A newly published article in the Journal of Clinical Oncology has reported that men being seen at specialized, multidisciplinary prostate cancer clinics are nearly twice as likely to accept initial active surveillance as men consulting individual practitioners.
The study reported by Aizer et al. was based on data from 701 men, all diagnosed with low-risk prostate cancer and managed at one of three tertiary care hospitals in Boston in 2009. The patients were all seen either at a multidisciplinary prostate cancer clinic (where they were seen by a combination of urologic, radiation, and medical oncologists in a concurrent setting) or they were seen by individual practitioners in sequential settings.
Here are the basic results reported by Aizer et al.:
- Among the men seen at a multidisciplinary clinic, 43 percent selected active surveillance as their first-line form of management.
- Among the men seen by individual practitioners, 22 percent selected active surveillance.
- The proportion of men initially treated with radical prostatectomy or radiation decreased by approximately 30 percent.
- Several specific factors were significantly associated with selection of active surveillance as a first-line management option, including
- Older age (odds ratio [OR] =1.09)
- Unmarried status (OR = 1.66)
- Increased Charlson comorbidity index (OR = 1.37)
- Consultation at a multidisciplinary clinic (OR = 2.15)
While most men are still not being seen at multidisciplinary clinics today, there is a strong potential message here to patients — as well as to the clinical community. Of course it remains a fact that what patients may be told at a multidisciplinary clinic still depends on the knowledge, communication skills, and intent of the participating specialists.
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk, Treatment | Tagged: active surveillance, AS, consult, Multidisciplinary |
THE "NEW" PROSTATE CANCER INFOLINK 
I strongly recommend providing recognized multi-disciplinary prostate cancer clinics. Personally I prefer a listing in the Long Island/New York City area, but a wider geographic listing would be great. I recently had treatment using CyberKnife. Outcome is good so far, but there are some residual bowel issues (frequency). My urologist (private practitioner) recommended this. Three independent radiation oncologists also recommended treatment. I did not go to a medical oncologist. I believe my numbers were borderline active surveillance or treatment (Gleason 6/7;two independent pathological analyses), with tumor both sides of prostate. So I went for the treatment.
For 7 years, we ran a multi-disciplinary prostate cancer clinic in which the represented specialties were urology, radiation oncology, geriatrics, and psychiatry. We designed the clinic to care for a medically and psycho-socially complex and relatively ill patient population; we saw patients synchronously, as described in the article.
Were there differences in medical and psycho-social case mix between the synchronous and sequential care delivery models described? If so, does this explain the variations in the proportions chosen of active surveillance? In other words, were the patients who chose to see (or were to chosen to be seen) in the multi-disciplinary model generally sicker and is this the reason they deferred surgery, radiation, and the like? Is it possible that the synchronicity is actually irrelevant to the treatment variations described?
Arnon:
Other studies have also suggested (but not “proven”) that the “simultaneous” multidisciplinary model is more likely to offer a full and neutral discussion of all of the appropriate options for a specific patient than the “sequential” model, but I believe a great deal inevitably depends on who is in the room and what their mindsets are.
Even in the “simultaneous” model, if a “dominant” senior surgeon is present along with a young and relatively inexperienced radiation oncologist and a medical oncologist who doesn’t actually treat many patients with prostate cancer, I suspect that the message that the patients will hear is rather different than those they would hear if a team of mutually respectful specialists sets out to give patients the very best possible guidance.
Unfortunately, opinionated convictions often get in the way of giving people really good, actionable guidance. (Vide: the state of politics in the USA today.)
Neutrality is the not taking of a position. In our model, it was not that positions were not taken but that many were presented, at times conflicting. More ambivalence than neutrality.
At the heart of this is how patients are selected for which clinic. If the sick ones go to the multidisciplinary clinic, which is what we saw in ours, then it’s their health, not the composition of the clinic, that probably explains their choice to have active surveillance.