OPTIMIZING THE PATH OF CARE FOR PATIENTS WITH PROSTATE CANCER: WORKING IN A NETWORK

• Published in: Anticancer research Vol. 38; no. 4; p. 2504
• Main Authors: Magnani, Tiziana, Albo, Giancarlo, Avuzzi, Barbara, Bellardita, Lara, Casale, Alessandra, Catanzaro, Mario, Cerrotta, Annamaria, Colecchia, Maurizio, De Luca, Letizia, Di Florio, Teresa, Donegani, Simona, Dordoni, Paola, Fallai, Carlo, Grassi, Paolo, Longo, Fabrizio, Macchi, Alberto, Marenghi, Cristina, Menichetti, Julia, Messina, Antonella, Morlino, Sara, Chiorda, Barbara Noris, Paolini, Biagio, Procopio, Giuseppe, Stagni, Silvia, Tesone, Antonio, Torelli, Tullio, Vaiani, Marta, Verzoni, Elena, Villa, Sergio, Zaffaroni, Nadia, Nicolai, Nicola, Salvioni, Roberto, Montanari, Emanuele, Monti, Patrizia, Valdagni, Riccardo
• Format: Journal Article
• Language: English
• Published: Athens International Institute of Anticancer Research 01.04.2018
• Subjects: Biopsy; Boards; Brachytherapy; Cancer; Cancer surgery; Cancer therapies; Chemotherapy; Collaboration; Colleges & universities; Completeness; Complications; Consultation; Crosstalk; Cryopreservation; Data collection; Diagnostic systems; Disease control; Division; Emergency medical services; Fund raising; Guidelines; Health care; Hematuria; Information dissemination; Malignancy; Meetings; Narcosis; Optimization; Patients; Positron emission tomography; Prostate cancer; Protocol (computers); Radiation; Radiation therapy; Radioisotopes; Research projects; Robotic surgery; Robots; Semen; Surgery; Surveillance; Tumors; Urological surgery; Urology
• ISSN: 0250-7005; 1791-7530

According to the status of disease, multiple therapies and observational strategies are available for prostate cancer patients, including surgery, external radiotherapy, brachytherapy, hormonal therapy, chemotherapy, and radionuclide metabolic therapy, as well as observational programs such as active surveillance and watchful waiting. The path of care for this malignancy is rather complex, involving several health care professionals, and it requires a multidisciplinary approach at specific time points of the disease trajectory. When the health settings cannot provide prostate cancer patients with all the consultations and procedures required for a proper disease management, efforts should be made to implement the path of care, in order to address all patient needs through the collaboration among institutions. This is also in line with Valdagni et al. (1, 2), who stressed the importance of formalizing networks to meet all requirements of a Prostate Cancer Unit. Although multidisciplinary clinics (weekly multidisciplinary first consultations and twice a week observational program followup) and activities (weekly tumor boards) for prostate cancer patients had been running on a regular basis since 2004, the Prostate Cancer Unit at Fondazione IRCCS Istituto Nazionale dei Tumori, Milan (INT PCU), was only formalized in 2009, and updated with respect to staff and activities in 2013. In 2014, also with the help of external auditors, bottlenecks and areas with room for improvement were identified (3). Besides organizational and administrative problems, the auditors stressed the lack of robot-assisted surgery and of emergency department (ER). In addition, the uro-oncologists attending the PCU had limited experience with functional and andrologic urology. The Division of Urology at Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico (Policlinico) of Milan, hosting the Specialty in Urology of Milan University, was a referring center for robot-assisted surgery, with extensive experience in urology and andrology. Policlinico had no radiotherapy or brachytherapy unit as well as no experience in the multidisciplinary management of prostate cancer patients and no significant caseload of patients on active surveillance or watchful waiting. In February 2017, INT PCU and with INT become an academic center as Policlinico, and Policlinico formalized an agreement aimed to join efforts, share common diagnostics and therapeutic guidelines to implement the path of care for prostate cancer patients. The collaboration was meant to offer prostate cancer patients referring to both centers a complete path of care, to optimize human and technological resources and meet the standards of a PCU as described in Valdagni et al. (1) and Valdagni et al. (2). INT PCU and Policlinico identified a scientific coordinator and a project manager in each center to supervise the collaboration and check activities and work flows, respectively. Scientific coordinators and project managers agreed on a provisional caseload for every single procedure in each center, which was included in the agreement and was evaluated every 3 months. Moreover, a detailed description of the work flow, the activities, the specialists in charge, and both contact and patient information was prepared and shared among INT PCU, Policlinico clinical and admin team. In detail, INT PCU patients could be referred to Policlinico for functional urologic consultations and procedures, robot-assisted surgery, andrologic consultations, semen cryopreservation, and ER admission. Policlinico patients could be referred to INT PCU for radiotherapy, brachytherapy, observational programs (active surveillance and watchful waiting) and chemotherapy. In addition, Policlinico urologists could attend the INT PCU tumor boards and start working in a MDT setting. On the other hand, INT PCU urologists could assist to robotic radical prostatectomies performed at Policlinico. The agreement refers to the possibility of starting a second phase, focused on clinical, experimental, and translational research projects as well as fund raising and educational activities. Between February 2017 and October 2017, Policlinico referred 17 patients to INT PCU. Nine patients were evaluated by INT PCU radiation oncologists for radiotherapy, 6 patients were discussed in INT PCU tumor board, 1 patient was evaluated by INT PCU medical oncologists. Prostate Specific Membrane Antigen Positron Emission Tomography scan was prescribed to 1 patient, and it was performed in one of the few centers working in this field in Italy, which has had a strong collaboration with INT PCU. PCU INT referred to Policlinico 14 patients. Seven patients were evaluated for urinary symptoms, 2 patients requested the consultation by urologists expert in sexual therapy, 1 patient was interested in robotic surgery, 1 patient referred to Policlinico ER, 1 patient on active surveillance required biopsy in narcosis and 1 patient had macro-hematuria after radiotherapy. Patients referred to INT PCU and Policlinico, and participation of Policlinico urologists at INT PCU tumor boards were recorded by INT PCU project manager, who checked on the data every month as regards caseload and update of patient charts with external consultations. Although both centers paid much attention to detailing work flows and responsibilities and to sharing information with the staff, a few problems occurred. Particularly, patients of both INT PCU and Policlinico referred to the centers without an appointment or documentation for 4 times. One patient, who referred to ER with post-biopsy complications, was seen by clinicians not informed of the formalized collaboration. These inconveniences could be explained by the little promotion that was intentionally acted by INT and Policlinico directors, by the inadequate knowledge of protocols and procedures run by the centers, by the working habits in non-formalized networks, and by the insufficient knowledge of the group members. However, solutions were found and were implemented in order to overcome these barriers. The scientific coordinators spread news of the formalized collaboration with colleagues of other specialties; the project managers organized meetings with clinicians and the administrative staff. Meetings will be scheduled over the forthcoming months to present single activities and protocols. The collaboration proved to be helpful for both INT PCU and Policlinico 1) to complete the path of care for each institution, 2) to improve efficacy and efficiency of diagnostic and therapeutic procedures, 3) to make therapies accessible, 4) to optimize the use of resources, and 5) to promote cross-talk between groups. Patients were happy to have appointments organized and a referral center in touch with one’s clinicians. However, it is important to organize meetings to share thoughts, experience and guidelines between the groups. At the same time, it is fundamental to improve data collection of the cases from each center, to monitor the collaboration and identify potential weaknesses and criticisms that might hamper this synergy. In addition, other areas of interest could be explored and excellences of both centers further appreciated.