The Prostate, New Concepts and Developments
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Prostrate cancer is a common cancer in males with increasing rate of incidence these days. Two known markers prostatic acid phosphatase PAP and prostate specific antigen PSA have been used for diagnosis and in the clinical management of prostate cancer patients. The present study shows that the circulating immune complexes CICs may be associated with the pathogenesis of prostate cancer and their progression. CICs were investigated in 50 prostate cancer patients having different grades of the disease and 45 benign prostate hyperplasia patients BPH.
Estimation of CICs was done using 3. The results obtained were compared with normal healthy individuals. Present investigation shows CICs may be associated with the pathogenesis of prostate cancers. The further qualitative analysis of CICs may help us to formulate specific immunological tests for early detection, management and monitoring the efficacy of treatment in prostate cancers. Olivier Cussenot, Genetic susceptibility to prostate cancer.
What’s New in Prostate Cancer Research?
Epidemiology of prostate cancer in India. Meta Gene Dec; 2: — Descriptive epidemiology of the cancers of male genital organs in greater Bombay. Indian J cancer ; Sexually active elderly less prone to prostate cancer. Chu TM. Prostate cancer- associated markers. The contribution of prostatic acid phosphatase and prostate specific antigen in the diagnosis of prostatic cancer.
Bio Markers, Apr-Jun; 3 2 : J Urol. Prevalence of prostate cancer among men with a prostate specific antigen level Bostwick DG. Prostate specific antigen — Current role in diagnostic authology of prostate cancer. Prostate cancer progression in the presence of undetectable or low serum prostate-specific antigen level. Prostate cancer screening. Recent Results. Cancer Res. Serial prostatic biopsies in men with persistently elevated serum prostate specific antigen Values. J Urology ; 6 : The use of prostate specific antigens density to enhance the predictive value of intermediate Levels of serum prostate specific antigens.
J Urology Mar; 3pt 2 ; McNeel DG. Prostate cancer immunotherapy. OpinUrol, May: 17 3 : Immunotherapy for Prostate cancer- recent progress in clinical trials.
ClinAdv Hematology Oncol. Elkord E. Immunology and Immunotherapy approaches for prostate cancer. Prostate Cancer Prostatic Dis. Prognostic value of serum markers for prostate cancer.
Discovery of LHRH and development of LHRH analogs for prostate cancer treatment
Scand J UrolNephrol Suppl. Detection of circulating immune complexes by polyethylene glycolprecipitation complement Consumption test in urological malignant disease. Hinyokikokiy, 30; Evaluation of cell mediated and circulating immune complexes as prognostic indicators in cancer patients. Cancer detection Prev, ; 22 2 : Prognostic significance of circulating C patients. Jap J. For each category, key process areas were defined and partitioned into requirements for prostate cancer centres. These requirements were specified by criteria, which, in turn, were substantiated by best practice elements extracted from the sources mentioned above Figure 1.
To continuously improve our approach, the developmental progress was subjected to periodic reviews by team members. Mindjet Mindmanager Software was applied to manage the resulting hierarchically structured knowledge database. With more than criteria, the model describes best practice elements in all different fields of a prostate cancer centre. A structured survey matrix was derived from the comprehensive database by using the Mindjet Mindmanager Software. This survey matrix is thought to be used in on-site interviews with variable numbers of stakeholders depending on the size and organisation of a centre.
Interviewees might comprise physicians, executive management, medical and non-medical personnel, administrational staff, and referrers. Obtained information is then entered into an EXCEL spreadsheet database to allow a standardised and systematic evaluation of each requirement, based on the fulfilment of each criterion. Next, fulfilment is assessed by the team with best practice standards as reference as defined by the criteria and notes and subsequently ranked on a 4-point Likert-scale ranging from 1 not fulfilled to 4 completely fulfilled. Data are summarised in radial bar charts, along with a description of problems and potential solutions.
In general, Act On Oncology comprises three phases systematic assessment, elaboration of results, presentation of findings. The on-site assessment by three consultants usually lasts for 3 to 4 days. The elaboration and presentation of results requires 2 to 3 weeks. The INT was selected because of its long-term experiences in both multidisciplinary care of prostate cancer patients and prostate cancer research  , . The multidisciplinary clinic at INT has two components, weekly multidisciplinary consultations of specialists and weekly clinical case discussions.
During the on-site survey, 24 employees representing all relevant clinical processes including management, controlling, data management, and clinical trial handling were interviewed by two members of the core team and one associate member, accompanied by a translator if necessary Tab. The duration of each interview was about one hour; the whole interview phase lasted three days.
Additional information on infrastructure and IT-related subjects was acquired during a guided tour through the facility. Obtained information was analysed as described above and presented in a standardised presentation that included results and recommendations. The five categories were then split into 30 clusters of related activities key process areas , which were thought to best characterise the main functional units.
In detail, 16 key process areas were defined for clinical processes, 8 for centre communication and management, 4 for infrastructure and IT, 2 for strategy and research. The selection of process areas was continuously challenged and revised if necessary. Next, these 30 key process areas were divided into requirements. To finally characterise each requirement, criteria were defined and further substantiated by notes Figure 1. Having defined and organised the different categories, process areas, requirements, and criteria, a structured survey matrix for on-site interviews was created.
After the interview phase, obtained information was entered into a spreadsheet database and the degree of fulfilment of each requirement was appraised and quantified by the team. Results were then visualised in radial bar charts, thus immediately giving an overview of the process quality of the whole centre. A three-colour code illustrated the urgency of management attention Figure 2.
On the outer circle, the corresponding maturity level of each category is provided. During the on-site assessment of the INT, several processes and features were considered best practice when compared with the best practice experience integrated in the Act On Oncology database. These processes and features included the weekly multidisciplinary clinics, the weekly multidisciplinary case discussions, the psychological support for patients early in the decision making process, and the existence of active surveillance protocols.
In the multidisciplinary clinics, prostate cancer patients are counselled by a multidisciplinary team consisting of urologists, radiation oncologists, medical oncologists for advanced, hormone-refractory and metastatic disease , and psycho-oncologists. Supportive care, rehabilitation, and specialist palliative care interventions are available on demand.
Case discussions then aim at sharing decisions made in the multidisciplinary clinic, tailoring therapeutic strategies, and evaluating the adherence to guidelines. Urologists, radiation oncologists, medical oncologists, psychologists regularly participate in these discussions, while pathologists, radiologists, and experts in supportive and palliative care join in on demand. Trained administrative personnel is further employed to improve the clinical workflow by reminding patients of their clinic appointments and collecting required information.
Together with the preparation and adoption of shared institutional guidelines, these measures were considered to increase the quality of care and to contribute to a successful enrolment in protocols, above all in active surveillance studies. Regular patient satisfaction surveys, the high level of evidence based decision making, and the considerable contribution to clinical research were viewed as additional quality indicators.
In contrast, substantial need for improvements was identified in centre management and infrastructure. For example, the collaboration between the departments of urology and radiation oncology was not defined at the management and strategy level, and the corporate identity within the prostate cancer unit was not particularly evident.
Most importantly, the prostate cancer program received limited support from the hospital administration. In particular, there was no sufficient budget and staffing allocated to the program, resulting in a continuous need for other non-institutional funding sources. Moreover, the INT infrastructure did not support the clinical workflow optimally.
In summary, beside several best practice elements, some opportunities for improvements of operational processes, management, and infrastructure were identified. Concrete measures were suggested in a systematic management summary. A reassessment is planned in about two years to evaluate whether the suggested measures lead to the expected improvements. Multidisciplinary care has been recognised to improve the quality of care and to positively influence outcome in some types of cancer such as breast cancer  ,  , .
Therefore, multidisciplinary management of patients with other cancers like prostate cancer is increasingly advocated  ,  ,  , . Multidisciplinary management in specialised prostate cancer centres implies new organisational and management challenges  ,  , . Hospitals traditionally have a vertical management structure with individually operated clinics or departments, while a horizontal management approach would be more appropriate to align and integrate the different medical, supportive, and management functions to achieve high medical and operational standards  ,  , .
To improve the standard of cancer care, different national and European certification programs for breast and prostate cancer care have been launched representing a promising step towards continuous quality improvement and standardisation of cancer care  ,  ,  ,  , . However, quality and efficiency of operational processes and the level of integration of services are usually not in the main focus of certification programs. Thus, to complement existing certification programs, we developed the Act On Oncology approach which isas to our knowledge the first example to apply the CMMI for the structured assessment of prostate cancer centers.
In contrast to other consulting practices in the market, the predefined interview matrix of Act On Oncology allows a quick and reproducible analysis of a center within a few days. Act On Oncology aims to generate a holistic view on the operational processes in each unit of a cancer centre, their interfaces to each other, and the level of integration. As suggested by recent publications, the transition of a purely vertical organised centre into a cross-linked structure depends on different management functions and an effective communication among departments and divisions  ,  , .
Communication strategies are useful to generate a corporate identity within a centre but also in the outbound communication with patients and referrer. Cross-departmental collaboration is not only a prerequisite to create a corporate strategy, but is also required for the conduct of clinical trials, which are an important source for scientific impact and financial resources.
Healthcare IT and centre infrastructure were identified as further overarching categories since both influence the performance of healthcare delivery . In health care industry, IT is an asset that helps to improve quality of health services, to manage rising costs and changing organisational needs, and to improve data exchange within a centre. As first of its kind, Act On Oncology establishes reference points to which process quality and efficiency as well as the level of integration of the different stakeholders can be related.
Improving the quality of care relies on several factors, from the adoption and routine application of guidelines for diagnosis, treatment and follow-up, to the multidisciplinary management of patients  ,  , . In addition, quality of care also bases on structural issues such as the provision and integration of different services and resources  ,  , .
Measures to meet these requirements may include the centralisation and standardisation of multidisciplinary care, the application of IT solutions, the improvement of management structures, the streamlining of workflow processes including interfaces with referrers, and the development of joint strategies  ,  ,  ,  ,  ,  , .
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In our pilot study, Act On Oncology identified areas for improvement on multiple levels. Despite the promising achievements in the implementation of multidisciplinarity at the staff level, the pilot study revealed the need for an overriding management framework to promote the collaboration among departments, to allow a corporate identity to evolve, and to canvas additional support. In this regard, it is important to note that an advanced organisational infrastructure appears to improve both outcomes of cancer patients  ,  and cost efficiency of clinical processes  ,  ,  , .
As a first improvement that has been implemented in the meanwhile, the centre administration and the Health Director at INT described and formalised the organisation of the prostate cancer unit. The document defines both categories of personnel assigned to the prostate cancer unit core team, non-core team, project team and clinical activities multidisciplinary clinics, observational setting clinics, clinical case discussions.
The implementation of this suggested measure can be considered as the first positive effect of the Act On Oncology assessment. During the assessment, several features of the prostate cancer unit were ranked as best practice, reflecting the efforts that have already been made at the INT: the multidisciplinarity of designated weekly clinics and tumour board meetings, the presence of a psychologist in the multidisciplinary clinics and case discussion meetings, and the existence of an active surveillance program  ,  ,  ,  ,  ,  , .
Act On Oncology employs a structured and predefined interview and assessment matrix. The experiences from the development phase and the pilot study, along with experiences from the assessment of radiology departments  , suggest a high level of reproducibility with low interobserver variability. However, one limitation of our method is related to the global diversity of health care systems. Although several cancer centres in Germany, Italy, and the US have been analysed, this diversity might not be appropriately addressed by our model.
This is particularly important once our model should be used for global benchmarking of cancer centres. To address this limitation, our approach is subjected to a continuous improvement process. We expect that, after additional global assessments, Act On Oncology might be applied as a benchmarking tool in the future . In conclusion, Act On Oncology provides a feasible tool to evaluate quality and efficiency of operational processes in prostate cancer centres.
During a pilot study, several best practices and opportunities could be identified. Measures for improvement were elaborated and their effectiveness has to be proven in a future reassessment.
Broad scale assessments will be necessary to apply Act On Oncology as a benchmarking tool for cancer centres. We thank Stefan Lang for his medical editorial assistance with this manuscript. Financial support for medical editorial assistance was provided by Siemens AG.
Management of Benign Prostatic Hyperplasia - American Urological Association
Siemens AG Healthcare Sector provided support in the form of salaries for authors Wieland Voigt and Josef Hoellthaler, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. National Center for Biotechnology Information , U. PLoS One. Published online Sep 5. Eugenio Paci, Editor. Author information Article notes Copyright and License information Disclaimer.
Competing Interests: Dr. Wieland Voigt and Dr. Received Mar 1; Accepted Aug 1. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited. Abstract Background Multidisciplinary care of prostate cancer is increasingly offered in specialised cancer centres.
Objective To develop a standardised operational process assessment tool basing on the capability maturity model integration CMMI able to implement multidisciplinary care and improve process quality and efficiency. Design, Setting, and Participants Information for model development was derived from medical experts, clinical guidelines, best practice elements of renowned cancer centres, and scientific literature.
Results and Limitations Several best practice elements such as multidisciplinary clinics or advanced organisational measures for patient scheduling were observed. Conclusions In the pilot study, the AoO approach was feasible to identify opportunities for process improvements. Introduction Owing to the growing options for diagnosis and treatment, the optimal management of prostate cancer patients is still controversial.
Materials and Methods Project members The Act On Oncology approach for the systematic assessment of prostate cancer centres was developed by four consistent team members with a medical or consulting background core team. Act On Oncology database To develop the model, scientific literature, certification criteria of the German cancer society  , and medical guidelines were analysed and consolidated  , . Development of the organisational structure As an established tool for continuous process optimisation in the industry, the CMMI method provided the basis for the Act On Oncology approach.