We must increase the number of, and accrual to, clinical trials. The best way is in the setting of multidisciplinary clinics.
Three main factors have significantly changed this scenario: First, risk stratification has allowed the clinician to better identify patients at presentation who are at high risk for PSA failure following attempted definitive treatment, typically those with ≥T2c disease, Gleason 8-10, or a PSA >20.0 ng/mL (JAMA 1998; 280:969-74). These patients are likely to fail monotherapy and will likely require a multimodal approach.
Second, the definition of advanced disease is evolving. Clinicians rarely see men at presentation with metastatic disease; more often, they present with biochemical recurrence. Subsequently, many will have prolonged disease-specific survival extending past a decade (JAMA 1999; 281:1591-7).
For these reasons, we face exciting times in the treatment of high-risk and advanced prostate cancer. More than ever, coordinated care among urologists, radiation oncologists, and medical oncologists is required to ensure optimal patient care (see, "Coordinated care maximizes advanced PCa outcomes,"). This multidisciplinary effort has been employed in other disciplines to optimize patient outcomes in a multitude of cancers, among them, breast cancer.
To make similar strides in prostate cancer, we need to work as a team to complete randomized, controlled trials. The AUA committee updating the guideline for the management of localized prostate cancer found a meager 27 randomized controlled trials that met strict criteria for incorporation into the final document. To advance the field of prostate cancer, we must increase the number of, and accrual to, clinical trials. The best way to accomplish this is in the setting of multidisciplinary clinics.
Many institutions have established clinics that integrate the urologic oncologist, radiation oncologist, medical oncologist, and a patient advocate within one clinic. The patient has the advantages of meeting with three medical specialists at one site and of having expertise from a prostate cancer survivor. Further, this approach has increased communication among the treating physicians and has reduced the concern of losing patients to another specialty.
A new age is dawning in the treatment of advanced and high-risk prostate cancer. A multidisciplinary effort will increase communication among specialists and should foster an environment in which more patients can be enrolled in clinical trials, particularly high-risk patients destined to fail monotherapy. Additionally, "one-stop shopping" gives the patient easy access to multidisciplinary expertise with one clinic visit. As coordinated care is adopted by more institutions and practices across the country, patients ultimately will benefit and the field will advance.
Dr. Thrasher, a member of the Urology Times Editorial Council, is professor and chair of urology at the University of Kansas Medical Center, Kansas City.