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Editorial

The Prostate Cancer Unit: A Multidisciplinary Approach for

Which the Time Has Arrived

Leonard G. Gomella *

Department of Urology, Jefferson Kimmel Cancer Center, Thomas Jefferson University, 1025 Walnut Street, 1102 Philadelphia, PA 19107, USA

Large US-population-based studies of prostate cancer

patients suggest that oncology specialist visits relate

strongly to prostate cancer treatment choices for localized

disease [1]. Studies also indicate that specialists tend to

prefer and recommend the modality they themselves

deliver. It is recognized that there is a paucity of

comparative studies demonstrating superiority of one

standard treatment modality, surgery or radiation, over

another with regard to localized prostate cancer. Additional

strategies include active surveillance and a variety of

minimally invasive and focal therapies that continue to

evolve and that are used in routine clinical care [2].

Therefore, prostate cancer specialists consider it essential to

ensure that men have access to balanced information,

including risks and benefits, before choosing a specific

treatment for localized disease. Adequate pretreatment

counseling can potentially reduce treatment regret and

improve outcomes [3]. One approach to dealing with

the complexities of prostate cancer management is the

coordination of care among providers, known as the

multidisciplinary model.

There are few published reports of multidisciplinary

clinic outcomes for all malignancies and even less for

prostate cancer. A 2010 review was unable to definitively

determine a causal relationship between multidisciplinary

care and outcomes such as survival [4]. However, our group

now has convincing data that is discussed later in this

paper.

One of the current challenges in assessing the impact of

multidisciplinary care models is the lack of a formal

definition of what multidisciplinary cancer care actually

is. This approach can take many forms, but a true

multidisciplinary care model, as described by Hong et al

[4], fundamentally encompasses ‘‘collaborative patient care

by a team of individuals where all diagnostic and treatment

* Tel. +1 215 955 1702; Fax: +1 215 923 1884.E-mail address: leonard.gomella@jefferson.edu.

0302-2838/$ – see back matter # 2011 European Association of Urology. Publis

options are discussed and tailored for each patient.

Although the team composition may vary by disease site

and institution, independent contributors may include

representatives from medical oncology, radiation oncology,

surgery/surgical oncology, pathology, diagnostic imaging,

palliative care, nursing, nutrition, and social work.’’ Another

challenge is that multidisciplinary interactions between

the providers and the patient can take place in different

venues such as clinics, in cancer service-line programs, by

defined care pathways and protocols, or through multidis-

ciplinary tumor conferences, also known as tumor boards. It

is my personal belief that true multidisciplinary care for

a man with newly diagnosed prostate cancer must

involve real-time interaction between the various specia-

lists and the patient because the treatment options and

decisions for this disease can be extensive and, at times,

controversial.

A European policy on prostate cancer units with formal

certification has been proposed recently based on a

discussion by the European School of Oncology [5]. These

prostate cancer units are more commonly referred to as

genitourinary (GU) cancer or prostate cancer multidisciplin-

ary clinics in the United States. This multidisciplinary model

has been successfully implemented in Europe for breast

care. These centers were based on a 2003 policy enacted by

the European Parliament that established a network of

certified multidisciplinary breast cancer units [6]. The

German Oncology Society (Deutsche Krebsgesellschaft)

designed a network of prostate cancer units that manages

prostate cancer in a multidisciplinary manner in that

country [5]. Other organizations in the United States, the

United Kingdom, Asia, and Australia have had discussions to

promote and establish multidisciplinary programs as a

tenet of routine cancer care for most disease sites including

prostate cancer [4].

hed by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2011.08.023

E U R O P E A N U R O L O G Y 6 0 ( 2 0 1 1 ) 1 1 9 7 – 1 1 9 91198

Although the potential benefits of these specialized care

units are generally accepted for tumors such as breast

cancer, the adaptation of this model in the care of prostate

cancer patients has not been widely implemented to date.

The slow adaptation is likely multifactorial and includes

physician, financial, and institutional barriers as well as the

limited volume of published reports in this area. In a study

from Milan, Italy, clinicians acknowledged that the multidis-

ciplinary clinic has advantages in terms of patient education

and data acquisition, but a clear physician preference for this

multidisciplinary setting for prostate cancer did not emerge

[7]. The authors reported that in one-on-one encounters,

specialists feel more comfortable interacting with the patient

and that the process of building trust was easier in a

nonmultidisciplinary setting. In this study, clinicians recog-

nized the value of the multidisciplinary approach in terms of

effective communication with patients. The report stresses

the importance of a proper organizational structure and

the need for teamwork to optimize the multidisciplinary

approach. Other studies have confirmed that one important

outcome measure, satisfaction of patients and their families,

is high in these type of programs [8,9].

These proposed prostate cancer units should be capable

of providing optimum counseling and treatment recom-

mendations across the spectrum of all stages of prostate

cancer. In addition, the units must also provide access to

support services in areas such as psychosocial counseling,

rehabilitation, and management of other potential compli-

cations of treatment. Nursing navigators further support

and enhance the patient care experience. Data acquisition

and validation of outcome parameters should be a part

of any of these programs, new or existing.

My radiation oncology colleague Dr. Richard Valicenti

and I were the founding members of the Jefferson Kimmel

Cancer Center GU Multidisciplinary Cancer Center in

January 1996. We originally described its structure

and implementation in 2000 [10]. On a weekly basis,

urologists, radiation oncologists, medical oncologists,

pathologists, radiologists, social workers, clinical trial

coordinators, nursing navigators, and other support staff

gather at one site to evaluate and counsel patients with GU

malignancies in real time. Prostate cancer is the most

common tumor type seen, and a conference that includes a

pathology review and a brief case discussion is held just

before the session. Although the majority of patients remain

with us for their longitudinal care, second opinions are also

provided. The change in 2008 from a preclinic conference to

a postclinic conference has been the only substantive

modification of the program design over the last 15 yr.

Genetic counseling, integrative medicine support, and

nutritional and pain management are not part of our

formal clinic visit but are made available to our patients at

the Kimmel Cancer Center. Participation in support groups

and the opportunity to participate in the ‘‘Buddy System,’’

matching up similar patients by demographics and disease

state, are also encouraged as part of the program. Although

most men are newly diagnosed, the full spectrum of

prostate patients with varying stages is also seen, and

specific physician or specialty consultation is usually

scheduled in advance by the navigator but can be easily

modified based on the real-time nature of the clinic. I

believe our Jefferson Kimmel Cancer Center GU Multidisci-

plinary Cancer Center is the longest continually running

center of its kind at a National Cancer Institute–designated

cancer center in the United States.

In the fall of 2010 we reported for the first time in

prostate cancer that patient survival outcomes for high-risk

men, when stratified by disease stage, are improved by our

multidisciplinary clinic approach. For localized T2 disease,

our 5-yr survival data approached 100%, which is to be

expected based on other benchmarks such as Surveillance

Epidemiology and End Results (SEER) data. However, when

analyzing men with locally advanced disease, the enhanced

outcome was most pronounced for T3 prostate cancer, with

a statistically significant improvement in 5-yr survival of

almost 90% compared to SEER, with a 78% survival

probability [8].

The benefits of the prostate unit or multidisciplinary

center concept include the potential to improve patient

outcomes; to enhance program visibility; to provide

patients with convenient, high-quality care; to enhance

education of trainees and staff; to improve clinical trial

accrual; to allow standardization of data collection; and to

provide the host institution with downstream benefits

through patient retention. The potential challenges include

the fact that programmatic success is determined primarily

by physician participation and enthusiasm; actual time

expended may not be efficient for specialty physicians, and

there is some loss of physician autonomy. The program also

requires dedicated staff, space, and resources beyond the

core GU oncology specialty services. It is critical that all

centers collect data prospectively to establish protocols and

audit criteria to benchmark their activities and validate a

core principle of these centers, namely, improving patient

outcome. The specific design of each multidisciplinary

prostate clinic in the United States can vary greatly because

there are no specific guidelines or recommendations

for such activity, although the centers that have published

suggest that simultaneous encounters in a real-time clinic

setting are commonplace [8,9].

The discussion paper from the European School of

Oncology by Valdagni and colleagues proposes general and

specific recommendations along with mandatory require-

ments for prostate cancer units [5]. The long-term goal is to

develop a network of certified prostate units across Europe.

Our European colleagues are to be highly commended for

bringing this concept forward in such an organized and

defined fashion. These prostate cancer units will help

ensure a uniform and, hopefully, optimum outcome for men

with all stages of prostate cancer.

Conflicts of interest: The author has nothing to disclose.

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