HOW TO DO MULTIDISCIPLINARY CARE?

Khurshid A. Guru, MDKhurshid.guru@roswellpark.org

Chair of Urology Department

Professor of Urologic Oncology, Roswell Park Comprehensive Cancer Center

Director of A.T.L.A.S (Applied Technology Laboratory for Advanced Surgery) Program

UROLOGIC MALIGNANCIES? • For the prostate cancer cases (n = 67), the Central MDT did not

change outright the Local MDT decision in any case, but in 6 of 67 (9.0%), advised/excluded patients from clinical trials.

• For bladder cancer cases (n = 19), 4 of 19 (21.0%) patients had their management changed by the Central MDT.

• The one kidney cancer case had its Local MDT decision changed by the Central MDT.

• Two hundred sixty-nine consecutive new patients presented with an outside diagnosis of a urologic malignancy for diagnostic or treatment considerations .

• All cases were reviewed and discussed at a tumor board with all members of the different subspecialties present.

• Cohort was comprised: prostate (34%), bladder (23%), kidney (35%), testicle (5%), and other (1%).

• Only 35% of patients had no changes in diagnosis or treatment

• Changes in diagnosis were most common in bladder (23%) cancer.

• Changes in treatment were most common in bladder cancer (44%).

HOW TO IMPROVE OUTCOMES?

• MDT meetings were attended by three consultants in urology, a lead clinician, a pathologist, a radiologist, an oncologist, two urology nurse practitioners and junior staff.

• Two of 124 cases had their clinical management changed as a result of the meeting. These were identified (amongst 10 others) as potential ‘change cases 'prior to the meeting.

• Four changes were made to histological reports and 1 to radiology; none of these affected clinical management.

• Discussion of cancer cases at MDMs made no difference to the clinical management in over 98% of cases.

• Phase 1: 148 patients (61%) were candidates for neoadjuvant chemotherapy (NAC). Consultation for NAC was sought for 44 patients (29%),

• Phase 2: multidisciplinary approach.

• Significant improvement in referral for NAC use was seen (78%)

• 71% (vs 36%) received NAC

• The NAC utilization rate improved from 10.8% to 55% over 1 year with a diligent multidisciplinary approach.

IS THE INCREASE IN THE UTILIZATION OF NAC USEFUL?

• SEER-Medicare data from 2004-2011.

• 694/4534 (15.3%) of patients received NAC

• increasing from 11.0% in 2004 to 24.8% in 2011.

• Up to 50% didn't receive a cisplatin based chemotherapy.

• This underscores the importance of better identifying patients eligible for neoadjuvant therapy

BLADDER CANCER

• Radical cystectomy (RC) with pelvic lymph node dissection is the gold-standard treatment for muscle invasive bladder cancer (BC) and for refractory high-risk non-muscle invasive BC [1].

• Significant morbidity related to the procedure, with complication rates reported up to 50% [2].

• Recently, the Enhanced Recovery After Surgery principles (ERAS) has been incorporated into the care of bladder cancer patients, which was associated with improved postoperative recovery and decreased costs while maintaining quality of care [3].

1. Chavan S, Bray F, Lortet-Tieulent J, Goodman M, Jemal A. International variations in bladder cancer incidence and mortality. European urology 2014;66(1):59-73

2. Lawrentschuk N, Colombo R, Hakenberg OW, et al. Prevention and management of complications following radical cystectomy for bladder cancer. European urology 2010;57(6):983-1001

3. Geltzeiler CB, Rotramel A, Wilson C, Deng L, Whiteford MH, Frankhouse J. Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA surgery 2014;149(9):955-61

“NEEW” PATHWAY(NUTRITION, EXERCISE, PATIENT EDUCATION,

WELLNESS)

• The Cystectomy Pathway is designed to improve patient's experience before, during, and after surgery.

• Like a training schedule one would follow before running a marathon

• The team: physical therapists, social workers, dietitians, ostomy nurses, anesthesiologists, medical oncologists and urology

• A weekly team meeting is held.

* COORDINATING CARE THROUGH A MULTIDISCIPLINARY CLINICAL PATHWAY FOR PATIENTS UNDERGOING A ROBOTIC RADICAL CYSTECTOMY IN AN ONCOLOGY SETTING. Oncology Nursing Forum. 46(2):12, MARCH 2019

HOW IS THE NEEW PATHWAY DIFFERENT?

MarathonPatient

centered MDT team

Postoperative care

After discharge follow up

Preoperative care

ROLE OF THE TEAM MEMBERS • Oncology specialized nurse:

• Arranging appointments with medical oncology clinic if advocated by multidisciplinary tumor board meeting to avoid any delay in treatment.

• Scheduling all follow up appointment with other specialties

• Physiotherapy:

• Bladder cancer patients will be assessed before and after the surgery for functional mobility with 6 minutes’ walk test and 30 seconds sit to stand test.

• In hospital, postoperative goals to walk 3-4 times per day with assistance of staff for at least 100 feet each session starting for day 1. The patients are monitored objectively with, maximum distance and functional mobility time

• Nutritionist:

• Before surgery nutritional screening will be done for the patient to provide recommendations that help the patient to meet calorie, protein and fluid needs for each individual patient.

• During the hospital stay, the goal is optimization of fluid and electrolyte balance and meeting the calories requirements.

• Follow up meetings after discharge to discuss strategies to minimize any nutritional related symptoms such as nausea, constipation or taste changes

ROLE OF THE TEAM MEMBERS

• Social worker:

• Provide resources for any concerns, such as anxiety, depression, substance use, financial concerns and caregiver issues before and after the surgery.

• Stoma nurse:

• Familiarizes the patient to ostomy and clean intermittent catheterization in case of neobladder diversion before the surgery with help of educational materials.

• In the hospital, making sure about the ability of the patient / caregiver to change the stoma bag. After discharge, preparing the patient to deal with pouch irrigation and reporting related complications

THE IMPACT OF WEEKLY MULTIDISCIPLINARY MEETING ON THE EARLY PERIOPERATIVE OUTCOMES AFTER ROBOT-ASSISTED RADICAL

CYSTECTOMY: A MATCHED ANALYSIS

• Retrospectively review:

• 2 groups: those who were enrolled in the NEEW cystectomy pathway VS those in the pre-pathway era.

• Perioperative outcomes (estimated blood loss, operative time, blood transfusion, return of bowel function, functional mobility time, pain score, length of intensive care unit and hospital stay, and 30-day complications and readmissions) were compared.

• Multivariate analyses were modeled to assess for association between NEEW pathway and perioperative outcomes

RESULTS

• 64 patients (33%) in the NEEW pathway group vs. 128 patients (67%) in the pre-pathway group.

• NEEW pathway group:

• shorter ICU stay (p=0.02 )

• shorter mean inpatient stay (6 vs 7 days, p <0.01) f

• aster return of bowel function (3 vs 4 days, p < 0.01)

• lower pain scores on days 1, 2 and 3 after RARC (p<0.01) .

• Fewer 30-day high grade complications (5% vs 16%, p=0.02 ),

• but similar 30-day readmissions (p=0.11).

AFTER DISCHARGE

CONCLUSION AND FUTURE DIRECTIONS

• NEEW pathway was associated with improved short term perioperative outcomes after RARC

• This may lead to faster hospital discharge and reduce the cost burden

• Occupational therapists and a patient support group has been added the NEEW pathway

WHO ELSE NEEDS TO JOIN THE TEAM?