Approccio multidisciplinare per il tumore della prostata

A multidisciplinary prostate cancer clinic relieves some of the hassle and burden of traveling to numerous clinics, as well as the anxiety of having to wait for appointments with various providers, to find out about planned treatment.

For cancer patients, it is often an overwhelming process to undergo diagnosis and treatment with different healthcare providers, who practice in different clinics, and even in different cities.

A multidisciplinary prostate cancer clinic relieves some of the hassle and burden of traveling to numerous clinics, as well as the anxiety of having to wait for appointments with various providers, to find out about planned treatment. At a multidisciplinary prostate cancer clinic, all the providers are available on the same day, in the same place, and can work together to formulate a cohesive treatment plan. In contrast, when you have healthcare providers providing diagnosis and treatment in different practices, everyone works in a vacuum to some extent. Providers are not knowledgeable about all the possible implications of the patient’s treatments. Thus, a medical oncologist may not see all the urology implications of certain cancer treatments, and a urologist may not be fully knowledgeable about the side effects of cancer treatments such as chemotherapy.

Multidisciplinary clinics operate in different ways. Some are true multidisciplinary clinics; the providers are present in the same location on the same day, and work together on each patient’s treatment plan. So, at the end of the day, the patient receives a multidisciplinary care plan that considers every health provider’s expertise and perspective. Even when providers have different opinions, these differences can be discussed in front of patients, so that they understand all the pros and cons of a treatment plan. This type of communication between providers gives patients more faith in their treatment, as well as in the healthcare system. It can also be reassuring for patients to hear the same message about planned treatment from different specialists.

Other multidisciplinary clinics operate as “virtual” clinics: the providers communicate by email or phone, but every provider’s perspective is considered in a timely way when coming up with the patient’s care plan. In contrast, a patient who receives care from various providers who are not in a multidisciplinary setting may be treated by physicians who do not communicate with each other, and whose electronic medical records (EMRs) are not even linked.

It is very valuable from both the patient’s and the provider’s viewpoint to have good solid cohesive communication between the different providers in a multidisciplinary clinic. In our multidis-ciplinary advanced prostate cancer clinic, we have providers that include a participating urologist, medical oncologist, and a radiation oncologist. We also have dedicated support staff, including a clinic manager, advanced practice nurses, and physician assistants, as well as dedicated registered nurses (RNs).

From the provider’s standpoint, it is crucial to be able to talk to colleagues about challenging cases, and make treatment plans in close collaboration with providers in other disciplines. It increases their knowledge and education about a plan of care, and makes them better doctors at the end of the day. Having providers talk to each other about a case is not usually problematic, because as physicians, we love to get an answer from colleagues and get one quickly.

Now that we have oral agents for treating advanced castration resistant prostate cancer (CRPC) such as enzalutamide and abiraterone, questions often arise about treatment decisions, if one of these medications fail. The question that often faces urologists is whether a patient should be treated sequentially with another oral agent, or with chemotherapy. It’s a real benefit to talk these complex decisions over with a doctor from another specialty. Patients with metastatic CRPC can also have urinary symptoms while undergoing oncology treatments, and it’s important to have a urologist on board who can treat incontinence, blockages, and infections. On the other hand, you don’t want to run into a urinary tract infection while a patient is on a cytotoxic agent, so having doctors available with both medical oncology and urology expertise is vital.

There are challenges to running a multidisciplinary cancer clinic. One of the problems is having adequate support staff who can handle different types of treatment. A nurse trained in medical oncology does not necessarily have expertise in performing urologic procedures such as bladder scans.Yet, for a urology nurse, performing these procedures is second nature. A urology nurse may not have much experience dealing with the complications of systemic therapy, such as neutropenic fever or intractable nausea and vomiting. Having support staff that can cover all these specific areas of expertise is important, but it can be difficult to train people to be conversant in several different disciplines.

Physical space can also be an issue. For a practice to be efficient, you must have multiple rooms running at the same time. With the additional providers required by a multidisciplinary clinic, you may need additional space and support staff to keep the clinic running smoothly. The idea is not to slow down the flow of patients seen by any of the clinic’s doctors.

In an era when doctors see increasing numbers of patients each day, and have increasing demands for documentation, the challenge is to remain efficient. When you have multiple providers in a multidisciplinary clinic, and you haven’t worked out the spacing and support staff questions beforehand, it can be a daunting task to optimize everyone’s time.You want to make sure that everyone’s time is used in the most valuable way. Since it can be problematic to find sufficient space to run a multidisciplinary clinic under one roof, many clinics are maintained virtually.

In a virtual clinic, cases may not be discussed in the same space, but everyone is on the phone at the same time to create a treatment plan for every patient. Virtual clinics can be clinics in which providers are in the same building, but on different floors, or even in different buildings throughout the community.

At Vanderbilt, we have a multidisciplinary advanced prostate cancer clinic that takes place in one space on campus. In a community setting, however, having a virtual clinic is often the only way to operate a multidisciplinary cancer clinic. As more medical centers and clinics merge, however, it will also become easier for multidisciplinary community cancer clinics to take place in a central location. Thus, patients will obtain better care, and may be able to be seen sooner for problems such as treatment complications.

For clinic managers, it can be a demanding task to put together schedules in a way that makes sense for all the providers, support staff and patients involved in a multidisciplinary clinic. Medical oncologists and radiation oncologists should be in the clinic on the same days that urology surgeons are available and not in the operating room. From a scheduling standpoint, you must make sure that nurse practitioners and physician assistants, who are well trained, are available to help pick up routine care when physicians cannot be present. These allied health professionals should also be up to date on every patient’s care plan, and be part of making that plan, which takes time. It’s helpful to encourage good communication about care plans and scheduling with regular phone calls and emails to ensure that patients experience continuity of care.

In an era of bundled payments, a multidisciplinary clinic can create efficiencies, because a patient can be seen by different providers on the same day, and even at the same time, rather than having several different appointments with multiple providers. If providers can ask for opinions from other specialists, and get quick answers, it helps avoid additional physician visits and even errors. Due to the improved communication that takes place at a multidisciplinary prostate cancer clinic, lab tests are less likely to be repeated unnecessarily, and there’s less risk that scans will be double-ordered, for instance.

We’re likely to see an increase in multidisciplinary localized prostate cancer clinics as well as advanced prostate cancer clinics in the near future. Studies have shown that establishing collaborative environments for treating localized prostate cancer is associated with triaging patients to higher rates of active surveillance, rather than treating patients with prostatectomy or radiation. Thus, a multidisciplinary localized prostate cancer clinic can be an advantage for payers, because it saves money by steering patients to less expensive interventions, and improves patient care. Eventually, multidisciplinary prostate cancer clinics will also include health professionals who provide psychosocial support, palliative care, and nutritional counseling as well as medical oncology, radiation oncology and urology. Having these support services within easy access will ensure earlier referrals and more comprehensive healthcare—so there’s less risk for patients to “fall through the cracks.”

For patients, it can be a relief to be involved in a multidisciplinary prostate cancer clinic. As well as relieving the anxiety and emotional burden of having to visit providers in different offices, a multidisciplinary cancer clinic eases the physical burden of having to travel to different locations. It’s also a benefit for caregivers, who can derive psychosocial benefits from having care delivered at just one clinic, where all the patient’s healthcare providers collaborate on a treatment plan.

Although staffing can be challenging for multidisciplinary cancer clinics, it is less of an issue for clinics that are in the same practice or under one roof. The use of physician assistants and nurse practitioners in a multidisciplinary clinic will depend on the scope of a practice, local regulations, as well as how a practice already uses these allied health professionals.Yet nurse practitioners and physician assistants can be very important additions to a multidisciplinary cancer clinic, because they can take on routine follow-up cares, and enable doctors to see more patients and provide improved quality care. An RN dedicated to a multidisciplinary clinic may also be useful, since they can help with the increased documentation and paperwork involved in running these clinics.

Another issue that can be problematic for multidisciplinary cancer clinics is billing. So far, our multidisciplinary advanced prostate cancer clinic has not had problems billing for services provided by different members of our professional team, or billing for facility fees. That process has been made easier by the fact that we are all practicing at the same location. Billing for healthcare provided in a virtual multidisciplinary clinic in the community, however, may face more roadblocks, since urologists, medication oncologists and radiation oncologists all practice in different settings. In the future, however, billings by virtual multidisciplinary prostate cancer clinics in the community should become easier as payers recognize the efficiencies of these clinics.

Physicians who decide to participate in a multidisciplinary prostate cancer clinic should be aware that their patient volume may increase dramatically, since each discipline will be involved in devising the patient’s care plan in the early stages. So, a medical oncologist may contribute to the patient’s care plan, even before that patient transitions to chemotherapy. As these multidisciplinary clinics become busier, the challenges of having sufficient space become more difficult. Thus, having enough space and the ability to expand is important.

Healthcare providers who start multidisciplinary clinics will find that patients will come out of the woodwork to attend these clinics. Patients are often eager to participate in multidisciplinary cancer clinics, because of the care coordination, quality treatment and psychosocial benefits offered there. Patients who come to these clinics know that their doctors and other healthcare providers are working in concert to make the smartest treatment decisions possible. For healthcare providers, on the other hand, a multidisciplinary cancer clinic has the potential to improve patient satisfaction through cohesive treatment plans. Such clinics also offer easy access to collaborators who can help optimize your patient care.

Fonte: https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/94108-the-multidisciplinary-cancer-clinic-everyday-urology-full-text-article.html