Addressing Challenges and Controversies in the Management of Prostate Cancer with Multidisciplinary Teams

Abstract

The diagnostic and treatment landscapes of prostate cancer are rapidly evolving. This has led to several challenges and controversies regarding optimal management of the disease that outpace guidelines and clinical data. Multidisciplinary teams (MDTs) can be used to engage the array of specialists that collaborate to treat complex malignancies such as prostate cancer. While the rationale for the use of MDTs in prostate cancer is well known, ways to optimally use MDTs to address the challenges and controversies associated with prostate cancer management are less well understood. One area of MDT care that remains undefined is how MDTs can most effectively provide guidance on clinical decision-making in situations in which information from novel diagnostic testing (genetic testing, molecular imaging) is substantially different from the established clinical risk factors. In this review, we provide a clinical perspective on ways that MDTs can be used to address this and other challenges and controversies across the prostate cancer disease continuum, from diagnosis to end-of-life considerations. Beyond clinical scenarios, we also review ways in which MDTs can mitigate disparities of care in prostate cancer. Overall, MDTs play a central role in helping to address the daily vexing issues faced by clinicians related to diagnosis, risk stratification, and treatment. Given the accelerating advances in precision medicine and targeted therapy, and the new questions and controversies these will bring, the value of MDTs for prostate cancer management will only increase in the future.

Fig. 1

FDA-approved therapies for advanced PC. Initial years of approval in the USA are shown. ^aApproved for the treatment of adult and pediatric patients with unresectable or metastatic, microsatellite instability-high, or deficient mismatch repair solid tumors (including PC) that have progressed following prior treatment and for whom no satisfactory alternative treatment options exist. ^bApproved for the treatment of adult patients with mismatch repair–deficient recurrent or advanced solid tumors (including PC), as determined by an FDA-approved test, that have progressed on or following prior treatment and for whom no satisfactory alternative treatment options exist. ^cApproved for the treatment of adult patients with prostate-specific membrane antigen–positive mCRPC who have been treated with androgen receptor pathway inhibition and taxane-based chemotherapy. CRPC castrate-resistant prostate cancer, FDA Food and Drug Administration, ¹⁷⁷Lu lutetium-177, mCRPC metastatic castrate-resistant prostate cancer, mHSPC metastatic hormone-sensitive prostate cancer, nmCRPC nonmetastatic castrate-resistant prostate cancer, PARP poly (ADP-ribose) polymerase, PC prostate cancer

Fig. 2

Involvement of the PC MDT along the patient journey. The patient journey in PC consists of 4 core steps (initial presentation, diagnosis and staging, treatment decision, and follow-up and monitoring). With rapidly evolving diagnostic and treatment landscapes, MDTs play central roles in addressing challenges and controversies related to the diagnosis, treatment, and monitoring of the disease. These challenges include deciding on which diagnostic tests to complete, interpreting the results of novel genetic testing and imaging, choosing an appropriate course of action when results from novel tests conflict with conventional risk factors, and selecting among multiple medically reasonable treatment options. Typical members of a PC MDT include urologists, med oncs, rad oncs, nurses, and radiologists/NMPs; however, composition of the MDT can vary be center and the extent of disease. Additionally, nuclear medicine specialists, pathologists, genetic counselors, and molecular testing experts will play increasingly prominent roles in current and future practice. ^aThe treatment decision and follow-up and monitoring steps can be part of a repetitive cycle if a patient’s disease is progressing and/or failing to respond to multiple therapies. ^bVarying involvement. ADT androgen deprivation therapy, APP advanced practice provider, ARPI androgen receptor pathway inhibitor, AS active surveillance, BT brachytherapy, chemo chemotherapy, CT computed tomography, MDT multidisciplinary team, med onc medical oncologist, MRI magnetic resonance imaging, NMP nuclear medicine physician, PARPi poly (adenosine diphosphate [ADP]) ribose polymerase inhibitors, PC prostate cancer, PCP primary care physician, PET positron emission tomography, PSA prostate-specific antigen, PSMA prostate-specific membrane antigen, rad onc radiation oncologist, RT radiation therapy, TNM tumor-node-metastasis

Fig. 3

MDT process for integrating information from established and novel risk factors to determine a management strategy. MDT process for integrating information from established and novel risk factors to determine a management strategy. There is often a lack of evidence-based metrics and guideline recommendations for patients who have different risk profiles based on established and novel risk factors, such as a patient with low-risk localized GG1 PC but with a high-risk BRCA2 mutation. MDTs can help navigate situations in which the evidence base is incomplete by using the diverse perspectives and expertise of those members on the MDT to evaluate the existing data, assess the suitability of different management strategies, and determine the need for additional testing. Often, there will be several medically reasonable management options supported by limited data, necessitating a shared decision-making approach with patients, and making sure they understand the benefits, risks, and unknowns of each option. Key members of the MDT in this clinical scenario are the specialist treatment decision makers (urologists, radiation oncologist, medical oncologist), individuals who can advise on the nuances of the patients existing risk factors (pathologists, genetic testing experts), and other clinicians who can advise on additional testing such as nuclear imaging (nuclear medicine physicians). GG1 Grade Group 1, MDT multidisciplinary team, NMP nuclear medicine physician, PC prostate cancer