The 6‐year attendance of a multidisciplinary prostate cancer clinic in Italy: incidence of management changes

Abstract

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.

Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes

“…Whereas inward responsibilities consisted of scheduling agendas for meetings, drawing up the list of patients to be discussed, ensuring that all necessary tests were obtained and available in advance of the discussion, and recording the MDT decisions and rationales agreed [34,38,42,45,46], outward tasks entailed communicating decisions to patients/families, GPs, providers and referring physicians, as well as coordinating outpatient visits and referrals from satellite centres, and facilitating the link to research either directly or by improving liaison with the clinical trial coordinator [24,32,34,38,42,43,53,54]. Other studies documented the role of clinical nurses in guiding the patient through the care pathway or assuming the task of coordinating the follow-up [29,40,42,43,45,47,[53][54][55][58][59][60][61]63]. The main responsibilities fulfilled by nurses were: providing psychosocial support and education to the patient; managing treatment-related toxicities and side-effects; coordinating services (diagnostic and treatment agenda); facilitating liaison with external support services; managing patient transition across the cancer network; and acting as a focus of communication between team and patient.…”

“…Several papers differentiated team composition by identifying three levels of involvement, i.e., "core", "allied" (or "extended") and "expert support" membership. Core and allied members included radiologists, pathologists, surgeons, radiation and medical oncologists, oncology nurses, palliative care physicians, head and neck specialists, nuclear medicine specialists, respiratory disease physicians, gastrointestinal disease physicians and anaesthesiologists, some of whom were frequently sub-specialised by tumour site [20,29,30,[32][33][34]42,43,45,52,53]. The support members included psychologists, nutritionists, dieticians, plastic surgeons, speech therapists, patients' GPs, physiotherapists, practitioners of complementary medicine, orthopaedic specialists, medical physicists, odontologists, faith counsellors, biologists, data managers, genetic counsellors, hospital pharmacists, social workers and occupational therapists [24,27,40,45,49,54,55].…”

“…The studies documented two motivating principles: firstly, MDTs ensure more appropriate treatment through a preoperative review of imaging and pathology results [19,20,22,25,26,40,42]; and secondly, a multidisciplinary approach guarantees the most up-todate treatment for all cancer patients seen at the facility or discussed online [16,18,21,23,32,33,35,[38][39][40][41]53]. Other clinical-based goals included improving patients' quality of life [24,32,42,[53][54][55] and setting up a structured followup care plan [53,[59][60][61].…”

“…Firstly, there were meetings, which lasted anywhere from 30 min to 2 h and included either all or a selection of diagnosed and/or referred patients; patients were selected by the specialist in charge based on the case's level of complexity or the wide range of therapeutic possibilities, prearranged team criteria, or triage by the clinical coordinator [27,30,[32][33][34]46,48,50]. A second MDT format was the multidisciplinary clinic, where patients were not only seen but also simultaneously examined [16,38,40,53,54] or remotely coordinated by all board members [42]. Finally, online conferences made use of specific web-based software to organise and conduct online tumour board meetings among clinicians within a given hospital [16] or nationwide [18].…”

“…Nonetheless, an analysis of the studies allowed the differentiation between 'inward' responsibilities (MDT organisation and efficient direction) and Harrison [45] Lanceley [46] Soukop [47] Choy [48] Chirgwin [49] Scher [ Wilcoxon [52] Magnani [53] Hudak [54] Wiederholt [55] Maslin-Prothero [56] Kuroki [57] Sweeney [58] Brennan [60] Jefford [61] Hong [62] Jones [63] Bellardita [64] Mandate adapted from Wright et al [12] 'outward' responsibilities (clinical management of the care plan). Whereas inward responsibilities consisted of scheduling agendas for meetings, drawing up the list of patients to be discussed, ensuring that all necessary tests were obtained and available in advance of the discussion, and recording the MDT decisions and rationales agreed [34,38,42,45,46], outward tasks entailed communicating decisions to patients/families, GPs, providers and referring physicians, as well as coordinating outpatient visits and referrals from satellite centres, and facilitating the link to research either directly or by improving liaison with the clinical trial coordinator [24,32,34,38,42,43,53,54]. Other studies documented the role of clinical nurses in guiding the patient through the care pathway or assuming the task of coordinating the follow-up [29,40,42,43,45,47,…”