Prostate cancer units

Facts and expectations

Deliu-Victor Matei European Institute of Oncology

A Prostate Cancer Unit – a place where men with

prostate cancer can be cared for by specialists in

prostate disease working together within a

multiprofessional team – is suppose to offer the most

suitable organisational structure for caring for

prostate cancer patients at all stages, from newly

diagnosed to advanced disease, including

prevention and treatment of the main complications

of the malignancy and its treatments.

2010

Prostate Cancer Unit: background

Prostate cancer, due to

- the complexity of the treatment options (active or

observational)

- the need of high-quality medical procedures, supportive

care and rehabilitation

heavily benefits

General recommendations

Certification based on the fulfilment of agreed

mandatory requirements should be assessed by an

accredited independent European body, in order to ensure

consistency and uniformity in data collection

To provide care for patients with prostate cancer at all

its stages

To enrol at least 10% of all patients into innovative

clinical trials, to provide research opportunities and to

accept trainees

To provide teaching, either for junior staff or for

students on a national or international basis

To manage their own budget, covering all the work of

the Unit, including provision for ongoing education

Mandatory requirements (1)

Critical mass:

a sufficiently large caseload is required to run regular

clinics and make it practical and cost-effective

it should cover a population of at least 300,000 people

it should enrol at least 10% of all patients into innovative

clinical trials, to provide research opportunities and to

accept trainees

It should provide teaching, either for junior staff or for

students on a national or international basis

it should manage their own budget

Mandatory requirements (2)

Documentation:

audit meeting at least once a year

written protocols for diagnosis and for the management

of prostate disease and cancer at all stages.

all relevant data should be collected, recorded and

available for analysis, evaluation and audit

Mandatory requirements (3)

Core team:

Clinical director

Uropathologists (30%T: P, >150 sets of PBx)

Urologists (>25RP/yr, 50%T: P)

Radiation Oncologists (>25RT/yr or 15BRT/yr, 50%T: P)

Medical Oncologists (>30pts/yr, 30%T: P)

Nurse specialist in prostate cancer cure

Data manager

Mandatory requirements (4)

Non-core personel:

Radiologists

Medical physicists

Radiation therapy technologists

Physiotherapists

Palliative care specialists

Professionals offering

psychological support

Sexologists/andrologists

Geriatrician

Clinical trial coordinator

Patients advocates

Organisation of Prostate Cancer Unit (1)

Multidisciplinary case management

->90% of cases have to be discussed

All the following options must be available: radical

prostatectomy, external radiotherapy, brachytherapy,

observational strategies, hormonal therapy, chemotherapy,

palliative care and psychological support

-clear and easy-to-understand written and oral

information regarding the diagnosis and/or treatment /

observational options have to be provided; psycologist and

genetist counseling should be available.

Organisation of Prostate Cancer Unit (2)

Treatment and observational setting

-a clear, exhaustive and detailed written record

of the treatment and follow-up plan (MDM) has to be

provided

-centralised pathologic review of diagnostic

biopsies carried out elsewhere should be performed

on a regular basis before treatment

-RP, EBRT, BRT, HT, ChT, palliative care, have

to be performed in the PCU

Clinics

-new cases, follow-up, recurrent/advanced Pca

Organisation of Prostate Cancer Unit (3)

Equipment

radiology equipment for complete and adequate imaging

of prostate disease: conventional radiology, TRUS, bone

scan, MRI, CT, PET-CT.

daVinci® platform

the RT dept. must be two megavoltage units, a BRT unit,

a simulator and a computerised planning system

appropriate pathology equipment: processors,

microtomes, staining machines and immunostainers

all equipment should be no more than 10-years-old and

should be well maintained

RT

IEO Prostate Cancer Unit: the Core

U Int

Rad Onc MDM

The hub of a PCU is the

converging the support activities of other divisions/departments ... as PCa patients refer primarily to the urologist.

Prostate Cancer Unit

RT

IEO Prostate Cancer Unit: Patients referral

U Int

Rad Onc

Over the past decade, there has been widespread adoption of RALP and increasing centralization of Pca surgery at high-volume centers. On a population level, the number of RP performed has risen substantially.

in NJ, NY, and Pennsylvania

Nr of RP/y Nr of Hosp performing RP

2000 2009 Variation

Nr RP 8115 10241 +26%

Nr of Hosp RP 390 242 -37%

% hosp 62% 2% 59% 9% -4.9% x4.5

Contribution % RP 19% 20% 8% 57% -68% x2.8

% da Vinci 0% 0% 11% 100%

Nr RP/y 10.2 48 -0.7 +8,5-

12.4

2002 2008 Var.

Proportion of all prostatectomies A

48,1% 72%

Incidence of PCa in Wisconsin

4238 3900 -7,97%

Nr of PCa-pts who underwent surgery

33,1% 38,1% +25,6%

I phase: the advantage of adopter hospitals over the non adopters

II phase: non adopter hospitals remain out of the market

12

111

133

222 252

304

418

115 115

166 152

165

125 78

52 28

16

9

0

50

100

150

200

250

300

350

400

450

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

RRP

RALP

47% 63% 95% 81% 90%

=mean level of nr RRP/yr

IEO Prostate Cancer Unit: Patients referral

98%

However, in some cases, other

may become leader in clinical/research activities, especially if patients or research orderers refer primarily to this Dept.s

Prostate Cancer Unit

RT

IEO Prostate Cancer Unit: Patients referral

U Int

Rad Onc

will determine both

Prostate Cancer Unit

Multidisciplinary Discussison Meeting

RT U Int

Rad Onc MDM

GUIDELINES

PCU: The Hub

Out-Patient

RALP

Primary RT

AS

Primary therapy: support activities (1)

Out-Patient

RALP AS

Pathology: Bx

Rad: mp MRI Critical deadlocks

time to get the

pathlogy

limitation in MRI

availability

Standardization

pathology

PIRADS (MRI)

RALP

Primary therapy: support activities (2)

PHYSIO-THERAPY

EF REHABILITATION

PO MONITORING

Primary therapy: outcomes

Out-Patient

RALP

Primary RT

Adj RT/WW

PSM

GU Toxicity

Advanced disease / primary therapy failure

Out-Patient

Relapse/ Progression

Advance disease

MULTIMODALITY

RALP /RT

HORMONS

RT

Multidisciplinary Discussison Meeting

U Int

Rad Onc MDM

MULTIMODAL/ SALVAGE THERAPY

ADJ /TOX THERAPY

GUIDELINES

RT

Multidisciplinary Discussison Meeting

U Int

Rad Onc MDM

MULTIMODAL/ SALVAGE THERAPY

ADJ /TOX THERAPY

GUIDELINES

RESEARCH

TRANSLATIONAL

CLINICAL RES.

Research

IORT MRI HRPC TRIALS CYBERKNIFE

BKV CELLULAR CULTURES

TRANSLATIONAL CLINICAL RES.

SUPPORT ACTIVITY

DATA MANAGER & BIOSTATISTICS

TRANSLATIONAL RESEARCH LABORATORY

RT

Multidisciplinary Discussison Meeting

U Int

Rad Onc MDM

MULTIMODAL/ SALVAGE THERAPY

ADJ /TOX THERAPY

GUIDELINES

RESEARCH

TEACHING

J. CLUB CASES DISCUSS.

The role of a PCU is to guarantee a

for the

the clinical activity

the research

Conclusions

Counseling / performing the primary therapy

MDM guidelines

Suport activities (pathology, imagistic, physiotherapy, ED rebabilitation, FU strategies)

Therapy for toxicity, PSM

MDM case discussion

Therapy for relapse or advance disease

MDM case discussion

Conclusions: clinical activity

Research

MDM discussion for clinical trials

Suport activities (translational research)

Theaching

MDM case discussion, journal club

Specialistic (surgical, RT, medical oncology)

Conclusions: teaching&research activity

Adoption of High technology

Ensures critical mass

Ensures High quality in

decision making

therapy delivery

clinical outcomes

Conclusions : high technology adoption

Pca incidence

rates increased in

nearly all countries

Pca morta-

lity rates

increased in lower

resource settings and

declined only in high

resource countries