New Approach to Prostate Cancer Care Draws Patients with Riskiest Disease
In choosing where they get treatment, prostate cancer patients tend to opt for a major cancer center if they have severe disease, but stick closer to home for less complicated cases, even when offered a model of care that taps numerous experts.
The findings by Duke Cancer Institute researchers, published in the January issue of the Journal of Urology, are the first large analysis of the so-called multidisciplinary care strategy that gives prostate cancer patients access to a surgeon, a medical oncologist, and a radiation oncologist -- all in a single visit.
The care team then decides as a group what's best for the patient, easing the bias for any one specialty.
Such multidisciplinary care has been common in Europe and is often used in the United States for breast and lung cancers, but it can be expensive and difficult to structure outside of large, sophisticated hospitals.
The approach may be increasingly useful as prostate cancer patients now face a complex array of treatment options, including different surgical methods, radiation therapies, and active surveillance.
"Optimum management of prostate cancer continues to be controversial and not well defined," said lead author Suzanne B. Stewart, MD, a urology resident in the Duke Prostate Center. "With so many options, it can leave patients with uncertainty and distress."
Stewart said the Duke team set out to determine whether the multidisciplinary approach could be a viable model of care for hospitals and community doctors, providing prostate cancer patients more standardized, less fragmented information. Figuring out how patients are drawn to the multidisciplinary model, and who then stays for treatment, is an important step in expanding the services beyond big cancer centers.
The Duke physicians studied two groups from 2005 to 2009, including 701 patients who sought an evaluation at Duke's multidisciplinary prostate cancer clinic, and 1,318 who accessed care in the hospital's traditional urology prostate cancer center or genitourinary oncology clinics.
In the multidisciplinary clinic, which is generally offered once a week, the men seeking evaluations tended to be younger, white, more affluent, and live further away than Duke's typical prostate cancer patients. Sixty-one percent of the men sought the clinic on their own, rather than through a doctor who referred them because they had a difficult case.
But those patients often didn't stick around to undergo treatment. About 42 percent of the multidisciplinary clinic patients took the expert advice and then opted for treatment closer to home, especially if they had low-risk disease. As a result, those who actually got multidisciplinary care were sicker, and were demographically similar to typical Duke prostate cancer patients -- younger, black, lower income, and living nearby.
Stewart said that finding raises questions about access to multidisciplinary care for many prostate cancer patients. Poorer men who lived more than 100 miles from the clinic were less inclined to travel for the evaluation and treatment in the model program, particularly if they weren't referred by a physician.
Judd W. Moul, MD, senior author of the study, said spreading the multidisciplinary approach beyond major hospitals and cancer centers remains a costly proposition that could be an impediment to removing barriers to care.
"From the patient perspective, it's a wonderful opportunity to get an in-depth education about the disease, but it's difficult for many health systems to do something like this, considering the time commitment of multiple cancer specialists needed at the same time for the clinic," Moul said. "In light of multitude new treatments that have been approved in the last two years for advanced prostate cancer, it is critical to embrace the multi-D concept so that patients can become acclimated to the total care team earlier in their disease course."
W. Robert Lee, MD, MEd, a radiation oncologist and co-author of the study, agreed that new treatment choices have complicated the decision process for patients. "Prostate cancer is a disease with many options for treatment," Lee said. "It is our hope that this format allows patients to make wise decisions on what treatment is best for them."
The Duke team is now exploring whether patients fare better in multidisciplinary clinics than in regular care. For many of the physicians who have participated in the multidisciplinary approach, the treatment model has already proved useful.
"What I've learned from practicing in our multidisciplinary environment has helped me make better decisions for my patients," said Daniel J. George, MD, director of genitourinary medical oncology.
In addition to Stewart, Moul, Lee and George, study authors included: Lionel L. Bañez; Cary N. Robertson; Stephen J. Freedland; Thomas J. Polascik; Donghua Xie; Bridget F. Koontz; Zeljko Vujaskovic; Andrew J. Armstrong; Phillip G. Febbo.
Funding for the study was provided by the Committee for Urologic Research, Education and Development at Duke University. The study authors reported no conflicts of interest.