Daniel R. Saltzstein, MD
In a mission statement, the Large Urology Group Practice Association (LUGPA) states its aim to provide urological surgeons “…the means to access resources, technology and management tools… to care for patients with acute and chronic illnesses of the genitourinary system in an efficient, cost effective, and clinically superior manner.”
Urology San Antonio has transformed itself into a model reflective of these expanded group practice goals, part of a nascent trend in large urology group practices to provide cancer care where before patients would be referred out to oncologists. In this interview for Urologists in Cancer Care
, Daniel R. Saltzstein, MD, director of Clinical Research, describes steps Urology San Antonio has taken toward creation of such a comprehensive urologic care practice, including establishment of a bone health clinic and an advanced prostate cancer clinic. Saltzstein looks ahead to new therapies that will continue to expand the options for advanced prostate cancer and the management of bone metastasis, and comments on the controversial recent US Preventive Services Task Force (USPSTF) statement on PSA screening.Urologists in Cancer Care: Could you speak about your practice’s decision to start a bone health clinic? What provided the impetus, and what challenges did Urology San Antonio face in its early development?
We realized a number of years ago, as more literature was being published, that androgen-deprivation therapy (ADT) was associated with a lot of potential side effects, and that as a specialty, we were not addressing those needs. It was difficult in our setting to change this. We had fragmented care. Among a group of 25 physicians, we had six offices and were addressing bone health and the various ADT side effects differently. As a group, we decided that we wanted to develop “centers of excellence” in standardized care. We thought it would be best if we managed this goal in one location, with a model that included “physician champions” and “physician extenders.” Within approximately one year we had instituted two clinics under the guise of our centers of excellence concept. One was a bone health clinic and one an advanced prostate cancer clinic.How do you manage the delivery of the complex services you added to the practice with the launch of these clinics?
We manage with established protocols and the help of a physician assistant (PA). Each patient who comes to the clinic receives similar care. When a patient comes to the clinic for bone health issues arising from treatment with an androgen-deprivation therapy, we determine their status with DEXA scans. The PAs check compliance with calcium and vitamin D and exercise. Because androgen-deprivation therapy has side effects other than those relating to bone health, we check weight, cholesterol, diabetes status, and we inquire about symptoms such as hot flashes. If patients need a dental evaluation because we are worried about the side effects of some of the medicines, we take care of that.
The value of having a clinic like this is emphasized in light of new evidence for an improvement in survival with continuous androgen-deprivation therapy, meaning that patients may be taking it longer.1
This suggests that we will be dealing more and more with the side effects of these medicines.Your large group practice also instituted an advanced prostate cancer clinic. Could you describe the rationale for that initiative?
We established an advanced prostate cancer clinic for reasons similar to those that resulted in the bone health clinic at Urology San Antonio—as a move toward a center of excellence concept, where all advanced prostate cancer care is provided in one setting.
Urologists now have a number of different products in our quiver (eg, sipuleucel-T, abiraterone, enzalutamide) that are “urology-friendly.” Urologists are very comfortable giving these medications in the office versus referring patients out to oncologists for advanced chemotherapeutic care.
Also, Urology San Antonio and a number of other large urology group practices throughout the country are starting to form alliances with oncologists to offer a “one-stop shopping” option for prostate cancer patients.What involvement does your organization have in clinical trials, and how does your organizational structure support this activity along with rendering patient care?
We have an active clinical trials research division and have been involved in clinical trials for 12 to 15 years. Urology San Antonio Research, of which I am director, has been involved in clinical trials for many agents that have come out for the treatment of bone health and for advanced prostate cancer care.