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Multidisciplinary Care andManagement Selection in Prostate CancerAyal A. Aizer, MD, MHS,* Jonathan J. Paly, BS,† and Jason A. Efstathiou, MD, DPhil†

The management of prostate cancer is complicated by the multitude of treatment options,the lack of proven superiority of one modality of management, and the presence ofphysician bias. Care at a multidisciplinary prostate cancer clinic offers patients the relativeconvenience of consultation with physicians of multiple specialties within the confines ofa single visit and appears to serve as a venue in which patients can be counseled regardingthe risks and benefits of available therapies in an open and interactive environment.Physician bias may be minimized in such an environment, and patient satisfaction rates arehigh. Available data suggest that low-risk patients who are seen at a multidisciplinaryprostate cancer clinic appear to select active surveillance in greater proportion. However,relatively few studies have investigated the other added value that multidisciplinary clinicsprovide to the patient or health care system, and therefore, additional studies assessing theimpact of multidisciplinary care in the management of patients with prostate cancer areneeded.

Semin Radiat Oncol 23:157-164 © 2013 Published by Elsevier Inc.

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Background

Prostate cancer is the most common nonskin malignancyaffecting American men, with 241,740 cases diagnosed

in 2012.1 However, despite its high prevalence, prostate can-er-specific mortality rates for patients with prostate cancerre relatively low, and population-based data suggest thatnly approximately 14% of patients will die of their disease.2

Patients with low-risk prostate cancer (Gleason score of �6,pretreatment prostate-specific antigen [PSA] of �10 ng/mL,and clinical stage of T1c or T2a)3 have an even more favorable

rognosis. Complicating the management of low-risk pros-ate cancer is the fact that there are essentially no data touggest that definitive treatment impacts prostate cancer-spe-ific survival when compared with active surveillance, anpproach which entails the use of PSA levels, digital rectalxaminations, and periodic prostate biopsies to monitor forrogression of disease and to implement curative therapy ifnd when such progression occurs.3-6 Trials that comparedefinitive therapy with expectant management used ap-roaches consistent with watchful waiting, in which patients

*Harvard Radiation Oncology Program, Boston, MA.†Department of Radiation Oncology, Massachusetts General Hospital, Bos-

ton, MA.The authors declare no conflict of interest.Address reprint requests to Jason Efstathiou, MD, DPhil, Department of Radia-

tion Oncology, Massachusetts General Hospital, 100 Blossom Street, Cox 3,

Boston, MA 02114. E-mail: jefstathiou@partners.org

1053-4296/13/$-see front matter © 2013 Published by Elsevier Inc.DOI: 10.1016/j.semradonc.2013.01.001

ere not rigorously screened for progression and/or did noteceive definitive therapy at the time of earliest progres-ion.7-9 Therefore, when compared with contemporary con-ervative management approaches, the impact of definitiveherapy in patients with low-risk disease is unknown. More-ver, for patients in all risk groups, there are no widely ac-epted prospective trials from the United States or Europehat have compared radical prostatectomy with radiationherapy. To date, only 1 published, prospective, randomizedrial has compared these 2 therapies10; although this trialound a progression-free survival benefit favoring the prosta-ectomy arm, the clinical impact of the study was minimal,iven improper randomization technique, selection bias, andn unequal distribution of prognostic factors between the 2ohorts.11,12 In addition, the trial was conducted �30 yearsgo, and both surgical and radiotherapeutic practices havehanged significantly over this period.13-19 Therefore, from

the perspective of tumor control, the optimal managementfor prostate cancer remains largely unknown.

Although the adverse effects and quality of life associatedwith surgical and radiotherapeutic options for prostate can-cer differ, it is not apparent that the overall quality of lifedecrement is better or worse with one particular therapy.Rather, each treatment (radical prostatectomy, external beamradiation, brachytherapy) carries a unique profile of adverseeffects that can impact quality of life. Patient- and spouse-reported toxicities after radical prostatectomy, external beam

radiation therapy, and brachytherapy were prospectively col-

157

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158 A.A. Aizer, J.J. Paly, and J.A. Efstathiou

lected and reported descriptively by Sanda et al.20 In thisstudy, 1201 patients and 625 spouses were queried regardingquality of life measures before and after treatment for theirprostate cancer. After radical prostatectomy, no substantivebowel toxicity occurred; urinary incontinence was observed,but urinary irritation and obstruction improved, particularlyin men with large prostates. Patients treated with externalbeam radiation therapy or brachytherapy experienced symp-toms of urinary irritation and obstruction, although thesesymptoms improved with time. All 3 groups experiencedquality of life impairment related to sexual dysfunction.Quality of life in patients receiving hormonal therapy alongwith radiation therapy appeared to be worse among multipledomains. Therefore, the study by Sanda et al and other recentstudies demonstrate that each definitive treatment for pros-tate cancer is associated with a unique toxicity profile.21,22

It does appear, however, that active surveillance is associ-ated with reduced adverse effects relative to definitive treat-ment. In a decision analysis by Hayes et al,23 active surveil-lance was associated with greater quality-adjusted lifeexpectancy than management with definitive therapy.Kasperzyk et al24 analyzed data from the Physicians Healthtudy and found that expectant management, as comparedith immediate treatment, was associated with less urinary

ncontinence and impotence, although increased crude ratesf obstructive urinary symptoms were seen in the expectantanagement arm. Of note, in this trial, active surveillance

nd watchful waiting could not be distinguished.The multitude of treatment options available to patients

ith prostate cancer, particularly those with low-risk disease,s substantial. In addition to open, laparoscopic, and roboticadical prostatectomy, patients can undergo external beamadiation therapy, brachytherapy, or active surveillance. Inddition, patients are sometimes offered hormonal therapyither as primary monotherapy or in conjunction with radi-tion; less proven treatments such as cryotherapy, high-in-ensity focused ultrasound, and focal surgery or ablation areometimes presented to patients as well.25-27 Even when se-ecting external beam radiation therapy, patients are offered a

ultitude of delivery, dose, fractionation, and localizationtrategies.28-32 Interestingly, ownership of radiation oncology

equipment by physicians with the potential to self-referseems to affect utilization rates. Mitchell et al33 showed thatthe practice pattern of nonradiation oncologists referring pa-tients for radiation therapy at centers in which they haveownership is associated with a 58% increase in proceduresand 48% increase in costs relative to nonconflicted practices.As a result, legislation targeting referral to centers where thereferring physician has a financial interest has been imple-mented.34

In addition to financial drivers of referral patterns, avail-able data suggest that physician bias, in which physicians aremore likely to recommend the therapy that they are capableof delivering, complicates the objective delivery of informa-tion to patients trying to decide among various therapies forprostate cancer. Moore et al35 showed that 79% of Americanurologists would opt for radical prostatectomy and 92% of

American radiation oncologists would choose radiation ther-

apy when queried as to how they would want to be treated ifdiagnosed with prostate cancer. Fowler et al36 performed asurvey-based study that demonstrated that both urologistsand radiation oncologists overwhelmingly recommend thetherapy that they are capable of delivering. Given the multi-tude of options available to patients, clear and unbiased pre-sentation of all potential therapeutic options should be con-sidered the standard of care.

Multidisciplinary CareGiven the number of options available to patients with pros-tate cancer, the lack (in most cases) of proven survival benefitsupporting one therapy over another, and the presence ofphysician bias, multidisciplinary clinics offer an appealingapproach to the management of patients with prostate cancerby providing patients the opportunity to meet with prostatecancer specialists spanning multiple specialties during a sin-gle consultation or visit. Such a model of cancer care affordspatients the opportunity to learn about all management op-tions simultaneously and to discuss the recommendations oftheir treating physicians in an open and interactive fashion,thus allowing for shared decision-making and a potentialreduction in physician bias.37,38

The format of multidisciplinary clinics varies by institu-tion, although such clinics usually involve urologists, radia-tion oncologists, and medical oncologists, who often see thepatient concurrently within the single visit (Figure 1).37 Some

ultidisciplinary clinics involve dedicated radiologists andathologists who may either be physically present or availabley telephone, and many have dedicated oncology nurses, re-

Figure 1 Schema for care by individual practitioners (A) versus carein a multidisciplinary prostate cancer clinic (B). (Color version of

figure is available online.)

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Multidisciplinary management of prostate cancer 159

search coordinators, and social workers. Pertinent patient clin-ical records are sometimes discussed by the multidisciplinarycare team before the start of clinic, an approach that has beenanecdotally suspected to improve efficiency.39 Patient visits to

ultidisciplinary clinics are generally lengthy, given the num-ers of clinicians and supporting staff that patients encounter.39

However, during the consultation, the patient has an opportu-nity to meet all the relevant specialists and is counseled regard-ing all available treatment options worthy of consideration in aninteractive fashion, and therefore is not required to make mul-tiple independent trips to the hospital or outpatient center todiscuss each specific management option.

In other disease sites, multidisciplinary cancer clinics havebeen associated with decreased time from diagnosis to initi-ation of treatment, shorter time to completion of necessarypretreatment consultations, and fewer patient visits to clini-cians’ offices before initiation of care.40 Multidisciplinary

hysician discussions have been shown to be associated withmproved adherence to guidelines supported by the litera-ure,41 although it is important to note that such benefits haveeen demonstrated in oncological disease sites other thanrostate cancer. Medical students, residents, and fellows mayimilarly benefit from multidisciplinary clinics by the expo-ure provided to physicians of differing specialties, and pro-ider satisfaction with multidisciplinary clinics is high.42,43

For all of these reasons, it appears that multidisciplinary clin-ics are increasing in popularity, but despite the growing prev-alence of such multidisciplinary clinics, the quantity of datasupporting their use is minimal. In addition, only a paucity ofstudies exist to show that multidisciplinary clinics affectmanagement, and almost no quality data within the prostatecancer literature exist to show that such clinics affect survivaloutcomes.

Published ExperiencesWith MultidisciplinaryProstate Cancer ClinicsPublished experiences with dedicated multidisciplinaryprostate cancer clinics are presented in Table 1, and are de-scribed in greater detail in the following text.

Table 1 Published Experiences With Multidisciplinary Prostat

InstitutionYear

Published

Multidiscipin Exis

Since a

Jefferson Medical College44 2010 199enter for Prostate DiseaseResearch45

2009 200

uke46 2012 200arvard affiliated37 2012 199

nstituto Nazionale dei Tumori,Milan47

2012 200

illiam Beaumont Cancer 2012 201

Center48

Investigators from the Jefferson Medical College at ThomasJefferson University, who established one of the first multi-disciplinary prostate cancer clinics in the United States, havereported patient satisfaction outcomes from their multidisci-plinary prostate cancer clinic, originally established in1996.44 The multidisciplinary clinic at Jefferson involves

rologists, radiation oncologists, medical oncologists, pa-hologists, on-call radiologists, dedicated oncological nurses,ocial workers, and research assistants. The clinicians attend-ng the multidisciplinary clinic meet before the clinic starts toeview pertinent patient records and to discuss the possibleanagement options that are appropriate for a given patient.

atient response to the Thomas Jefferson University multidis-iplinary care setting is favorable; �90% of prostate canceratients seen at the clinic rated their experience as “good” orvery good” within all measured domains, including waitime for the appointment, wait time at the clinic, explanationf the multidisciplinary care process, treatment with respectnd dignity, and explanation of treatment options provided.n addition, between 93% and 98% of patients would recom-end the clinic to others. The vast majority of patients whoere diagnosed with prostate cancer at this institution opted

o receive all or part of their treatment there.39 This finding isonsistent with other reports, indicating that the patient re-ponse to the multidisciplinary care setting is favorable.43,49

Brassell et al45 recently published the multidisciplinaryprostate cancer clinic experience from the Center for ProstateDisease Research/Walter Reed Army Medical Center (CPDR/WRAMC).45 The multidisciplinary care team at CPDR/

RAMC consists of urologists, radiation oncologists, an-rologists, clinical psychologists, patient educators, andesearch coordinators. Clinical research plays a large role inhe activities of the clinic, and on average, there are 15 activerials relating to various aspects of prostate cancer preventionnd management at a given time. In addition, the clinicalenter maintains patient serum and tissue banks as well as aatient data registry, which has allowed for research investi-ations relating to characterization of prostate cancer-specificene/protein alterations, androgen regulated genome and ex-ression, experimental models for prostate cancer biology,nd translational research defining diagnostic and prognosticiomarkers. As of 2009, �300 peer-reviewed publications

cer Care

Care

st Oncology Physicians Involved

Urologist, radiation oncologist, medical oncologistUrologist, radiation oncologist, andrologist

Urologist, radiation oncologist, medical oncologistUrologist, radiation oncologist, medical oncologistUrologist, radiation oncologist, medical oncologist

Urologist, radiation oncologist, medical oncologist

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had resulted from the research efforts at CPDR/WRAMC.45

The experience of CPDR/WRAMC indicates that multidisci-plinary prostate cancer clinics can serve as launching pointsfor integrated clinical and translational research endeavors.

Stewart et al46 recently reported outcomes from the multi-isciplinary prostate cancer clinic at the Duke Universityedical Center (and another associated multidisciplinary

linic). The investigators found that patients seen in theirultidisciplinary clinics (vs those seen in urology-only clin-

cs) were younger (63 vs 65 years), had higher socioeconomiclass/income (annual income of $40,963 vs $39,013), andesided further from the cancer center than other patients,espectively. Of the 407 patients who attended the multidis-iplinary clinic at Duke, 58.1% of patients opted to pursueare at the same institution; such patients tended to beounger, have lower income, be of African American decent,e physician referred, and reside closer to Duke than thoseho pursued treatment elsewhere. Of those who received

reatment at Duke, 51.7% underwent prostatectomy, 32.8%nderwent radiation, 9.3% underwent active surveillance,.4% underwent ablative therapy such as cryotherapy or ra-iofrequency ablation, and 3.7% underwent primary andro-en blockade. Notably, 10.4% of patients were enrolled on alinical trial, and such patients were more likely to have high-isk disease than low- or intermediate-risk disease. The ex-erience from Duke was one of the first published reports touggest that patients who attend multidisciplinary prostateancer clinics may be different from those who do not.

Before 2012, studies had largely not shown that consulta-ion at a multidisciplinary clinic affects treatment selectionelative to consultation by 1 or more individual practitionersn patients with prostate cancer. Recently, Aizer, Efstathiou,nd other collaborators from our group evaluated 701 con-ecutive, retrospectively obtained patients with low-riskrostate adenocarcinoma managed at 1 of 3 academic insti-utions affiliated with Harvard Medical School in the year009: Massachusetts General Hospital, Brigham and Wom-n’s Hospital, and Beth Israel Deaconess Medical Center (alln Boston, MA).37 Patients were either seen at a multidisci-plinary clinic or, alternatively, by 1 or more individual prac-titioners in sequential settings. A multidisciplinary clinic wasdefined as a setting in which concurrent consultation with atleast 2 of the following specialties was obtained: urology,radiation oncology, and medical oncology. In nearly all cases,a urologist and a radiation oncologist were both present at themultidisciplinary clinic; the presence of a medical oncologistwas more variable. Any patient seen in a multidisciplinaryclinic was assigned to the multidisciplinary clinic cohort,even if seen by individual practitioners in separate settings atanother time.

All patients ultimately elected for either management byactive surveillance or underwent monotherapy with radicalprostatectomy, external beam radiation therapy, or brachy-therapy; no patient received combined modality therapy oralternative therapies such as cryotherapy, high-intensity fo-cused ultrasound, or primary androgen deprivation therapyas an initial treatment strategy. Notably, patients seen in a

multidisciplinary clinic were similar to those seen by individ-

ual practitioners in terms of age, comorbidity, family history,race, income, or the percentage of positive cores between the2 cohorts. Baseline PSA levels were slightly higher in patientsseen in a multidisciplinary clinic, although the absolute dif-ference was only 0.4 ng/mL (P � 0.003). The investigatorsfound that consultation at a multidisciplinary clinic nearlydoubled the proportion of patients choosing active surveil-lance as an initial strategy and decreased selection of prosta-tectomy, external bean radiation therapy, and brachytherapyby relative percentages of 24%, 41%, and 30%, respectively(P � 0.001), see Figure 2 (adapted with permission). On

ultivariate logistic regression analysis (presented, with per-ission, in Table 2), older age (odds ratio [OR]: 1.09 [95%

onfidence interval {CI}: 1.05-1.12]; P � 0.001), unmarriedocial status (OR: 1.66 [95% CI: 1.01-2.72]; P � 0.04), in-reased Charlson comorbidity index (OR: 1.37 [95% CI:.06-1.77]; P � 0.02), a lower percentage of positive coresOR: 0.92 [95% CI: 0.90-0.94]; P � 0.001), consultationith more experienced physicians (OR: 1.04 [95% CI: 1.01-.07]; P � 0.01), and consultation at a multidisciplinarylinic (OR: 2.15 [95% CI: 1.13-4.10]; P � 0.02) remainedignificantly associated with pursuit of active surveillance.

The number of physicians and specialties encountered wasssociated with selection of active surveillance on univariate,ut not multivariate, analysis, suggesting that the multidisci-linary clinic itself, and not merely the number or type ofhysicians seen, is important to the shared decision-makingrocess for selection of active surveillance.37 Notably, theRs for institution of treatment did not achieve statistical

ignificance on either univariate or multivariate analysis. Al-hough Massachusetts General Hospital showed a trend to-ard increased active surveillance on univariate analysis (ORs Beth Israel Deaconess Medical Center, 1.41, P � 0.16), theultivariate results (OR: 1.02, P � 0.95) were closer to theull, likely due to a high prevalence of multidisciplinary caret Massachusetts General Hospital.

Strengths of this study included that it evaluated a large,ulti-institutional, and contemporary cohort of patients, and

hat many relevant demographic, clinical, and provider co-ariates were collected and included in the multivariate anal-sis. In addition, both patients seen in the multidisciplinaryrostate cancer clinic and those managed by individual prac-itioners were seen in the same calendar year. However, thetudy had a number of important limitations, most notablyhat given the retrospective nature of the study, it is conceiv-ble that patients seen in multidisciplinary clinics were fun-amentally different from those seen by individual practitio-ers in separate settings, especially given the aforementionedata from Duke, which indicated that patients seen in theirultidisciplinary clinics were younger, had higher socioeco-omic class, and resided further from the cancer center thanatients seen in a urology-only clinic.46 This possibility was

mitigated to some extent in the Harvard study, given thatpatients seen in a multidisciplinary clinic were similar tothose seen by individual practitioners in terms of variablesthat may affect utilization of active surveillance (eg, age, co-morbidity, annual income, family history, percentage of pos-

itive cores).

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Multidisciplinary management of prostate cancer 161

We have also investigated the association of multidisci-plinary care and pursuit of active surveillance in men withvery low-risk prostate cancer, particularly those with limitedlife expectancy. In very low-risk patients with a life expec-tancy of �20 years, the National Comprehensive CancerNetwork recommends active surveillance as the primary op-tion.3 Preliminary results suggest that rates of active surveil-ance are higher in very low-risk patients with limited lifexpectancy when consultation at a multidisciplinary clinic isbtained, suggesting that multidisciplinary care may be asso-iated with minimization of overtreatment of prostate can-er.50

Other studies have examined the treatment selected bypatients seen in a multidisciplinary clinic. Korman et al48

from the William Beaumont Cancer Institute examined pa-tients seen in their newly instituted multidisciplinary clinic inthe year 2010-2011 and compared them with historical con-trols at their institution. Their approach to multidisciplinarycare is unique, in that the referring physician can specify the

Figure 2 Pie chart (from http://nces.ed.gov) showing pebeam radiation, brachytherapy, and active surveillance, aby individual practitioners (1B) (P from Fisher exactmultidisciplinary care with care by individual practitiopermission from Aizer et al.37 (Color version of figure is

urologist, radiation oncologist, and medical oncologist that

the patient will see in consultation, an approach employed inorder to preserve referral patterns. Each patient’s case is dis-cussed at the beginning of the clinic, where pathologists andradiologists are also present. Korman et al found that low-riskpatients who were seen at a multidisciplinary clinic were lesslikely to select prostatectomy (30.4% vs 44.0%, P � 0.03)and more likely to select either external beam radiation(41.1% vs 26.6%, P � 0.02) or active surveillance (14.3% vs6.1%, P � 0.02) than patients seen before the institution ofthe multidisciplinary clinic. Intermediate-risk patients seenat a multidisciplinary clinic were more likely to select exter-nal beam radiation therapy (59.3% vs 40.3%, P � 0.006) andless likely to pursue active surveillance (0% vs 6.6%, P �0.04). In the high-risk group, significantly more patients un-derwent external beam radiation (95.2% vs 68.6%, P �0.01), supplemental androgen deprivation therapy (76.2%vs 51.1%, P � 0.03), and supplemental systemic therapy(14.3% vs 2.3%, P � 0.001) if they were seen at a multidis-ciplinary clinic, whereas fewer patients underwent radical

ge of patients selecting radical prostatectomy, externalified by consultation at a multidisciplinary clinic (1A) ormparing the 2 charts � 0.001) in study comparingmen with low-risk prostate cancer. Reproduced with

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prostatectomy (4.8% vs 25.6%, P � 0.03). They also noted

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162 A.A. Aizer, J.J. Paly, and J.A. Efstathiou

that multidisciplinary care was associated with increased ad-herence to guidelines published by the National Comprehen-sive Cancer Network in intermediate-risk patients (89.8% vs75.9%, P � 0.01); adherence patterns in low- and high-riskpatients were not statistically different among the 2 cohorts.48

Similarly, Magnani et al47 recently published the experi-nce of the multidisciplinary prostate cancer clinic at thenstituto Nazionale dei Tumori in Milan, Italy, between 2005nd 2011. Patients attending the clinic are seen concurrentlyy a urologist, a radiation oncologist, and a medical oncolo-ist. Typically, 10 patients are seen over the course of 8ours. A 2-hour case discussion follows each clinic, withdditional clinicians and supporting staff present, where per-inent aspects of each case are discussed. Patient satisfactionatings were high; the investigators used a 7-point scale (inhich a score of 1 designates “very poor quality,” whereas a

core of 7 indicates “very high quality”). Scores between 5nd 7 were achieved for all measured domains, includingbservance of privacy, care provided by technical/nursingtaff, care provided by the clinical staff, information on healthnd medical care provided, observance of scheduling, andait times. Rates of overall satisfaction between 6 and 7 were

chieved. In terms of treatment selected by patients attendinghe multidisciplinary prostate cancer clinic, one of the mostotable results was that rates of active surveillance among

ow-risk patients were 44% in 2006 and increased each yearntil 2009, when such rates were 81%. Collectively, datarom the Instituto Nazionale dei Tumori in Milan, the Wil-iam Beaumont Cancer Institute, and the Harvard Hospitalso seem to indicate a strong association between multidisci-linary care and pursuit of active surveillance in patients with

Table 2 Multivariate Logistic Regression for Choice of Active Sby Individual Practitioners in Men With Low-Risk Prostate C

Variable

Age (per year)Ethnicity (AA vs white, ref � AA)Marital status (married vs single, ref � married)amily history (yes vs no, ref � yes)

Income (per $1000/year increase)Charlson comorbidity index (per unit)PSA (per ng/mL)% positive cores (per 1% increase)# physicians seen (per increase of 1)# specialties seen (per increase of 1)Mean experience of physicians met (per year increase)Highest physician rank met (stepwise: asst/inst, assoc, full)Multidisciplinary clinic (no vs yes, ref � no)Institution*

BIDMCMGHBWH

Abbreviations: AA, African American; asst/inst, assistant professoMedical Center; BWH, Brigham and Women’s Hospital; CI, confiOR, odds ratio; PSA, prostate-specific antigen; ref, reference; yr

*If MGH set as reference, BWH vs MGH reveals HR of 1.39 (95% CReproduced with permission from Aizer et al.37

ow-risk prostate cancer.

Given that approximately 240,000 cases of prostate cancerre diagnosed per annum, and given the rapid recent rise inealth care expenditure and the national mandate to findeans to curb such costs, the potential cost savings and

etter utilization of limited resources associated with activeurveillance cannot be overstated. Eldefrawy et al51 found

active surveillance to have lower 10-year cumulative medicalcost than radical prostatectomy, external beam radiationtherapy, and brachytherapy. Corcoran et al52 used Medicarereimbursement rates to illustrate lower 15-year cost with ac-tive surveillance than radical prostatectomy. Speculation ex-ists that current reimbursement practices could potentiallyplace substantial financial and time burdens on both the phy-sicians and the institutions that operate multidisciplinaryclinics, as multidisciplinary clinics have been criticized forbeing slow, time-consuming, and inefficient. However,given the high retention rate reported by several multidis-ciplinary prostate cancer clinics (which minimizes sepa-rate consultations with physicians at other institutions)39

and the higher rates of active surveillance associated withmultidisciplinary care,37,47,48 multidisciplinary clinics mayresult in cost-savings when all relevant factors are consid-ered, although formal studies are needed to further inves-tigate such assertions.

Despite the potential benefits to patients, physicians, andthe health care system at large, several limitations of multi-disciplinary care should be pointed out. First, multidisci-plinary clinics may be more readily implemented in tertiarycare facilities within major metropolitan centers and may notbe practical in all settings, such as in communities in whichprostate cancer specialists are separated by great distances.

llance in Study Comparing Multidisciplinary Care With Care

Multivariate OR 95% CI P

1.09 1.05-1.12 <0.0011.1 0.37-3.34 0.861.66 1.01-2.72 0.040.69 0.43-1.12 0.131 0.99-1.01 0.311.37 1.06-1.77 0.020.97 0.87-1.07 0.50.92 0.90-0.94 <0.0011.28 0.87-1.87 0.211.09 0.65-1.83 0.741.04 1.01-1.07 0.011.16 0.85-1.60 0.352.15 1.13-4.10 0.02

1.0 (ref)1.02 0.54-1.93 0.951.42 0.76-2.65 0.27

ctor; assoc, associate professor; BIDMC, Beth Israel Deaconessinterval; full, full professor; MGH, Massachusetts General Hospital;

-2.37), P � 0.23.

urveiancer

r/instrudence, year.I: 0.81

Second, it is likely that providers see fewer patients per day in

Multidisciplinary management of prostate cancer 163

the multidisciplinary setting, although this has not beenproven. Finally, it is plausible that younger physicians mayfeel apprehensive about voicing opinions regarding prostatecancer management when surrounded by older more expe-rienced physicians.37

What should patients and providers do in situations whereconsultation at a multidisciplinary clinic is not feasible, giventhe limitations described above? Our group has hypothesizedthat improved patient access to information regarding prostatecancer may allow patients to make more informed decisions. Tothis end, Gray, Efstathiou, and collaborators have opened aprospective observational cohort study (http://clinicaltrials.gov NCT01673581) evaluating the usefulness of a Web sitedesigned to inform patients with prostate cancer about thediagnosis of prostate cancer and potential management op-tions, with the main outcome being patient understanding ofavailable management strategies, as determined by question-naires. Gray and Efstathiou have hypothesized that patientutilization of such a Web site will better inform them of theavailable treatment options and will allow patients to makedecisions that are more consistent with their own goals ofcare.

The management of prostate cancer is complicated by themultitude of management options, the lack of proven supe-riority of one modality of management, and the presence ofphysician bias. The available data suggest that implementa-tion of multidisciplinary models of care for patients withcancer, when feasible, may be associated with high patientsatisfaction rates and may alter practice patterns in ways thatminimize physician bias. Therefore, multidisciplinary caremodels should be considered for delivery of care when feasi-ble. Accordingly, experts continue to advocate for use ofmultidisciplinary models of care for many patients with pros-tate cancer.53 However, given the relative lack of investiga-tions attempting to describe the value that the multidisci-plinary clinic imparts on the patient and health system atlarge, as well as the lack of data showing that multidisci-plinary care affects treatment outcomes, additional studiesare needed to evaluate the clinical and economic impact ofmultidisciplinary care in prostate cancer.

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