How Multidisciplinary Care Impacts Prostate Cancer Treatment

Multidisciplinary care is a collaborative approach where various healthcare professionals come together to provide comprehensive care for patients, according to the National Institute of Health website, which is essential for optimizing treatment and preserving quality of life in patients with prostate cancer, according to Dr. Ravi Munver, a professor of Urology and vice chair of the Department of Urology at Hackensack University School of Medicine.

“Prostate cancer is the one type of urologic cancer where multidisciplinary care is of utmost importance,” he emphasized.

Munver is also the vice chair of Urology, the chief of Minimally Invasive and Robotic Surgery, the director of Robotic Surgery and Minimally Invasive Urological Oncology Fellowship, and the director of the Living Donor Kidney Surgery Program, all at the John Theurer Cancer Center, part of Hackensack Meridian Health.

To hear more from our conversation with Munver, check out what he had to say about making prostate cancer easier to understand for newly diagnosed patients.

CURE: How can patients tell the clinical trial might be a good option for them?

Ravi: Clinical trials are a very interesting thing when we discuss therapies with patients. I typically consider two types: investigator-driven clinical trials and company or corporate-sponsored clinical trials.

When someone is offered a clinical trial, you first want to find out who is initiating it. Is it the physician themselves, who might say, “Hey, I want to try something, and I want you to consider this because we may or may not see benefits”? Or is it a company or corporate sponsor? In the latter case, you should be aware that there might be some incentives for the physician or institution. This doesn't mean it's a bad thing, but as the patient, you want to be informed and understand the basis for that clinical trial being offered to you.

Clinical trials are beneficial when they offer some type of advantage to the patient and the overall patient community. For example, if someone has localized prostate cancer and is clearly a candidate for certain standard therapies, a clinical trial may not be the right fit. However, if you have a rare or more advanced form of prostate cancer, a clinical trial in conjunction with one of the standard-of-care therapies might offer you an advantage; that could be a good reason to consider it.

Can you discuss the importance of a multidisciplinary approach to cancer care for patients to have a better understanding of it?

Prostate cancer is the one type of urologic cancer where multidisciplinary care is of utmost importance. The way I describe multidisciplinary care to patients is to imagine a triangle with the patient at the center. The three points of this triangle are the urologic oncologist, like me, who performs surgery; the radiation oncologist, who delivers radiation; and the medical oncologist, who can offer a variety of medications to treat prostate cancer.

Sometimes prostate cancer is treated multimodally, meaning it's not just surgery alone, radiation alone, or medications like immunotherapy or chemotherapy alone. Sometimes it's a combination of two, or even all three. So, I position the patient in the center and explain that three different types of cancer physicians will be involved in their care, and it's important to understand the role of each.

If someone decides they want surgery, that's perfectly fine, but they may need radiation or medication, immunotherapy, or chemotherapy afterward. If they choose radiation, they may need surgery or immunotherapy or chemotherapy afterward. And if they go straight for immunotherapy or chemotherapy, there may still be a role for surgery or radiation in the future. Multimodal therapy for prostate cancer is extremely important.

Here at Hackensack University Medical Center, when I arrived over two decades ago, the first two people I met outside of my department were the medical oncologist and the radiation oncologist. We've developed a very close relationship because even if a patient wants surgery, I'll still advise them to discuss radiation, immunotherapy, or chemotherapy with the other two specialists. Then, they can come back and make their decision, because sometimes they may hear a different perspective from the other practitioners, the other oncologists, and they might change their mind or look at it from a different viewpoint. Similarly, sometimes patients will go to a radiation oncologist or a medical oncologist, and those specialists will say, “Well, you should really undergo surgery, because that's going to be the best chance for a cure, and we will certainly be involved in your care should you need it.”

Are there any additional procedures you'd like to discuss around kidney or bladder cancer that patients should be aware of before we close out today?

When I consider the realm of minimally invasive surgery for prostate, kidney, and bladder cancer, one of the biggest triumphs has been the shift from maximally invasive to minimally invasive approaches. This means moving from large incisions to small ones. Robotic surgery, which has been around for 25 years, has been instrumental in allowing practitioners to offer these minimally invasive therapies.

Robotic surgery has now become the standard for prostate, kidney, and bladder cancer, offering smaller incisions, faster recovery, greater precision during operations, and better outcomes. This has significantly impacted all aspects of care. For kidney cancer, robotic surgery has also made it possible to perform partial nephrectomies for the majority of treatable patients. This means we can remove only the tumor and a portion of the kidney, preserving the rest. We can do this for the overwhelming majority of our patients, which wasn't the case even 10 or 20 years ago.

Now, in the fields of kidney and even prostate cancer, artificial intelligence is becoming more prevalent, especially in imaging. When I perform my robotic kidney or prostate surgeries, we can create an AI-driven virtual model of the kidney and kidney tumor, or prostate and prostate cancer. This allows me to plan preoperatively and navigate the surgery intraoperatively, leading to a more precise, finite surgery. I know where the tumor is and understand the anatomy beforehand and during the operation. These 3D virtual models, created by machine learning technology, enable us to perform more precise operations with greater confidence and higher success rates.

In the realm of bladder cancer, we have progressed significantly. Surgery is, of course, the gold standard for superficial bladder cancer, where we simply scrape out the tumor and preserve the bladder. However, some people need their entire bladders removed. That was the standard about 20 years ago: if the tumor recurred after being scraped out, we would proceed directly to removing the entire bladder. Now, we have a number of different intravesical therapies — meaning inside the bladder — where we can instill medication to kill the cancer, prevent recurrences, and prevent progression to a point where a patient might need their bladder removed.

Another important aspect is neoadjuvant chemotherapy for bladder cancer. This means patients receive chemotherapy for a few weeks before their bladders are surgically removed. This is managed by the medical oncologist, who gives chemotherapy to shrink the cancer. Consequently, when we surgically remove the bladder in patients who need it, we have a better chance of getting all the cancer out without needing additional therapy or risking future spread.

Finally, there's always the aspect of bladder-sparing procedures. These involve a urologist, medical oncologist, and radiation oncologist. The urologist scrapes out the tumor, the radiation oncologist delivers radiation, and the medical oncologist administers chemotherapy. So, chemo-radiation in conjunction with surgically scraping out the bladder tumor can help preserve the bladder, allowing patients to live a normal life without having their bladders removed and a new bladder reconstructed. This is awesome.

Transcript has been edited for clarity and conciseness.

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