urological cases (66.7% for testicular cancer, 42% for bladder cancers, 26% for prostate cancers, and 19% for kidney cancers). High impact cases, those with either a major change in the management plan, or a plan developed where there was none, were twice as likely in patients with metastatic disease.
IMPLEMENTATION OF A MDCC: THE UNIVERSITY OF TEXAS MEDICAL BRANCH EXPERIENCE
To the author’s knowledge no study has addressed the implementation of a prostate cancer MDCC with respect to disease risk, time to survival, and quality of life. We at the University of Texas Medical Branch (UTMB) recently instituted a urologic oncology multidisciplinary center to address the issues of an MDCC and to evaluate the structure and operation of the clinic to highlight factors impacting success in improving patient care and outcomes of patient care. A formal evaluation of UTMB’s urologic oncology center to measure outcomes and quality data will be used to determine areas of improvement.
The need for the long-term commitments of all participants and the institution cannot be underestimated in establishing a multidisciplinary clinic. In our plan all newly diagnosed prostate cancer patients must be evaluated in the MDCC. The patient is enrolled in the Prostate Cancer Registry and the case is then presented to the tumor board. The patient’s referring urologist is given the findings of the case and the board’s recommendations. The patient is always involved in their care and has the final say in deciding on the treatment.
Effective patient care in a multidisciplinary setting needs a team champion, and the involvement of the physicians on the team for a concerted and coordinated activities of multiple disciplines. When this occurs there is a perception of greater team effectiveness. Contributing to a perception of team effectiveness is patient education, patient satisfaction, balance among culture values, openness to innovation, and adherence to rules and accountability. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness. 12
In 2011 a reporting and quality improvement system was developed by the Commission on Cancer (CoC) of the American College of Surgeons to assist CoC-accredited cancer programs in promoting evidenced-based cancer care at the local level. The Rapid Quality Reporting System (RQRS) is a Web-based, systematic data collection and reporting system. Beginning January 2017, RQRS participation will be required for all CoC-accredited programs. The RQRS advances evidenced-base treatment through a prospective alert system for anticipated care which supports care coordination required for breast and colorectal cancer patients at participating cancer programs. The System provides real clinical time assessment of hospital level adherence to quality of cancer care measures. It is well studied in breast and colorectal cancer 9,28 but so far not in urological cancers.
We anticipate that the treatment in the environment of the new multidisciplinary clinic will demonstrate with improved processes of care, evidenced by: (1) shorter time to initial therapy receipt, (2) increased likelihood of multi-modality therapy receipt, (3) increased likelihood of clinical trial enrollment evaluation, and (4) increased likelihood of adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines, (5) patient satisfaction, (6) and lower costs.
The literature shows many benefits of an MDCC including patient satisfaction, increased accuracy of care, decreased time to follow-up and treatment, better quality of life, enhanced graduate medical education, better adherence to national cancer guidelines, and improved survival in multiple non-urological cancers. These benefits were largely studied in non-urological cancers. The literature for an MDCC in urological cancers is sparse and the majority of the literature found was for prostate cancer. This represents an area of need, especially in the context of testicular, bladder, and renal cancer. The RQRS system has yet to be evaluated in the context of urological cancers despite being a mandated requirement.
We look forward to further study. Some potential future projects would include: prospective survey of patient perceptions of the urological MDCC; comparison of our patient population pre/post MDCC of follow-up time, time to treatment, increased NCCN guideline adherence, increased clinical trial enrollment, decreased duplicated tests, decreased time to treatment; evaluate plan changes following multi-disciplinary tumor board meetings.
In this era of value-added medical practice, cost benefits can be evaluated analysis of various metrics, such as reduced costs by omitting duplicated tests. Possibly downstream revenue would be generated by an MDCC.
Written By: Stephen B. Williams, MD and Ashish M. Kamat, MD, MBBS, FACS
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