Multidisciplinary Management of Prostate Malignancy Joseph W. Basler, PhD, MD*, Carol Jenkins, RN, and Gregory Swanson, MD

Address *Departments of Urology and Radiation Oncology, University of Texas Health Sciences Center, MC7845, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA. E-mail: [email protected] Current Urology Reports 2005, 6:228–234 Current Science Inc. ISSN 1527-2737 Copyright © 2005 by Current Science Inc.

Most urologic malignancies are diagnosed initially and managed by urologists. However, better outcomes may be attained by integrating the surgical, medical, and radiologic disciplines. The primary care physician remains an important cornerstone whose talents should not be underestimated in the overall patient management scheme. Additional services such as endocrinology, physical therapy, pain control, hospice, nutrition, biofeedback, and hyperbarics, among others, should be considered in the overall health care team. The organization of the team, including definition of the duties of key personnel and even the physical framework of the clinic, contribute to its success in treating patients with prostate cancer. Pitfalls of the process also are discussed in this article.

Introduction The most commonly diagnosed urologic malignancies include prostate cancer, urothelial malignancies, renal cancer, and testicular cancer. The diagnosis of each is made through a thorough evaluation of signs and symptoms related to the affected organ systems. Initial staging evaluation and treatment of localized disease also falls exclusively in the hands of the urologist, except in the case of prostate cancer. In this case, patients occasionally are diagnosed by interventional radiologists in conjunction with primary care and initial treatment may involve only consultation with radiation oncologists. However, these patients may need the care of a urologist because of treatment-related side effects (eg, hematuria, irritative voiding) or disease progression. Clinical associations among specialty physicians have come about through a realization that multimodal therapies are more effective for renal, advanced urothelial, and testicular cancer. Furthermore, the lack of effective curative therapy for prostate cancer in advanced stages and lack of consensus on optimal treatment for localized disease

have spawned clinical trials that have become ubiquitous among cancer treatment centers. Multidisciplinary clinics (MDC) for cancer patients have been the subject of several recent reports. Strasser et al. [1] reported retrospectively on their experience with a palliative care MDC for advanced cancer patients. Their questionnaire-driven study indicated an improved level of patient satisfaction with the clinic and an increased number of constructive recommendations in the MDC setting. Ko and Chaudhry [2] reported their experience with cancer patients in the multidisciplinary setting, emphasizing the need for continued vigilance with respect to existing comorbid variables. A report by Gabel et al. [3] in 1997 demonstrated improved patient satisfaction and a shortened interval to initiation of treatment in the MDC setting. Along the same lines, Chang et al. [4] reported that the MDC for breast cancer often provided patients with treatment options not otherwise offered. Valicenti et al. [5] reported on the experience with newly diagnosed prostate cancer patients at Thomas Jefferson University. Their experience was based on a model system in which each new prostate cancer patient was seen and examined by a urologist (100%), radiation oncologist (41%), and medical oncologist (5%) during the initial visit. Most patients (87%) had clinically localized prostate cancer. After the consultations, the clinical team, which also would include a pathologist and radiologist (when necessary), presented each patient for discussion and generation of a recommendation of treatment options for the patient. Relevant clinical trials also were considered in the recommendations. Although most patients came for second opinions, a significant number (67%) ultimately chose to have treatment through the center. The organizational structure and commitment of the participants were considered key to effective functioning of the MDC. The design and function of their MDC seems ideologically and functionally sound. However, from a practical perspective, having three specialists in waiting for new prostate cancer patients will not always be economically feasible. This is especially true considering that the urologist and radiation oncologist may be the only ones called upon for the initial treatment of most patients. Another approach, in the face of more limited resources, is to only schedule combined visits for those most likely to benefit from them. The mechanism for this involves the development of guidelines for scheduling based on

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Table 1. The health care team for prostate cancer* Localized (cT1/2,N0,M0) Urologist Medical oncologist Radiation oncologist Primary care physician Endocrinologist Pain control Other

X X X

Locally advanced (cT3,n0,m0) X X X X

Metastatic (cTx,N1,M1–3) X X X X X X X

*The distribution of providers by prostate by cancer stage. The urologic and radiation oncologists are involved in every stage of management, while other specialists usually enter the treatment team for disease progression.

the likelihood of needing a particular specialist and the knowledge of the usual recommendations for similar patients’ conditions. Rather than describe treatment-specific diagnosis and treatment regimens for prostate cancer, this article focuses on the organizational structure and responsibilities of various services in a functional multidisciplinary prostate cancer management clinic. It will draw on the experiences gained over the past 5 years at the South Texas Veterans Administration Health Care System (STVAHCS) and University of Texas Health Sciences Center at San Antonio Department of Urology. The STVAHCS GU Tumor Clinic is a tertiary center that handles all of the referrals from San Antonio through the lower Rio Grande Valley and the southern Texas Gulf Coast. Approximately 4500 prostate cancer-related visits are scheduled annually. This multidisciplinary clinic system is similar in many respects to the Thomas Jefferson MDC structure, but it involves the use of generally agreed upon algorithms for patient counseling, thus eliminating extraneous re-evaluations while still providing a high level of counseling and care. Flexibility is important to allow unanticipated visits with specialists as needed. Some pitfalls of the system are addressed because experience has shown that even the most sophisticated systems have occasional oversights that may compromise effectiveness.

The Organizational Strata of a Successfully Integrated Multidisciplinary Clinic Mission The plan described assumes an active role for the MDC that spans the timeframe starting before the prostate cancer diagnosis, through treatment, and throughout the patient’s natural lifetime. The key focus of the clinic is to provide education, with diagnosis and treatment following as indicated. For the at-risk patient, diagnosis is offered when appropriate and desired. After diagnosis, if curative intervention is possible and likely to decrease morbidity or mortality, it is offered. However, for advanced disease, cancer management, rather than cure, usually is the strategy. The latter often requires the most cooperative effort

among specialists (Table 1). Quality-of-life maintenance becomes a primary focus and includes education, intervention to alleviate common complications of the disease process, and the management of side effects of treatment. Interspersed at all levels is the opportunity for patients to participate in current clinical trials from the National Cancer Institute and other private organizations.

Patient population In a general urology practice, the number of new and returning prostate cancer patients may not justify the effort of establishing the infrastructure necessary for a multidisciplinary clinic. However, in academic centers, VA tertiary referral centers, and well-referred community cancer centers, having multiple specialists available and consulting during a single patient visit may allow for more efficient use of resources and better patient satisfaction. Patient perspectives vary with regard to their expectations from such a clinic visit. Many would like to hear options and maintain complete control over the treatment choices. Others are willing to set the entire process onto the shoulders of the providers. In general, an assessment of the degree to which an individual patient is willing or capable of participating should be made during the initial visit. Identification and documentation of the key family caregivers also is of particular importance because these often are the points of contact for future testing, clinic appointments, and treatment decisions. Facility Clinic space for the multidisciplinary clinic should be ample enough to allow each involved specialist an adequate number of rooms so that the flow of patients is not inhibited. This requires adequately sized waiting areas and appropriate numbers of examination and counseling rooms. Because many patients will require extensive counseling and have one or more family members along, the counseling rooms should be larger and allow for comfort and privacy. In designing the clinic, details such as wall insulation to control inadvertent disclosure of private health information during discussions, adequate numbers of accessible bathrooms, examination rooms capable of

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Table 2. Documentation recommendations for the multidisciplinary clinic chart* Patient contact information Family or other significant person's contact information Identify decision-maker within the family Patient's decision-making abilities, delegations Advanced directives, power-of-attorney documents Physician list and contact information Primary care physician, other specialists, and providers Problem list Medical, surgical diagnoses/histories with dates Medication list Include start and stop dates of genitourinary-related medications Include outpatient administration log Laboratory and radiology reports (with summary sheets as necessary) Prostate-specific antigen and date list annotated with treatments Up-to-date notes and consultation reports Format notes for easy summation, coding, and database entry Clinical and pathologic staging information as indicated Concise summary of any conferences regarding the patient (including dates and providers) Future Upcoming testing, clinic visit schedules Reminders of necessary less frequent periodic testing (eg, bone mineral density testing) *Documentation recommendations that allow efficient evaluation, reevaluation, and treatment. In paper charts, a separate section for "pending review" helps to alert the physician to new laboratory and radiology reports. These generally are not filed until reviewed and signed. Electronic records often will have an alert mechanism for review of the new results.

handling wheelchairs and stretchers, and the ergonomics of the examination rooms should be considered. The flow of patients within the clinic should be designed to minimize possible patient embarrassment and maintain confidentiality. This is particularly important when patients having catheters or wheelchairs or those on stretchers are brought in for consultation. A successful design will not have patients crossing paths as they move through the facility. Examination room design also is important to allow the patient and physician to function within their own space. Too often, patients are forced to look at the back of the physician’s head as he documents the visit. A simple change in room design allowing the physician to always be facing the patient adds the invaluable eye contact that nurtures the physician-patient relationship. Because prostate examination is inherently messy, an easily accessible sink, soap, and towels for patient use are important and convey a sense of respect in the overall process. In addition, especially for patients with more advanced disease or recurrences after initial treatment attempts, ancillary capabilities such as laboratory, radiology (computed tomography, magnetic resonance, general X-ray, ultrasonography, interventional), nuclear medicine,

and cystoscopy should be available on site, or close by, to speed diagnosis and treatment recommendations. If the clinic is part of a larger facility, attempts also should be made to allow these patients priority in the ancillary departments on the day of their visits.

Record keeping The clinic records ideally should be shared and immediately available to the treating team and ancillary services. An integrated electronic medical record such as the VA computerized patient record system allows every aspect of the patients’ care to be reviewed without delays caused by poor handwriting or dictation/transcription processing. A list of current providers, including the primary care physician (PCP) and any other specialists with whom the patient may be involved, should be maintained with chart copies sent to each after the clinic visits. This will allow for a smooth integration of care should the patient require admission, further work-up, or medical clearance prior to procedures (Table 2). In the private sector, sources of frustration and delay that must be addressed include insurance restrictions on providers and facilities and precertification requirements for laboratory, radiography, and invasive procedures. Preclinic review of the patients’ records and previous studies and phone interviews by an experienced clinical nurse, physician assistant, or other designated provider may be able to anticipate testing and procedures so that the precertifications can be in process or completed by the time of the visit. Depending on the third-party insurer, it may be necessary to have the primary care provider prepare referrals for consultations by each of the physicians in the clinic in order for the visit to occur as designed. Intraclinic referrals (specialist to specialist; specialist to facility) may be appropriate and acceptable, but care must be taken to avoid shortcircuiting the referral documentation required by thirdparty insurers. Patient satisfaction may plummet if the visit leads to unexpected additional expenses for lack of attention to detail. Tumor registry Most hospitals operate a tumor registry in an ongoing effort to maintain their cancer program’s approval by the American College of Surgeons Commission on Cancer. For many reasons, the registry should be an integral part of the design of documentation in the multidisciplinary clinic. Anticipating the entry of these data by accurate clinical and, when appropriate, pathologic staging in the medical record will allow rapid entry into the Tumor Registry database and more efficient queries for quality assurance (QA) and research purposes (eg, screening for clinical trials, research papers). In many institutions, the Tumor Registry may be cumbersome because of data entry methodology and restrictions, but it remains a readily available resource from which to begin QA and research databases.

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Quality assurance database This database is important to assure that all patients are given equal access to available resources, to identify patients with incomplete evaluation and treatment, and to avoid the occasional patient who becomes lost to followup. The QADB may be as simple as a spread sheet that tracks the patient’s progress in appointments, laboratory tests, and imaging. More sophisticated endeavors will allow outcomes measures, such as patient satisfaction surveys, quality of life, voiding dysfunction, and sexual dysfunction instruments, and objective assessments (eg, prostate-specific antigen [PSA]) to be assessed with regard to treatments administered over time. Research database This database, which may be derived from the QADB, provides the basis for participation in clinical trials and new research efforts. Research databases in general will require approval and oversight by an institutional review board with appropriate measures instituted for patient confidentiality and consent.

Educational materials A multitude of educational materials from pamphlets, books, and web sites are available to allow the patient a hard copy of the information necessary to become informed and allow appropriate decision-making. The delineation of all of these goes beyond the scope of this article. However, each clinic should investigate the available resources for their population of patients or create their own materials. The main standards should be to present an honest and balanced approach to the topic of prostate cancer treatment. In centers that offer treatment, a general assessment of their local success rates and potential complication rates will be a helpful tool for the patient in preparation for treatment. When appropriate, document translations to the patient’s native language should be provided. Standardized reading material also is a valuable asset to define and document the informed consent process. The latter point should not be taken lightly because an underinformed patient or one who jumps to treatment without considering options may later claim physician culpability for poor results or complications. Careful documentation of the consultations, treatment planning conferences, and recommendations with detailed reasoning can protect the physician, the clinic, and its reputation. Support groups Although many physicians view prostate cancer support groups as fringe activity, they provide an important source of comfort and sharing of ideas. They also provide a window into the current thoughts of the general public regarding the diagnosis and treatment of prostate cancer and the complications of treatment that may go unreported in the office. Involvement by the MDC personnel as speakers, consultants, or advisors will help to fulfill the

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primary educational goal and provide an opportunity to dispel myths and misconceptions that may circulate in the lay community.

Key personnel The success of the multidisciplinary effort depends on the development of a personnel infrastructure that includes the clinical nurse (CN) or case manager (CM), the physicians, nurse practitioners, physician assistants, and ancillary personnel from scheduling clerks, billing/insurance specialists, technicians, and patient advocates. Although not all clinics will have each of these positions, the functions of each serve to speed progress through the system and hopefully improve patient satisfaction and improve clinical outcomes. Data supporting the latter two objectives are sparse, but are anticipated to justify the effort. In the scheme of things, the CN or CM serves as the main coordinator of activities and maintains patient contact information and scheduling. As the CN/CM gains experience with patients and the physician team, he or she will begin to anticipate the need for testing and allow smooth flow by initiating precertifications and paperwork as needed. A close interaction of this person with the clinic scheduling manager is essential. Another function of the CN/CM is to serve as a point of contact and monitor a patient’s progress through the system. Significant other noncancerous genitourinary problems also are monitored so that the patient does not become lost to follow-up with regard to other diagnoses within the clinic structure. Maintenance of an accurate problem list also will help to prevent such errors. Maintenance of medication administration logs also are an important aspect of the CN/CM, especially for patients undergoing hormone therapy (HT) or those receiving zolendronic acid infusions. The former can become unduly complicated for patients on an intermittent HT protocol without accurate documentation. The CN/CM also should carefully monitor the no-show list, reviewing each case and rescheduling visits and testing as indicated. The no-show rate at STVAHCH approaches 15% for the tumor clinic. Reasons for the missed visits are varied and include other illnesses, lost appointment reminders, and lack of transportation. Maintaining a focus on the patients’ disease process rather than their punctuality and adding flexibility to scheduling brings most back into the fold for appropriate follow-up. In some cases, close follow-up by the patient’s PCP with phone consultations and less frequent visits to the clinic are acceptable. The PCP usually is responsible for the initial contact with the clinic prior to the diagnosis of prostate cancer. In some centers, this consultation may be separate from the multidisciplinary clinic, although identification of the atrisk population allows possible participation in prevention strategies. PCPs are an invaluable asset for their expertise in managing the general medical problems and preanesthetic evaluation, should a procedure requiring anesthesia be

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necessary. In some instances, routine care and follow-up of the prostate cancer falls back to the PCP if long-distance travel makes clinic visits impractical for the patient. Continued monitoring of such patients and regular phone consultations are encouraged. In addition, pain control, nursing home, and terminal care issues are within the practice scope of many PCPs. A urologic oncologist or experienced urologist provides the backbone of the clinic structure because every aspect of care, from the initial referral by the PCP (or self referral in many cases) for suspicion of prostate cancer, through biopsies, treatment planning, and management of advanced disease, fall under his or her purview. As such, the urologic oncologist functions as the distributor of consultations to other services and must be well versed in the controversies, standards of care, and treatment (or non-treatment) options available. Care must be taken to avoid shunting patients to one treatment or service over others based on economic considerations, personal biases, or anecdotal experiences. In this regard, it is wise to set up standard operating procedures and algorithms, which define testing, timing of consultations to other specialists, and treatment options. These should be agreed on by the entire treatment team. The patient and family often will bring their own conception or misconception of the situation based on prior knowledge, readings, or experiences with the situations of friends and family. Therefore, an important part of the discussion is to seek out the patient’s perspective and preconceptions to provide a basis for the ensuing discussion. This will allow the physician to function in the primary role as educator, setting the stage for the patients and their family to be an integral part of the decision-making process. As mentioned previously, it often is necessary to assess the degree to which the patient is able or wants to be involved with the decision-making process. The family caregiver and PCP often are invaluable resources in assessing the appropriateness of recommendations based on the patient’s abilities or disabilities. In academic centers, integration of the urologic oncology fellows and urology residents should be a primary educational goal and will allow the urologic oncologist to supervise and better serve a larger group of patients. Nurse practitioners and physician assistants often are extremely helpful when fellows and residents are not involved or are in limited supply. In either case, algorithm-based management protocols, which keep less experienced providers on track, are helpful [6•,7••]. Treatment algorithms serve as a basis from which to start and should not be seen as inviolate because each patient has a unique set of circumstances. Radiation oncologists play an important role in treatment at every clinical stage. Specifically, after diagnosis of prostate cancer and initial counseling, the radiation oncologist provides an overview of radiotherapy options including potentially curative treatment (for localized disease) and palliative efforts for more advanced stages.

Historically, almost all patients with prostate cancer were seen first by a urologist; therefore, many radiation oncologists perceived that the role of radiation was getting short-changed in the discussion of options. This has resulted in some efforts to bypass the traditional referral patterns to make sure that patients are informed of every option. However, this circumvention may leave the patient with more limited options because surgical treatments generally are not presented and any other noncancerous urologic issues may remain unaddressed. For example, irritative voiding issues could be addressed by the urologist before radiation treatment with an expected improvement in post-treatment functional outcomes.

Other specialty providers Medical oncologists experienced in the management of prostate cancer who are familiar with the nuances of HT usually become involved when the patients have failed other forms of treatment or have presented with advanced disease. Clinical trials of chemotherapy agents in earlierstage disease (eg, pre-prostatectomy studies) are in development and may help to involve the medical oncologists earlier. Endocrinologists have become involved in the care of advanced cancer patients who are undergoing HT for the management of the bone-related side effects. Occasional involvement by orthopedists and neurosurgeons is necessary for dealing with advanced cancer- or osteoporosisrelated compressions and fractures. Pre-emptive treatments and procedures often may prevent devastating complications related to fractures. One of the goals of the MDC is to proactively identify potential complications such as these and deal with them through radiotherapy or medication before they get to the point where stabilization procedures are necessary. Biofeedback may be helpful in treating the complications of surgery (incontinence) or radiation (urgency). Hyperbarics have been helpful in the patient with irradiation cystitis. Physical therapists, nutritionists, and palliative care specialists (hospice) may become a regular part of the clinic for patients with advanced cancer. Integration of providers The combined clinic attempts to get beyond the self-serving turf issues and provides a forum in which a balanced approach and presentation can be provided to patients regarding their options in dealing with their cancer. This necessitates an open and honest dialog among the different specialists and with the patients. There are multiple issues to consider. For example, the radiation oncologists must acknowledge that from the perspective of cancer control alone, surgery indeed is the gold standard for cT1 and cT2 disease. For disease that is truly confined to the gland, radiation cannot improve on surgical removal. The hope of radiotherapy is to approach the surgical results, while avoiding the potential morbidity of a major surgery. At the same time, the urologic oncologists have recognized that surgery is not in the best interest of every patient. For

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patients with cT3 disease and higher or cT2 with a high risk of extracapsular extension, radiation alone or combined with surgery may be better able to encompass the disease. An honest dialogue also would point out that nerve-sparing prostatectomy and brachytherapy implant have approximately the same rate of long-term impotence; therefore, if that concern is the patient’s sole motivation for seeking brachytherapy, they may be misguided. In addition, high-grade cancers (Gleason score ≥ 7) do not always respond well to radiation, especially if those cancers are bulky. Such patients may be better served with a surgical approach including node dissection and planned postoperative radiation, depending on the final pathologic findings. Integration of services rather than competition should drive the clinic.

Localized Disease To facilitate discussions, appropriate new patients should be seen by a urologic oncologist and a radiation oncologists during the same visit. The potentially curative options are presented in as balanced a manner as possible and tailored appropriately for individual patients. The radiation oncologist gives a detailed discussion regarding external beam radiation therapy and brachytherapy and offers a perspective on other options. The urologic oncologist does the same for the surgical option. A specific discussion of risks and benefits for each modality also is presented. Taking the patient’s overall health into account, the physicians then can collectively make a recommendation. The unification of all of these considerations leaves the patients with treatment options tailored to their specific situation. In most cases, the initial visit ends at this point because the amount of information to be digested by the patient can be staggering. Patients may be encouraged to go home, read their information, check out recommended web sites, attend a support group meeting (eg, Us Too or other prostate cancer support group), and return for additional discussions and formulation of a treatment plan. Provision of patients with educational material and a statement regarding their particular cancer (clinical stage, Gleason score, PSA) is important. If desired, this will give the patient adequate documentation for second opinions or discussions with the PCP. At a minimum, the MDC patient should leave the visit with a feeling that there was a team approach to the problem, without the conflicting recommendations of a disparate group of physicians. This empowers patients to make treatment choices with which they can be satisfied. Once the patient’s desires are known and an informed decision is made, the appropriate specialists make arrangements for treatment and follow-up. A physician or clinic that makes the same recommendation to every patient, regardless of health status or tumor factors, likely is not functioning in their patients’ best interest. On the other hand, if the patient is presented with strongly opposing views, the

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process may lead to more confusion than help in the decision-making process.

Advanced Disease A combined approach using the skills of the urologic oncologist, radiation oncologist, and medical oncologist is crucial to managing the disease successfully. The goal of this approach is to control disease progression by minimizing the problems associated with local growth (eg, bladder outlet obstruction, hematuria, ureteral obstruction) and distant spread (eg, fractures, cord compression). However, disease progression is only part of the problem with these patients. The urologic oncologist usually assumes a primary role in coordinating the group effort and handling the HT that has become an inevitable part of the treatment plan. The latter requires an understanding of the issues regarding timing, duration, and expected outcomes of HT. Managing the sequelae of HT requires expertise in bone metabolism, hot flushes, fatigue, muscle wasting, anemia, and sexual dysfunction. In many cases, the advice of an endocrinologist, physical therapist, dietician, and others must be sought and coordinated as well. Advanced disease patients make up an increasing percentage of the population of the MDC as the clinic matures. They also are the patients most likely to benefit from inclusion in clinical trials.

Follow-up Responsibilities It is important to build a follow-up program that incorporates the input of the urologic oncologist and radiation oncologist. In the straightforward patient who is biochemically free of disease after treatment of localized disease and is suffering from no adverse sequelae, follow-up eventually may fall to the PCP with periodic reports back to the clinic regarding PSA levels and re-referral for additional consultation if other issues arise. For those at high risk of recurrence or those suffering from adverse sequelae of treatment, combined follow-up visits should be the rule until every issue is settled. Patients who suffer a local failure after radiotherapy are evaluated by the urologic oncologist to assess candidacy for salvage surgery or other modality (eg, HT). Any additional radiotherapy is coordinated with the radiation oncologist and chemotherapy with the medical oncologist. In most cases of failed local therapy, the urologic oncologist assumes a primary role in follow-up and further treatment planning. As such, these patients usually remain under the care of the urologic oncologist in the MDC for life.

Conferences In addition to the immediate discussion of individual patients, Tumor Board conferences, during which challenging cases are presented and openly discussed among the

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Table 3. Potential problems within the multidisciplinary clinic Inattention to other significant genitourinary or medical problems Lack of care coordination No-show consternation No treatment; no follow-up mentality Lost to follow-up patients Inadequate documentation of the treatment plan Inexperienced provided derails treatment plan New specialist with nonconforming ideas for treatment

physician specialists and other providers, provide an educational enhancement to the overall MDC process. Such conferences should be scheduled at an interval appropriate to the patient population, usually biweekly or monthly. Management strategies and new modalities for treatment often come from such discussions. The results of such discussions should be recorded in the patient’s record by the case manager for later discussion with the patient. Short literature reviews and presentations regarding key issues by the residents and fellows also may be a key component of the conference.

Potential Pitfalls of the Multidisciplinary Clinic Table 3 describes problems we have seen that may be related to the structure of the MDC for prostate cancer management. The first two issues occur when providers become too focused on their specific area of treatment of the prostate cancer. Patients also may decline or fail to keep follow-up visits with their PCP while being treated in the MDC. An adequate periodically reviewed problem list and encouragement regarding continued involvement of the PCP will minimize this issue. The next three issues relate partly to scheduling difficulties or inflexibility. A busy clinic may adopt policies that restrict return visits for no-shows or those not seeking active treatment. In no case should patients who decline clinical trials be excluded from follow-up. Our clinic attempts direct contact with a no-show patient, but many times works through the PCPs to arrange appropriate follow-up and testing. If distance or transportation is an issue, arrangements with a urologist or clinic closer to home can be made. If patients decline further recommended visits, careful documentation of their reasons should be entered in the record. Patients declining treatment are placed on observation protocol and scheduled for periodic testing and visits for re-discussion of issues as indicated. The CN or CM should maintain the QADB,

which should allow identification of “lost to follow-up” patients. Reasons for these include death, moving to another location, change in third-party insurance, and others. Careful documentation of attempts to contact these patients including certified return letters should be made in the patient’s clinic record. The latter three problems require attention to documentation, clear communication with the patient regarding the plans, and provision of the current algorithms for testing and management as new providers come on service. Periodic re-discussion of the algorithms in light of new clinical data is important as a measure to continually update treatment options.

Conclusions The MDC can function well as an educational resource for patients and provide state-of-the-art-care for patients with prostate cancer of all stages. Integrated activities of providers and an appropriate physical and personnel infrastructure are keys to success. Clear and concise documentation of treatment strategies along with a functioning quality assurance infrastructure are important to keep physicians on track and patients satisfied with their treatment.

References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.

Strasser F, Sweeney C, Willey J, et al.: Impact of a half-day multidisciplinary symptom control and palliative care outpatient clinic in a comprehensive cancer center on recommendations, symptom intensity, and patient satisfaction: retrospective descriptive study. J Pain Symptom Manage 2004, 27:481–491. 2. Ko C, Chaudhry S: The need for a multidisciplinary approach to cancer care. J Surg Res 2002, 105:53–57. 3. Gabel M, Hilton N, Nathanson S: Multidisciplinary breast cancer clinics: Do they work? Cancer 1997, 79:2380–2384. 4. Chang JH, Vines E, Bertsch H, et al.: The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer 2001, 91:1231–1237. 5. Valicenti RK, Gomella LG, El-Gabry EA, et al.: The multidisciplinary clinic approach to prostate cancer counseling and treatment. Semin Urol Oncol 2000, 18:188–191. 6.• Hamdy FC, Basler JW, Neal DE, Catalona WJ: Management of Urologic Malignancies. London: Churchill Livingstone; 2002. Outlines an algorithm-based approach to the management of every aspect of prostate cancer. 7.•• Theodorescu D, Rabbani F, Donat S: Follow-up of genitourinary malignancies for the office urologist: a practical approach. Part 1: prostate and bladder cancers. AUA Update Series 2004, 23:297–307. This referenced outline of follow-up protocols provides an excellent starting point for clinics.