Multidisciplinary Clinics in GU Oncology-How Do They Best Work?
By: Scott P. Campbell, MD; Dominic C. Grimberg, MD; Brant A. Inman, MD, MS | Posted on: 01 May 2021
It is generally agreed upon that the format of the operating room must be carefully designed to facilitate optimal efficiency and effectiveness to best serve our patients. However, considerably less planning is often put into the format and design of clinic, yet evidence suggests that a carefully designed multidisciplinary clinic (MDC) can improve patient satisfaction and the quality of care that is provided. Genitourinary (GU) malignancies such as urothelial and prostate cancer frequently require multimodal treatments across medical subspecialties and are often best managed in the setting of a MDC.
The benefits of MDCs are numerous. MDCs are associated with a reduced travel burden and less time off work for patients,1 decreased time from diagnosis to treatment,1,2 favorable patient and provider satisfaction ratings,3,4 and favorable patient outcomes.2 In addition, studies suggest that MDCs are associated with better adherence to established guidelines5; for example, the use of neo-adjuvant chemotherapy in the treatment of muscle invasive bladder cancer has been shown to be higher when patients are seen in a multidisciplinary clinic.6 MDCs can also provide ideal infrastructure for clinical trials and other investigational studies. For instance, the Prostate Cancer Clinical Program at Walter Reed is a MDC that works in affiliation with the Center for Prostate Disease Research (CPDR), and together they offer a streamlined approach to provide high quality care while conducting clinical trials and advancing the field of prostate cancer treatment.7
A variety of MDC formats have been implemented for GU malignancies. While it may seem obvious, the defining characteristic of a MDC is the presence of providers from multiple specialties in the same clinic on the same day to see the same patients. Traditionally this has been done in the same physical space, although with advancements in telemedicine it is possible that MDCs could be conducted virtually. In addition, a MDC should be focused on a single disease, such as bladder cancer, rather than a range of diseases or malignancies. This allows for the structure of the clinic to be tailored to the disease, which improves efficiency and degree of specialization of providers.
The specialties present in a GU oncology MDC vary based on the disease and complexity of the patient population. Typically these clinics involve providers from urology, radiation oncology and medical oncology. Additional specialty team members to consider adding when appropriate are pathology, radiology, clinical psychology, palliative care, nutrition, nursing specialists such as ostomy/wound care nurses, and research coordinators. An effective multidisciplinary approach to men with newly diagnosed low or intermediate risk prostate cancer could include just a urologist and a radiation oncologist, whereas treatment for patients with advanced prostate cancer or muscle invasive bladder cancer (MIBC) likely require input from additional specialties and a more all-encompassing approach.
Another common feature of an effective MDC is an organized forum for discussion among the providers. Some institutions prefer to hold this prior to consulting with patients, such as Thomas Jefferson’s University prostate cancer MDC during which patient medical history is discussed among the group prior to the clinic visit.7 In our opinion this structure is preferable for complex cases where the best course of action is not obvious to any individual provider. When conducted in this fashion, this forum resembles a tumor board that allows for formulation of a unified treatment plan that is then discussed with the patient at the time of consultation. Many institutions already hold tumor board conferences and this could represent an easy way to incorporate this meeting into an already existing format. In other circumstances, holding the forum after patient visits is preferable. This could be beneficial for followup patients, where clinical status or imaging obtained during the day of the visit may guide future treatment decisions. Furthermore, in some settings a forum amongst providers may not be necessary. For example, for localized prostate cancer the primary goal would be to counsel patients on their treatment options, and then each patient will reach out to providers in the future to move forward with their chosen treatment.
An additional factor to consider when designing a MDC is whether the service will focus on new patient consultations or if it will provide longitudinal care to patients. Once again, the most effective strategy will depend on the disease being treated and the physical plant where patient care takes place. Newly diagnosed localized prostate cancer is an ideal setting to have a new patient consultation clinic where patients follow up separately with either their surgeon or radiation oncologist for the desired treatment. MIBC is best treated in a longitudinal fashion as multidisciplinary followup and coordination is necessary at multiple time points. Furthermore, a hybrid approach can be effective where patients with MIBC may “graduate” from an MDC if in remission and then be reintroduced to the clinic if recurrence or complication were to occur.
Overall, there is no right way to establish an effective multidisciplinary clinic. The proper format should be customized based on the providers available, the disease of interest, and the patient population. Ultimately the most effective MDC will be one that the patients and providers reliably attend and that involves a team of providers that trust each other and are committed to working together to do what is best for each patient.
- Gardner TB, Barth RJ, Zaki BI et al: Effect of initiating a multidisciplinary care clinic on access and time to treatment in patients with pancreatic adenocarcinoma. J Oncol Pract 2010; 6: 288.
- Stewart SB, Moul JW, Polascik TJ et al: Does the multidisciplinary approach improve oncological outcomes in men undergoing surgical treatment for prostate cancer? Int J Urol 2014; 21: 1215.
- Magnani T, Valdagni R, Salvioni R et al: The 6-year attendance of a multidisciplinary prostate cancer clinic in Italy: incidence of management changes. BJU Int 2012; 110: 998.
- Litton G, Kane D, Clay G et al: Multidisciplinary cancer care with a patient and physician satisfaction focus. J Oncol Pract 2010; 6: e35.
- Vinod SK, Sidhom MA and Delaney GP: Do multidisciplinary meetings follow guideline-based care? J Oncol Pract 2010; 6: 276.
- Nayan M, Bhindi B, Yu JL et al: The initiation of a multidisciplinary bladder cancer clinic and the uptake of neoadjuvant chemotherapy: a time-series analysis. Can Urol Assoc J 2016; 10: 25.
- Brassell SA, Dobi A, Petrovics G et al: The Center for Prostate Disease Research (CPDR): a multidisciplinary approach to translational research. Urol Oncol 2009; 27: 562.
- 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.