Prostate cancer units Facts and expectationspliszka.net/uro-files/2013/prezentacje/7-matei.pdf · A...
Transcript of Prostate cancer units Facts and expectationspliszka.net/uro-files/2013/prezentacje/7-matei.pdf · A...
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