Raoul S. Concepcion, MD
When a patient develops advanced prostate cancer, that doesn’t mean his urologist needs to bid him farewell. Urologists should consider treating their patients with prostate cancer from diagnosis to death, rather than sending them to oncologists when their illness progresses, as long as that plan makes sense within their business models and cultures, several speakers suggested in May during a course offered at the 2014 Annual Meeting of the American Urological Association (AUA).
With that principle in mind, the 2-hour course—whose faculty included Raoul S. Concepcion, MD, of Urology Associates, a 34-member practice in Nashville, Tennessee, and editor-in-chief of Urologists in Cancer Care—outlined how to establish an advanced prostate cancer clinic in the community setting. “We are the experts of this disease, without a doubt,” said faculty member Basir U. Tareen, MD, of the 22-member Metro Urology in Minneapolis/St. Paul. “We see this disease from the beginning, with an elevated PSA [prostate-specific antigen], to the biopsy and to the treatment.
So it naturally holds that, even once we get into the advanced stages of the disease, we should be the ones that are managing it—it provides better continuity of patient care. We don’t want to suffer the same fate as many other specialties—cardiothoracic surgery, for example—where you get stuck being a technician, and sooner or later you have a lot of other specialties taking away this disease that we really are the experts of.”
Concepcion added that retaining these patients is vital to the survival of community urology practices.
“I challenge all of you, especially those of you in independent and community practice, to look at the revenue that is generated in your practice that is directly or indirectly related to prostate cancer, whether it’s lab work, visits, surgery, imaging, or pathology,” he said. “It’s a significant number, and may range anywhere from 25% to 50% of the revenue in your practice. Yet I will speculate that we’re a couple of tests away from potentially losing prostate cancer if we don’t grasp things like the use of multiparametric MRI, a better way to biopsy. Potentially, we could lose the whole disease.”
Remaining the primary specialty that treats prostate cancer will depend on urologists understanding and using not only new imaging modalities, but also the seven novel treatments for advanced prostate cancer that were approved since 2004—most, in fact, in 2010 or later. Doctors will also need to set up procedures in their offices for making that care available, emphasized the speakers, who included Greg Hanson, MD, also of Metro Urology. During the course, the speakers outlined the factors doctors will need to consider, and the tasks they will need to complete, in order to offer their patients comprehensive prostate cancer treatment in community practices.
Use and Sequencing of Newer Drugs
Urologists have traditionally been excellent at diagnosing and treating early prostate cancer, but after the chemotherapy docetaxel (Taxotere) was approved in 2004—because many did not understand its benefits—doctors sometimes spent too much time using hormonal treatments such as bicalutamide (Casodex) in an attempt to control progressive disease and manipulate PSA kinetics without a survival benefit, Concepcion said.
“I’m sure many of you heard from your medical oncology colleagues that the urologist always sent patients too late,” he said. “Ultimately, what happened is that we sent PSAs sky high.”
That may explain why it requires an adjustment in thinking, now, for urologists to consider continuing to treat patients with prostate cancer throughout the course of their disease, Concepcion said.
But with the rapid, recent approval of a host of new agents for advanced prostate cancer, each of which can offer a survival benefit of about 3.5 to 5.5 months, he said, expectations for what is possible within a urology practice have changed. “I think it’s important for us to understand all these drugs—not only their mechanisms, but more importantly [in what settings] they are approved by the FDA,” Concepcion said. “If you have an interest in this, it’s worthwhile taking the time to learn about these agents. It’s incumbent upon the urology world now to identify these patients earlier, because we all know there is plenty of data out there that suggest that the earlier we can identify patients with metastatic disease, the earlier we can start many of these patients on some of the various therapeutics that have a better survival benefit.”