Integrating Care for Prostate Patients: Multidisciplinary Model Pioneered

Leonard G. Gomella, MD, professor and chair of the Department of Urology at Thomas Jefferson University, consults with Edouard J. Trabulsi, MD, far right, an associate professor and specialist in urologic oncology.

For patients diagnosed with localized prostate cancer, the good news is that a variety of treatment options are available. Yet that benefit can also be a stumbling block. To learn about potential therapies, men often must visit a series of doctors with different specialties, sometimes hearing divergent opinions about their care. Then, it’s up to the patients to weigh all the information as they choose a treatment that will forever affect their quality of life.

Leonard G. Gomella, MD, professor and chair of the Department of Urology at Thomas Jefferson University Hospital (TJU) in Philadelphia, noticed that pattern in the mid-1990s, and it occurred to him that there was a better way to handle such cases.

“Sometimes patients would see the surgeon on a Monday, the radiation oncologist on a Wednesday, and the medical oncologist on a Friday,” he said. “We thought that coordinating the care of these men might be something good to try.”

So Gomella and Richard K. Valicenti, MD, MA, then director of the Radiation Oncology Department’s genitourinary (GU) program, spent a year pilot-testing a multidisciplinary clinic for patients with prostate and other genitourinary cancers.

“Our model was that we were all in the same place at the same time evaluating the patients, discussing the patients, and sharing information,” Gomella said. As a result, he said, clinic doctors were able to collaborate to give each patient a definitive treatment recommendation in a single visit.

Seventeen years later, the clinic remains an important part of the way the hospital treats patients with GU cancers, and has served as a model for other departments there interested in providing multidisciplinary care.

Multidisciplinary Clinic Workflow

Telephone nursing interview

• Data requested

• MDs identified

• Info package mailed

• Visit scheduled

• Slides requested

Pathology review of submitted slides with report generated before visit

•Preclinic group meeting

with presentation

•Pathology slide review

•Protocol and treatment

options reviewed

• Individual social work meeting

• Review of other ancillary services (integrative medicine, etc)

• Physician evaluation based on nature of problem

• Imaging review

Clinical trials eligibility assessment

Urologic Surgical Oncology

Radiation Oncology

Medical Oncology

Real-time case discussion

Complex/ rare case tumor board review

Referral letter to physician

Treatment plan and/or additional evaluation

Follow-up call to patient 2-3 days after visit

Treatment scheduled at Kimmel Cancer Center

Adapted from Gomella LG, Lin J, Hoffman-Censits J, et al. Enhancing prostate cancer care through the multidisciplinary clinic approach: a 15-year experience. J Oncol Pract. 2010;6(6):5-10.

Results From the Clinic’s First Decade

Particularly in prostate cancer, for which new treatments are continually being developed, Gomella believes the multidisciplinary approach has become more important than ever.Launched in 1996, the GU clinic has been operating longer than any other clinic of its kind at a National Cancer Institute (NCI)-designated cancer center in the United States, according to leaders at the Kimmel Cancer Center at TJU. They shared the wisdom of their experience in a 2010 paper about outcomes for patients with prostate cancer (J Oncol Pract. 2010;6(6):e5-e10).

While the clinic also helps guide treatment decisions in those with urologic cancers including bladder and kidney cancers, 83% of its patients have prostate cancer. TJU’s 2010 analysis looked strictly at the program’s success in treating those affected by stage III or IV locally advanced prostate cancer, a population that constituted 11.5% of the 384 patients per year who visited the clinic for treatment advice between 1995 and 2006.

With the article, the cancer center became the first in the United States to publish peer-reviewed data demonstrating that such patients, in follow-ups of at least five years after their clinic visits, boasted survival rates that exceeded national averages, said Gomella, an author of the article.

Patients who were treated for T3 NO MO prostate cancer had a five-year survival probability of approximately .90 as compared with a likelihood nationally of about .79 (P = .0007 according to a log-rank analysis and .0012 according to a Wilcoxon analysis). For patients with T4 NO MO prostate cancer, the survival probability was .70 at 60 months as compared with an approximate .50 nationally (P = .0847 log-rank and .1073 Wilcoxon). A P value below .05 was considered statistically significant.

Leonard G. Gomella, MD

In the paper, Gomella et al posited several reasons for the survival improvement: “technical expertise from fellowship-trained urologic oncologists and robotically assisted surgeons, radiation oncologists with specific academic interest in [prostate cancer] supported by strong dosimetry and radiation physicists, appropriate medical management and other supportive care, patient education, and patient’s socioeconomic status.”

The authors added that “the close real-time interaction may more appropriately identify patients who may benefit from combined modalities such as radiation with hormonal therapy or postoperative adjuvant radiation therapy, or clinical trials. It is our belief that the coordination of care provided by the multidisciplinary team is a factor to strongly consider in assessing the reasons for improved patient outcomes.”

Measuring Patient Satisfaction

When it came to patients with stage I or II prostate cancer, meanwhile, clinic outcomes matched those reflected in national averages described in NCI Surveillance Epidemiology and End Results (SEER) data, with 10-year survival data approaching 100%.By administering a six-item questionnaire to patients, clinic leaders also found that most of the men they helped with treatment decisions considered the consultation experience “good” or “very good” and would recommend the program to others.

“We looked at parameters like wait time, whether patients felt they got good information, and whether treatment recommendations were reasonable, and our scores were generally above 90% to 93%, which is extraordinarily high,” Gomella said. “That tells us the patients were happy with the encounter.”

While TJU did not track the rate of treatment regret among its patients with prostate cancer, the authors of the paper pointed to other data supporting the idea that multidisciplinary care can protect patients from regretting their treatment choices.

A problem faced by prostate cancer patients, they wrote, is that there’s often a lack of definitive evidence supporting one mode of treatment over another. Citing two studies, the authors suggested that doctor specialty, rather than patient preference, frequently guides decisions about the treatment of the disease.

Complicating the matter is that there are so many treatment options available, Gomella said. Since the early 2000s, medical oncology has played a larger role as chemotherapeutic agents have been incorporated into the treatment of prostate cancer; robotically assisted laparoscopic prostatectomy has been added to the list of surgical options; and radiation therapy has evolved to include brachytherapy and the use of fiducial markers to track patients who are getting external beam radiation, he said.

A Barometer of Change in GU Cancer Care

A multidisciplinary setting can help patients navigate that confusing landscape, Gomella and his colleagues wrote. They said that a primary goal of the multidisciplinary GU cancer clinic approach “is to provide this balanced information in an open and interactive fashion, with all clinical specialists present at the same time,” they wrote. “Shared decision making through a discussion with different specialists about the risks and benefits of each treatment can decrease distress and posttreatment regret.”Between 2000 and 2009, changing trends in the treatment of prostate cancer became evident within TJU’s clinic, according to the authors.

One example, they wrote, is that patients to be treated with radiation therapy became slightly more likely to choose external beam radiation over brachytherapy. In 2000, about 60% of such patients chose external beam radiation; in 2009, about 85% chose it, the authors explained.

A bigger change has occurred among patients who opt for radical prostatectomies; in recent years, patients have become much more likely to choose robotically assisted surgery, Gomella said.

In 2005, when the procedure was relatively new, about 5% of clinic patients who opted for radical prostatectomy chose the robotically assisted procedure, according to the paper. The very next year, 65% of such patients chose the new technology, and by 2009, that number had jumped to about 90%.

“It’s been a nationwide trend since about 2001, when the da Vinci Surgical System got approved, and there’s been a gradual increase in the number of patients who undergo it,” Gomella said. “In the literature, the risks and benefits of the different forms of radical prostatectomy are debated, and so this is really driven by patients, who view it as more minimally invasive. Clearly, it has some advantages—in the first 24 hours there’s less blood loss, and the likelihood of discharge from the hospital 12 to 24 hours sooner—but at the end of the day, radical prostatectomy is about disease control and quality of life, and the debate is whether the expense of the robot is worth it when you look at the long-term results not being that different.”

Thomas Jefferson University Hospital in Philadelphia, above, offers the genitourinary cancer clinic in an outpatient facility.

Yet another change has been a shift in the composition of the patient population at the clinic, which typically sees between 600 and 700 patients with GU cancers each year. While the number of patients with bladder cancer has been rising, there’s been a drop in the number of patients with prostate cancer, Gomella said.

At the Forefront of a Trend

“Recently, there have been some stark decreases in the frequency of screening and biopsy for prostate cancer nationwide,” the doctor said, “so over the 2012-2013 calendar year we’re seeing a dropoff of 15% to 20% of our prostate cancer patients.”In addition to reflecting nationwide changes in the approach to prostate cancer treatment, TJU’s clinic has been at the forefront of a growing trend toward multidisciplinary care. Since it opened its doors, numerous other multidisciplinary clinics have sprung up.

Within TJU alone, seven have been spawned since the GU clinic was launched.

“The brain tumor center is a tremendous example of patients interacting with not only surgeons and radiation oncologists, but medical oncologists,” Gomella said. “We’ve also spun off a small renal mass program that focuses on patients who may not need major surgery or chemotherapy or other agents for kidney cancer, and they come into a small renal clinic where they’re seen by interventional radiologists, as well as the urologic surgeons, to discuss management.”

TJU’s remaining multidisciplinary clinics focus on breast cancer, senior adult oncology, lung cancer, gynecology, and gynecologic oncology

Outside TJU, multidisciplinary clinics focused on breast cancer are the most common, Gomella said. But, more and more, he said, GU clinics are also appearing.

Notable multidisciplinary clinics focused on GU cancers include those at The University of Texas MD Anderson Cancer Center; Walter Reed National Military Medical Center in Maryland; and Duke Cancer Institute at Duke University Medical Center in North Carolina, Gomella said.

Other cancer centers with NCI designation that operate multidisciplinary GU clinics include the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University in Maryland; the Arizona Cancer Center at the University of Arizona; the University of Michigan Comprehensive Cancer Center; and the Oregon Health & Science University Knight Cancer Institute. And there are clinics at additional medical centers around the country, including William Beaumont Hospital in Detroit, Michigan.

While some clinics employ the same strategies as TJU’s, Gomella cautioned that not all clinics that bill themselves as multidisciplinary actually fit that description.

“A lot of places say they do it, but really only a handful in the United States have all the doctors there at the same time and place interacting with patients,” he said.

The Structure of the Clinic

In Europe, though, the strategy “is becoming very popular,” Gomella added. “They’re developing centers of excellence and promoting these prostate centers as a way of bringing the best care to patients with prostate cancer.”TJU’s clinic takes place in the Bodine Center for Radiation Therapy in Center City Philadelphia, a clean, modern outpatient space that, on a rotating basis, also houses other hospital clinics.

Patients usually end up in the clinic, which is decorated with framed medical school diplomas and magazine articles about its doctors, for one of two reasons: to seek an initial decision about how to treat their disease, or to get a second opinion about a proposed treatment.

About half the patients are diagnosed by the hospital’s doctors, while the rest are referred by physicians within a 150-mile radius. Ultimately, about 90% end up carrying out their treatment plans at TJU. They return to the clinic, Gomella said, only if they need to decide on additional treatment plans as issues arise related to their disease.

During a visit, “the patient stays in one room, and all the different specialists and ancillary personnel, such as social workers, nutritional therapists, and clinical trial coordinators, come and see the patient,” Gomella said. Families are invited to be present for all appointments as “an extra set of ears,” the doctor added.

That’s especially helpful because patients see so many different experts, Gomella said. While just eight to 12 patients per day are seen in the clinic, that translates into 30 or 40 encounters, he said.

The clinic is typically staffed by about 14 or 15 people, including six physicians; one or two nurse coordinators; one or two physician extenders, such as physician’s assistants or nurse practitioners; and a handful of residents and fellows, since the clinic “is very core to our educational mission as an academic medical center,” Gomella said.

In addition, he said, “social workers have a quick talk with patients, determining what their status is and how they are from an insurance coverage or support network standpoint.”

Beyond that, the clinic offers a buddy system, Gomella said, “a very robust system of patients who have had different treatment options. If the patient would like to talk to somebody, we will match them up with someone close to their age and demographic who had the same treatment and has been formally trained with us.”

Finally, clinical trial protocol coordinators participate in a meeting that precedes every clinic, during which doctors review patients’ pathology reports and discuss treatment options.

Instituting Multidisciplinary Care

“There’s always a discussion of what potential clinical trial they’d be eligible for,” Gomella said, “and we get several clinic patients a week onto important NCI Cancer Center-designated clinical trials.”Of course, launching a multidisciplinary clinic isn’t easy, Gomella pointed out.

“Some may say it’s not an efficient use of the doctors’ time, because as opposed to seeing four or five new patients in the clinic in the morning, I may be able to see 10 or 12 on my own. However, when you step back and look at the benefits, they are enormous: convenience for the patient, educational value not only for families but for our trainees, fellows, and residents, and recruitment to clinical trials.”

To make it happen at any institution, he said, leaders must pledge their strong support in terms of making space and staffing available.

Instituting the idea in community settings can be even trickier, he said.

“If there’s a multidisciplinary clinic in the neighborhood, referring patients there is a very important thing for community oncologists to do,” Gomella said.

If a clinic doesn’t exist locally, he said, physicians can integrate elements of the idea into their practices. That should involve the establishment of partnerships between medical and radiation oncologists at local cancer centers and urologic surgeons in private practice, Gomella said.

“It’s important for everyone to understand that the management of prostate cancer is becoming a continuum of care, so medical and radiation oncologists should reach out to their surgical colleagues; likewise, the surgeons out there may improve patient satisfaction and outcomes through early referral to a medical or radiation oncologist,” he said. “In a community setting, the model of getting together with the other disciplines is something that usually takes a champion. Somebody has to be proactive.”

Looking Ahead

When there’s no multidisciplinary care available, Gomella added, patients can be their own advocates. “There are many good online resources patients can visit, like the National Cancer Institute and the American Cancer Society,” he said. “If a patient can’t find a multidisciplinary approach to their disease, they can at least educate themselves about the different treatment options, so they’re well-prepared when they go in for discussion with their surgeon, radiation oncologist, or medical oncologist.”Seventeen years after they launched TJU’s multidisciplinary GU program, and three years after they first published data, clinic leaders are planning a more detailed analysis of what their efforts have meant to patients, doctors, and the cancer center.

“We’re trying to take a deeper dive into our data to look at why there was such a difference among patients with stage III or IV advanced prostate cancer when you compare their outcomes to national standards,” Gomella said. “We’ll look at how many got CTs and how many were treated with adjuvant radiation or neoadjuvant hormones. In the next year or two, we’ll also try to look at true 10-year survival data, and to analyze treatment regret.”

Gomella, shown here in the genitourinary cancer clinic at Thomas Jefferson University Hospital, believes a multidisciplinary approach to treatment holds the potential for cost savings.

Finally, the cancer center hopes the numbers will show that its multidisciplinary clinic is more efficient than a traditional approach—a trend that would likely appeal to health insurers, the doctor said.

“When patients see all the doctors together,” he said, “we don’t order unnecessary tests. There’s a consensus on what’s the best imaging or blood test, instead of having everybody independently pick their own, so there may be some potential for cost savings.”

While most health insurers cover the services provided in the multidisciplinary clinic, Gomella said, occasionally an insurer doesn’t recognize the value of that setting.

“At that point, we go ahead and offer the care to the patient regardless of whether or not we get reimbursed,” he said.

But Gomella said that the worth of his clinic, and others like it, is becoming more widely understood.

He pointed out that Independence Blue Cross has named TJU a Blue Distinction Center for Complex and Rare Cancers, noting that bladder cancer is an area of expertise there.

“One reason is because of this multidisciplinary approach to things like bladder cancer,” Gomella said. “It is recognized that this strategy can help improve outcomes in some cancers.”