Supportive Care in Cancer

, Volume 21, Issue 8, pp 2327–2333

Multidisciplinary care in patients with prostate cancer: room for improvement

Authors

  • Räto T. Strebel
    • Department of UrologyKantonsspital Graubünden
  • Tullio Sulser
    • Department of UrologyUniversity Hospital Zurich
  • Hans-Peter Schmid
    • Department of UrologyKantonsspital St. Gallen
  • Silke Gillessen
    • Department of OncologyKantonsspital St. Gallen
  • Martin Fehr
    • Department of OncologySouthampton University Hospital
  • Urs Huber
    • Medical OncologyKlinik im Park
  • Miklos Pless
    • Department of OncologyKantonsspital Winterthur
  • Rudolf Morant
    • Tumor Center ZeTuP
  • Ralph Winterhalder
    • Department of OncologyKantonsspital Luzern
    • Department of Medical OncologyKantonsspital Graubünden
Original Article

DOI: 10.1007/s00520-013-1791-x

Cite this article as:
Strebel, R.T., Sulser, T., Schmid, H. et al. Support Care Cancer (2013) 21: 2327. doi:10.1007/s00520-013-1791-x

Abstract

Purpose

New multimodality treatment approaches for prostate cancer require multidisciplinary management of patients. We aimed to assess the current practices of multidisciplinarity and their possible implications in treatment management in Switzerland.

Methods

In a survey, urologists and medical oncologists in Switzerland were asked to include at least 25 or 15 consecutive patients with the diagnosis of prostate cancer, respectively. Information about treatment patterns and multidisciplinary parameters of these patients was collected retrospectively.

Results

Thirty-seven urologists and 20 oncologists from the French- and German-speaking parts of Switzerland representing 7 out of 11 non-university tertiary centres and 20/10 % of all office-based urologists/oncologists in Switzerland collected data on 1,184 patients. Sixty-five percent of the office-based (16/24 urologists; 6/10 oncologists) and 95 % of the hospital-based (10/11 urologists; 8/8 oncologists) physicians participate in multidisciplinary tumour boards (MTBs). However, only 1.5 % of patients with a new diagnosis of prostate cancer (13 of 883) are discussed at a MTB. Overall, second opinions at diagnosis are requested in 23 % of patients, mainly from radiation oncologists (8.4 %) or fellow urologists (7.4 %). Second opinions are more often requested by urologists who participate at MTBs and in case of advanced stage.

Conclusions

Participation at MTBs is high among Swiss urologists and oncologists in private practice and at non-university tertiary centers. In spite of that only a small minority of patietns with prostate cancer are presented at MTBs.

Keywords

Disease managementHealth care surveyInterdisciplinary communicationProstate cancer

Introduction

Prostate cancer is the most common solid tumour in men and the second most common cause of cancer death in Switzerland accounting for approximately 5,600 new cases and 1,300 deaths each year, respectively (http://assets.krebsliga.ch/downloads/krebszahlen_11_2009_d.pdf). Prostate cancer is a very heterogenous malignancy, and severity ranges from indolent to very aggressive [1]. The majority of newly diagnosed cases are clinically localised, and therefore, even with conservative management, a better outcome than three or four decades ago can be expected [2]. Substantial variation is found in the management of localised and locally advanced prostate cancer [3, 4] despite the fact that international guidelines are very comprehensive and regularly updated [5, 6]. For localised prostate cancer, both undertreatment of patients with high-risk disease and overtreatment of low-risk disease have been described [1, 710]. For metastatic castration-resistant disease, several new treatment options have recently shown improvement of overall survival, and palliative treatment has improved much [1114].

It is generally agreed nowadays that the multidisciplinary management of patients with cancer provides the best opportunity to optimize the outcome of patients and provide the best care according to existing guidelines [1517].

In the past few years, the multidisciplinary approach has also gained acceptance in the treatment of prostate cancer, and a recent report could demonstrate an improvement in survival for patients managed with multidisciplinary counselling [18, 19]. In Europe, requirements for specialised prostate cancer units have been proposed in 2011 clearly defining the need for a multidisciplinary approach by a team of specialists in prostate cancer care [20]. A basic requirement is the obligation to present and discuss all newly diagnosed patients with prostate cancer at the multidisciplinary tumour board (MTB) irrespective of their tumour stage.

In Switzerland, MTBs have been established in most hospitals and networks of private practices over the last years reflecting that multidisciplinary management of cancer patients in general has gained wide acceptance. However, no data exist on multidisciplinary management and on the use of MTBs for patients with prostate cancer in Switzerland. Thus, this survey was performed to assess the current practice of multidisciplinarity and its possible implication in the management of prostate cancer patients in Switzerland.

Methods

The survey was designed as an observational study. Board-certified Swiss urologists and oncologists in private practice or hospital based were asked to include 25 patients (urologists) or 15 patients (oncologists) with the diagnosis of prostate cancer. All departments of urology and oncology of the university hospitals and of secondary and tertiary care centres as well as office-based urologists and oncologists from all different cantons of Switzerland except Italian-speaking Ticino were approached for participation. Patients should be included consecutively within 1 month. No exclusion criteria were defined. Standardised online case report forms in German and French were used to retrospectively collect data on patient characteristics, detailed tumour characteristics, information on treatment and multidisciplinary parameters such as participation in multidisciplinary tumour boards (consisting of at least a urologist, medical oncologist, radiation oncologist, pathologist, radiologist and optionally a specialist in nuclear medicine) and referral for second opinion. The questionnaires were structured in three parts: (1) information about the physician filling out the questionnaire, (2) information about management at diagnosis including presentation at MTB and (3) in case of disease progression (local or systemic) information on further management.

The following baseline data were requested: PSA value, detailed TNM stage, Gleason score and Eastern Cooperative Oncology Group (ECOG) performance status at diagnosis. All physicians were asked whether they participate at multidisciplinary tumour boards or not. All physicians were asked to provide information about the primary therapy of prostate cancer including multidisciplinary management (presentation at MTB, second opinion). For oncologists, additional information related to the referring physician (urologist, radiation oncologist, general practitioner, self-referral), time point of referral and patient baseline characteristics at the time of referral as well as treatments initiated by the oncologists were requested. Urologists were asked if they had obtained a second opinion and if so from whom and at which time point of disease.

The data were entered into a central database. Statistical analyses were performed using chi-square test, Fisher's exact test and chi-square test for independence with the help of GraphPad InStat 3.1a computer software (GraphPad Software Inc., CA, USA). A p value <0.05 was considered statistically significant.

Results

The survey was performed in Switzerland from July 2009 to February 2010. Thirty-seven urologists (9 hospital based, 28 private practice) and 20 oncologists (7 hospital based, 13 private practice) from the French- and German-speaking parts of Switzerland agreed to take part in the survey. In total, 48 % of the approached centres (16 of 33) and 56 % of the approached private practitioners (41 of 73) agreed to participate in the survey. Out of 26 Swiss cantons, 19 cantons are represented in the survey. Of all Swiss private practice-based urologists and oncologists, 20 and 10 %, respectively, participated. The hospital-based physicians represented each one centre including 7 out of 11 of the largest non-university tertiary centres (>350 beds per hospital) in Switzerland. No physicians from one of the five university hospitals agreed to take part in the survey. Retrospective data from 1,184 patients (949 from urologists and 235 from oncologists) were entered into the database. The median age of patients at the time of diagnosis was 67 years (range, 38–92). Median initial PSA value at diagnosis was 8.9 ng/ml (range, 0.4–4,603 ng/ml) for patients documented by urologists and 28.5 ng/ml (range, 0.1–40,000 ng/ml) for those seen by oncologists. TNM stage and Gleason score at presentation are shown in Fig. 1. In general, patients seen by oncologists have more advanced disease at diagnosis.
https://static-content.springer.com/image/art%3A10.1007%2Fs00520-013-1791-x/MediaObjects/520_2013_1791_Fig1_HTML.gif
Fig. 1

a Tumour stage and b Gleason score at diagnosis of patients seen by urologists (purple) or oncologists (green)

Primary treatment for localised prostate cancer

Analysis of the primary treatment is based on patients entered into the database as clinical stage Tany, N0 or Nx, M0 or Mx, i.e. without proven evidence of lymph node or distant metastases and hence localised disease. Out of 1,184 patients, 988 presented initially with localised disease. Three percent of them had been first diagnosed with prostate cancer before 1997, 36 % in the years 1997–2006 and 61 % in the years 2007–2009. The treatment patterns were analysed according to D'Amico risk groups (Table 1) and age (Table 2). The majority of patients with low- and intermediate-risk prostate cancer undergo radical prostatectomy, whereas the frequency of external beam radiotherapy shows an increase with risk category. Radical prostatectomy is more frequently performed in younger patients, whereas the percentage of radiotherapy, watchful waiting and androgen deprivation therapy (ADT) increases with age. Only 1.9 % of patients have been treated with brachytherapy. The influence of age on treatment according to D'Amico risk groups is demonstrated in Fig. 2. The results show that only very few elderly patients >75 years are having a radical prostatectomy but are much more often treated with radiotherapy, ADT or simply watchful waiting.
Table 1

Distribution of primary therapies according to D'Amico risk groups

 

Low risk

Intermediate risk

High risk

n (%)

n (%)

% (n)

Radical prostatectomy

124 (50.8)

246 (61.8)

94 (31.6)

Watchful waiting

44 (18.0)

60 (15.1)

48 (16.2)

Percutaneous radiotherapy + ADT

5 (2)

25 (6.3)

46 (15.5)

ADT

2 (0.8)

13 (3.3)

60 (20.2)

Percutaneous radiotherapy

13 (5.3)

34 (8.5)

27 (9.1)

Active surveillance

42 (17.2)

8 (2.0)

4 (1.3)

Brachytherapy

14 (5.7)

4 (1.0)

0 (0)

Radical prostatectomy + percutaneous radiotherapy + ADT

0 (0.0)

3 (0.8)

12 (4.0)

Radical prostatectomy + ADT

0 (0)

5 (1.3)

6 (2.0)

Total

244 (100.0)

398 (100.0)

297 (100.0)

Table 2

Distribution of primary therapies according to age

 

<65 years

65–75 years

>75 years

n (%)

n (%)

n (%)

Radical prostatectomy

259 (64.9)

213 (46.4)

8 (6.2)

Watchful waiting

45 (11.3)

69 (15.0)

42 (32.3)

Percutaneous radiotherapy + ADT

17 (4.3)

47 (10.2)

17 (13.1)

ADT

10 (2.5)

28 (6.1)

46 (35.4)

Percutaneous radiotherapy

14 (3.5)

49 (10.7)

13 (10.0)

Active surveillance

17 (4.3)

35 (7.6)

4 (3.1)

Brachytherapy

13 (3.3)

5 (1.1)

0 (0.0)

Radical prostatectomy + percutaneous radiotherapy + ADT

15 (3.8)

8 (1.7)

0 (0.0)

Radical prostatectomy + ADT

9 (2.3)

5 (1.1)

0 (0.0)

Total

399 (100.0)

459 (100.0)

130 (100.0)

https://static-content.springer.com/image/art%3A10.1007%2Fs00520-013-1791-x/MediaObjects/520_2013_1791_Fig2_HTML.gif
Fig. 2

Analysis of the distribution of the primary therapies according to age and D'Amico risk groups

Referral to medical oncologists and treatment patterns of advanced stage prostate cancer

A total of 235 patients were entered by oncologists. The patients were referred to the medical oncologist in 48 % of the cases by urologists; another 48 % were referred from general practitioners and only 4 % from radiation oncologists. Indications for referral were to obtain a second opinion before (12 %) or after primary treatment (13 %), PSA failure after primary treatment (23 %), new metastases in untreated patients (12 %), PSA increase (16 %) or newly diagnosed metastases with ongoing ADT (23 %). Only 44 % of patients had a normal ECOG performance status (PS) at referral, 35 % had PS 1 and 21 % PS 2 or 3. At referral, 122 patients (52 %) had metastases or presented with castration-resistant disease.

Use of MTBs and multidisciplinarity

The majority of physicians in this survey participate in a MTB, including 65 % of office-based (16 out of 24 urologists and 6 out of 10 oncologists) and 95 % of hospital-based (10 out of 11 urologists and 8 out of 8 oncologists) doctors. Complete datasets of 883 patients recorded by urologists (out of 949) are available for evaluation of multidisciplinarity (recorded TNM stage, second opinion including MTB). The treating urologists presented 13 out of 883 patients (1.5 %) with primary diagnosis of prostate cancer at a MTB. Ninety-four percent of these 883 patients had localised disease (N0/x and M0/x). Overall, second opinions were requested at diagnosis by urologists in 204 of 883 patients (23 %): 8.4 % from radiation oncologists, 7.4 % from urologists, 3.5 % from non-specified other health care professionals (most likely general practitioner of the patient) and in 1.4 % from medical oncologists. The threshold for obtaining a second opinion is lower in case of participation of the physician at a MTB and in case of advanced disease, and this is statistically significant (Table 3). Treatment patterns for localised prostate cancer with respect to participation of urologists at MTBs are shown in Table 4.
Table 3

Second opinion obtained at diagnosis according to participation of urologist at MTB

N and M stage

No participation at MTB (N = 224)

Participation at MTB (N = 659)

p value

Mx/M0/Nx/N0 (N = 826)

20 of 204 (9.8 %)

165 of 622 (26.5 %)

<0.0001

M1/N1 (N = 57)

3 of 20 (15 %)

16 of 37 (43.2 %)

0.041

All patients (N = 883)

23 of 224 (10.3 %)

181 of 659 (27.5 %)

<0.0001

Table 4

Treatment patterns of localised prostate cancer depending on participation of urologists at MTBs

N0/M0/NX/MX

No participation at MTB, n (%)

Participation at MTB, n (%)

p value

Radical prostatectomy

103 (50.5)

335 (53.2)

0.50

Watchful waiting

32 (15.7)

114 (18.1)

0.43

Percutaneous radiotherapy + ADT

5 (2.5)

50 (7.9)

0.005

ADT

26 (12.7)

29 (4.6)

0.0001

Percutaneous radiotherapy

19 (9.3)

49 (7.8)

0.47

Active surveillance

7 (3.4)

42 (6.7)

0.12

Brachytherapy

9 (4.4)

9 (1.4)

0.02

Radical prostatectomy + percutaneous radiotherapy + ADT

1 (0.5)

2 (0.3)

NA

Radical prostatectomy + ADT

2 (1.0)

0 (0.0)

NA

Total

204 (100)

630 (100)

 

Discussion

The results of this survey reveal that presentation of patients with newly diagnosed prostate cancer at multidisciplinary tumour boards is minimal (1.5 % of all patients) despite very high participation of the involved physicians at MTBs. Taking into account all forms of second opinions at diagnosis, the percentage rises to 23 %. One wonders if these intriguing results truly reflect the situation in Switzerland at the time the survey was conducted.

What may be the reasons for the results achieved? Certainly this survey has several biases that need to be discussed: First, clearly, a survey is not an ideal instrument to give insight into details of practice patterns but rather provides a broad overview. Small differences can therefore not be given much attention; large differences, however, need to be explained even in this setting. Second, it is important to realize that the data were collected retrospectively, and of the patients included, 40 % were diagnosed and treated before 2007. However, assessment of practice patterns is usually performed in a retrospective manner as collecting such data prospectively might by itself induce a bias and lead to practice changes. Third, more urologists than oncologists were questioned, and radiation oncologists and general practitioners were not involved in the survey. On the other hand, in Switzerland, urologists are in nearly 100 % of cases the specialists who diagnose prostate cancer, and therefore, it was important that the survey included more urologists. Fourth, we can also be criticised for not including a larger number of oncologists and urologists and not succeeding in motivating the university hospitals to take part. University hospitals have in many cases been frontrunners in the multidisciplinary care. However, most patients in Switzerland with prostate cancer are diagnosed and treated outside of the five university hospitals. By including 20 % of all practice-based urologists and the majority (64 %) of all non-university tertiary centres (hospitals with >350 beds), after all, a fair number of health professionals involved in the treatment of prostate cancer in Switzerland participated. Finally, it might be that some of the questions concerning second opinion were misleading.

Even when taking the limitations of this survey into account, there remains a large discrepancy between participation of physicians at MTBs and presentation of patients with prostate cancer at diagnosis, leaving at least some questions. Why should multidisciplinary care in prostate cancer be promoted? On the one hand, treatment of prostate cancer, localised or advanced, has undergone many changes recently and has become more complex necessitating the impact of different specialities: for instance, in low-risk disease, active surveillance has been introduced into clinical practice [21, 22]. In the setting of high-risk disease, multimodality treatments (such as combination of ADT with external beam radiation therapy or adjuvant radiotherapy after radical prostatectomy for locally advanced disease) have been shown in randomized controlled trials to demonstrate higher efficacy [23, 24]. On the other hand, treating patients within trials to enhance our knowledge and improve the quality of treatment is of utmost importance and only possible with closer collaboration between urologists and medical oncologist as has been stated [25].

But is there an impact of multidisciplinary care on outcome of patients with prostate cancer? In fact, there are not many reports on patients' outcomes after multidisciplinary management in general. In prostate cancer, Gomella et al. reported as recently as in 2010 for the first time a possible improvement of survival due to multidisciplinary management in their clinic [19]. The impact was more pronounced for patients with T3 tumours with a statistically significant improvement in 5-year survival as compared with Surveillance Epidemiology and End Results (SEER) data.

In our survey, the patient characteristics at diagnosis in terms of median age and initial PSA values reported are very similar to data published based on the SEER and CaPSURE database [8, 26, 27]. Likewise, our results reveal similar treatment patterns as in recently published studies demonstrating that radical prostatectomy is the predominantly performed primary treatment in patients with localised prostate cancer, followed by external beam radiation therapy [3, 26]. However, we found that a majority of patients with low-risk disease are treated actively instead of considering active surveillance, possibly leading to a certain degree of overtreatment. In contrast, there appears to be an undertreatment of patients with high-risk disease mainly in patients treated with external beam radiation where only a minority receives additional ADT. When taking into account participation of the treating physician at MTBs, we could show that patients were significantly more likely to receive combined modality treatment if their treating physician participates at a MTB. There was also a trend for increased use of active surveillance. This is in concordance with the results of a recent study that demonstrated a significant increase in the use of active surveillance for patients with low-risk disease if they were seen in a multidisciplinary setting [28].

Conclusions

We conclude that certainly there is room for improvement in the multidisciplinary management of patients with prostate cancer in Switzerland given the results of this survey acknowledging its limitations. However, we feel that since this survey was conducted, the landscape in Switzerland has undergone several changes with increased awareness for the topic and improved communication between urologists and oncologists. This has certainly also been promoted by the publication of requirements for specialist prostate cancer units necessitating improved multidisciplinary structures. We are hopeful that this process is continuing, and we plan to conduct a follow-up survey in a few years time to report on the improvement.

Acknowledgments

This study was supported by an unrestricted grant from Sanofi-Aventis (Suisse) SA, Meyrin, Switzerland.

Conflict of interest

Richard Cathomas has a consultant role for Janssen Cilag and Sanofi-Aventis. Silke Gillessen has a consultant role for Novartis, Janssen Cilag, Pfizer, Sanofi-Aventis, GSK, and Millennium. All other authors report no conflicts of interest. We hereby state that we have full control of all data and we allow the journal to review the data if deemed necessary.

Copyright information

© Springer-Verlag Berlin Heidelberg 2013