BackgroundWhen treating bladder cancer patients, the most significant problems usually concern cases with high-grade non-muscle-invasive carcinoma, and a better understanding of which patients would benefit from early radical cystectomy is urgently needed. The uropathology community is seeking more user-friendly approaches to distinguishing between T1 cancers exhibiting different types of clinical behavior.MethodsAfter a retrospective review, we selected a group of 314 patients who underwent transurethral resection of the bladder (TURB) and were diagnosed with high-grade urothelial carcinoma staged as T1. Three different substaging systems were applied: one was the anatomy-based T1 a/b; and two involved micrometric thresholds of either 0.5 mm of invasion (as proposed by van Rhijn et al.), or 1 mm of invasion (as proposed in the present study). Early reTUR (repeated transurethral resection) was performed in 250 patients, and the same substaging approaches were applied to cases of T1.ResultsIt proved feasible to apply the 1 mm substaging system in 100 % of cases, the van Rhijn system in 100 %, and the anatomy-based method (T1 a/b) in 72.3 % of cases. At a mean follow-up of 46 months, the recurrence-free survival rate was significantly better (p < 0.001) in the group that underwent reTUR, while none of the three substaging systems reliably predicted recurrences. The 1 mm did seem promising, however, as a threshold for predicting progression, reaching statistical significance in the Kaplan Meier estimates (p < 0.04).ConclusionOur study shows that micrometric substaging is feasible in this setting and should be extended to include any early reTUR to complete the substaging done after the first TURB. It can also provide helpful prognostic information.
Study Type – Therapy (decision analysis)
Level of Evidence 2b
What's known on the subject? and What does the study add?
The benefits of the multidisciplinary approach in oncology are widely recognised. In particular, managing patients with prostate cancer within a multidisciplinarity and multiprofessional context is of paramount importance, to address the complexity of a disease where patients may be offered multiple therapeutic and observational options handled by different specialists and having severe therapy‐induced side‐effects.
The present study describes the establishing of a multidisciplinary clinic at the Prostate Cancer Programme of Milan Istituto Nazionale dei Tumori, its effects on the quality of care provided, and strategies implemented to meet upcoming needs and improve quality standards. Having analysed the data of the 2260 multidisciplinary clinics held from March 2005 to March 2011, our dynamic and modifiable organisational model was evaluated for ways to optimise the human resources, offer high‐quality standards, meet new needs and ultimately reduce costs. The study is focused on the organisational aspects and adds a perspective from one of the major oncological centres of reference in Italy and in Europe.
OBJECTIVES
To describe the establishing of a multidisciplinary clinic for men with prostate cancer at the Istituto Nazionale Tumori, Milan.
To evaluate the quality of care provided and to describe the management changes implemented to improve standards and meet new needs.
MATERIALS AND METHODS
In March 2005, we established a multidisciplinary clinic comprising weekly clinics and case‐discussion sessions.
We have altered the organisational model periodically to meet new needs and improve quality.
RESULTS
We held 2260 multidisciplinary clinics up to March 2011.
For stage distribution, patients with low‐risk prostate cancer increased to a peak of 61% in 2009, probably because of the anticipation of diagnosis and the active surveillance expertise of the Prostate Cancer Programme at Istituto Nazionale Tumori, Milan. The slight decrease in 2010 might be due to the availability of robot‐assisted prostatectomy in several hospitals in Milan, and the start of a multicentre active surveillance protocol in December 2009.
In terms of the efficacy of our multidisciplinary strategy, 11% of drug therapies (mostly hormones) prescribed outside our institute were terminated in the multidisciplinary clinic, and 6% of indications formulated in the multidisciplinary clinics were altered during the case‐discussion sessions.
CONCLUSIONS
The multidisciplinary approach needs to be adaptable to meet new needs and improve quality.
Our experience has proved successful for both physicians and patients. The team agrees on strategies; complex cases are managed by a multidisciplinary team; dedicated psychologists contribute their knowledge and perspectives; and patients report the feeling of being cared for.
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