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The Allegheny Prostate Center

Comprehensive evaluation and unbiased counseling on treatment options

by Russell Fuhrer, MD, and Ralph Miller, MD

In Brief

Allegheny General Hospital is a tertiary care teaching

hospital in Pittsburgh, Pa., and the flagship of the

nine-hospital West Penn Allegheny Health System.

The Allegheny Prostate Center was the first and

is the busiest organized multidisciplinary clinic in

the health system and in the region. The Allegheny

Prostate Center sees about 250 new analytic patients

a year. At this unique multidisciplinary clinic,

patients undergo a three to four hour evaluation and

education process where they are evaluated by both a

urologist and a radiation oncologist. A pathologist is

also in attendance to review the patient slides. At the

end of the examination, patients participate in a group

discussion of all major treatment options. Here's how

this innovative program was started and how it is

structured today.

Historically Allegheny General Hospital has been a leader in innovative approaches to the delivery of healthcare. In the early 1990s, researchers began investigating cryosurgery for the treatment of tumors. Jeffrey Cohen, MD, and Ralph Miller, Jr., MD, urologists at Allegheny General Hospital, saw the potential for adapting this technology to treat their prostate cancer patients. These physician leaders then developed and pioneered a program for the treatment of prostate cancer with cryosurgery. As the technology developed and was described in medical and popular literature, the number of patients seeking cryosurgery at Allegheny General Hospital soon increased rapidly. For a variety of reasons, however, many men who presented with the intent of undergoing cryosurgery were not candidates for this procedure and instead were sent to see a radiation oncologist.

It became obvious to both specialties that patients were presenting intent on cryosurgery but were not well informed about the myriad of other treatment options for prostate cancer. The urologists and radiation oncologists soon came to agree that the best way for patients to be fully informed about all the options for prostate cancer treatment was to talk with both specialties--ideally in a multidisciplinary clinic setting.

A Unique and Successful Partnership The concept for the Allegheny Prostate Center was born in 1996. The idea was to have a multidisciplinary clinic, which was not modality or "sales" oriented, but rather provided patients with options for management of their disease. Educating patients about their disease, describing to patients the various treatment modalities, and allowing the urologist and radiation oncologist to discuss patient cases as part of a multidisciplinary team would create an environment that would foster effective and competent decision making.

In addition to the unique partnership that was developing between the urologists and the radiation oncologists, the multidisciplinary clinic allowed patients to be more involved and vocal in the decision-making processes. In an unexpected outcome, the Allegheny Prostate Center soon fostered an environment of "group therapy'" for men with prostate cancer and their families. Patients were not only able to speak with providers about the objective aspects of their disease, but they also were able to talk with other men who were going through the same experience.

Our Model The Allegheny Prostate Center is housed in Allegheny General Hospital's Cancer Center and is staffed by two alternating urologists who are members of the same private group practice, Triangle Urology Group, and one hospitalemployed radiation oncologist. Other hospital-employed staff includes a radiation oncology nurse, billers, and a secretary. A hospital-employed pathologist is always available to review pathology slides on the day of the consultation. Though rarely required, when appropriate, a medical oncologist and a staff psychologist are also available to consult with patients.

Patients who are seen at the Allegheny Prostate Center are referred by multiple sources. Many referrals are made through the private urology practice that helps staff the prostate center. Other patients are referred by the hospital's radiation oncology department. Urologists and radiation oncologists outside of our healthcare system also refer patients to the Allegheny Prostate Center, generally for a specific treatment modality or for a second opinion. Still other patients are self-referred--either because they have heard about the program from other patients or because they found the program on the Internet.

The Allegheny Prostate Center sets aside two and one-half days per week for the multidisciplinary clinic. All patient visits are scheduled through the urology practice. Up to seven patients may be scheduled for 30 minute appointments within a four-hour period. Patients are encouraged to bring family members and are told to expect to spend the entire afternoon at the clinic.

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Oncology Issues September/October 2009

ACCC's Prostate Cancer Project Model Programs

Pittsburgh, Pennsylvania

Photographs courtesy of the Allegheny Prostate Center

Top, from left to right: Russell Fuhrer, MD, director of Radiation Oncology, Allegheny Prostate Center; Brian Karlovits, DO, radiation oncology resident, Allegheny Prostate Center; Ralph Miller, MD, director of Allegheny Prostate Center, Pittsburgh, Pa. Bottom, from left to right: Lisa Weiss, receptionist and executive secretary; Leslie Kozak, RN, nurse coordinator; Diana Verba, biller at the Allegheny Prostate Center, Pittsburgh, Pa.

The Clinic Visit When an appointment is made, the urology practice sends a packet of information to the patient, including: A DVD and booklet about the Allegheny Prostate

Center and the multidisciplinary clinic process. A list of what the patient needs to bring to the multidis-

ciplinary clinic. A description of what to expect at the clinic visit.

Emphasis is placed on the 3-4 hours of time the patient will spend at the Allegheny Prostate Center.

Basic information about prostate cancer and treatment modalities. Patients are also encouraged to go to the Allegheny Prostate Center's website at: .

A medical history and urologic history worksheet that must be completed by the patient and brought to the clinic visit.

Once patients are registered, the patient's outside records are requested and copied, and the patient's pathology slides are sent for internal review.

When they arrive at the Allegheny Prostate Center, patients are seen separately by the urologist and the radiation oncologist for full history and physical examinations. After all patients are seen and the pathology review is completed, patients go to a conference room. Here the urologist and the radiation oncologist provide an overview of the prostate cancer disease process and specific treatment modalities. Patients are then asked for permission to discuss their case with the group. If permission is given, the urologist and radiation oncologist will review individual cases and discuss treatment options with all patients and family members attending the clinic.

On the day of the visit, no decisions are made by the patient. And--because of the nature of this disease--only rarely is a patient encouraged to make a "quick" decision. Instead, patients are told to go home and think about the various treatment options and about where they would like to receive treatment--from their referring physicians or by physicians associated with the Allegheny Prostate Center.

At the end of the multidisciplinary conference, patients receive contact information for both the urologist and the radiation oncologist. Within one week of the clinic visit, a nurse at the urology practice follows up with patients by phone to discuss how they wish to proceed and to help with arrangements.

Our Treatment Options The Allegheny Prostate Center offers a full range of treatment modalities. At the multidisciplinary meeting, the urologist and radiation oncologist discuss these treatment options: Surgery (both a standard prostatectomy and a da Vinci

prostatectomy) Radioactive seed implants (brachytherapy) External beam radiotherapy (IMRT and IGRT) Cryosurgery Androgen deprivation to inhibit testosterone produc-

tion (hormonal ablation therapy) Expectant management (a "watch and see" approach) A combination of these treatments.

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Our treatment results with each of these modalities are shared with the patients and generally reflect our conservative approach to treatment.

While the Allegheny Prostate Center does not have written treatment guidelines, our urologists and radiation oncologists have developed general "agreements" about appropriate options related to patient age, performance status, PSA level and history, Gleason score, AUA score,

SHIM potency index, prostate size, and other factors. Over the past nine years of working together, rarely do the urologist and radiation oncologist drastically disagree on treatment recommendations. When disagreements arise, we tell the patient the rationale for our disagreement and work with them to resolve the issue. Generally the two specialties are able to agree on and provide a few reasonable treatment options for patients to consider.

Figure 1. Program Strengths and Weaknesses

Areas of Strength Our ability to present options to patients without

"pushing" or "favoring" any specific modality. Urologists and a radiation oncologist who philosophically

agree on prostate cancer and its treatment. Our willingness to send patients back to their referring

doctors for treatment. A low-stress patient environment. The quality and range of procedures that we can provide

for patients. A consistent pathology review by one or two experienced

pathologists. An environment that promotes patient interaction and

participation. A budget that is entirely funded through community

fundraising efforts of hospital staff and patients. Our fundraising efforts and our non-profit organization support our website (), development of our educational materials, the purchase of equipment for use in the treatment of prostate cancer patients, and the sponsorship of patient education events for the community.

Areas for Improvement We would like to begin prospective

and long-term outcomes data collection. We would like to implement a marketing plan for patients and referring physicians. We would like to collect qualitative and quantitative patient satisfaction data.

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Figure 2. Early Data on Treatment Options Chosen By Patients

45% 40% 35% 30% 25% 20% 15% 10%

5% 0%

4/96?3/97

4/97?3/98

4/98?3/99

Watchful Waiting Radical Prostatectomy Brachytherapy External Beam Radiation Cryosurgery External Beam Radiation + Brachytherapy

A Lesson Learned

Early in our program development, we invited members of the US Too and Man to Man support groups to the Allegheny Prostate Center. The idea was for these volunteers to provide emotional and experiential support for new patients from the perspective of patients who had been through the process and treatment. Despite coaching, we found that the volunteers were so wedded to the treatments that they had personally undergone that they could not be unbiased in their discussions with patients. While these volunteers did provide emotional support, they tended to undermine our approach of giving unbiased information about all of the treatment options available patients. For this reason, we discontinued the program until we can overcome the inherent biases that these volunteers bring.

Changes in Treatment Patterns The Allegheny Prostate Center has undergone significant changes in referral patterns over the years (see Figure 2). As stated previously, most patients were initially seen for cryosurgery, although many ultimately received other forms of treatment. When prostate brachytherapy was not widely utilized, the Allegheny Prostate Center began to see many patients interested in seed implants. As more community cancer centers began opening seed implant programs, those referrals decreased. Recently, the Allegheny Prostate Center initiated a robotic prostatectomy program and many patients are now drawn to the prostate center to specifically discuss this option. In other words, the Allegheny Prostate Center has observed that an increase in popularity of a certain procedure in the lay literature generally results in more patients coming to the prostate center intent on that procedure. After an in-depth discussion of the various treat-

ment options, however, patients may or may not ultimately undergo the procedure that they initially thought they wanted. And even those patients who do stay with their initial preference are much better informed of the details and alternatives to whatever procedure they choose.

While the Allegheny Prostate Center was originally conceived to help manage patients who were being evaluated for a specific treatment modality, cryosurgery, the center has evolved into a clinic where patients come for an unbiased review and discussion of their disease and its potential impact on them, recommendations for treatment, and a general overview of prostate cancer. Our patients learn about all the different modalities that are available and specifically, which ones are appropriate to their care. Patients understand that there is rarely a singular treatment that would be "best" for them and that they have choices about their care. Our multidisciplinary team helps patients and families work through the complex decisionmaking process inherent in comprehensive prostate cancer treatment.

As a physician who has seen well over 1,000 prostate cancer patients in nine years at the Allegheny Prostate Center, I can attest to the fact that a horizontally integrated, multidisciplinary approach to a complex disease and decision-making process ensures that patients make informed and appropriate decisions. There is no better way of providing informed consent for patients. I believe that all patients would benefit from such a process, and I encourage physicians and community cancer centers to develop programs that would be appropriate to the needs of their patients.

Russell Fuhrer, MD, is system director of Clinical Services at Allegheny Hospital, Department of Radiation Oncology, and director of Radiation Oncology at the Allegheny Prostate Center, and Ralph Miller, MD, is director of the Allegheny Prostate Center, West Penn Allegheny Health System, Pittsburgh, Pa.

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