Raoul S. Concepcion, MD
Urologists in Cancer Care
Director of Clinical Research
Urology Associates, PC
Three years ago, I was approached by the folks at OncologyLive
to gauge my interest in a publication that catered to the independent urology community, specifically those practitioners and groups that were actively managing genitourinary malignancies. The company’s sales force recognized that a plethora of new therapies had been approved in the area of metastatic castration-resistant prostate cancer (mCRPC), with more in many phases of clinical trial. The pharmaceutical companies involved in the development of these new agents provided a target-rich environment for potential sponsors and educational offerings. The challenge was how to engage and involve urologists in an area where historically very few had interest or experience. Everyone needs a good challenge now and then, right?
Today, as we start our fourth year of this publication, I believe we are making progress with that educational hurdle. Many groups are taking the initiative to start their own advanced prostate/therapeutic centers, folding in all the disciplines needed to manage these difficult patients. The American Urological Association has embraced the importance of our involvement. They are supporting postgraduate courses at the annual meeting, as well as throughout the year, to help urologists establish advanced therapeutic centers of excellence. There are more and more physicians in communities across the United States who have a better grasp and understanding of the agents approved and are now willing to take on the management of this challenging population. Nurse champions/navigators are in place to hopefully identify these potential patients in order to institute therapies when appropriate and avoid delay before the patients are symptomatic—our classic downfall in the past. The goal should always be better patient care, and more important, maintaining quality of life in the process. Remember (to steal a line from Eric Klein): Don’t confuse the ability to treat with patient benefit!
Yes, we are making strides in managing the mCRPC patient so that global adoption among independent urology groups takes place. The importance of this adoption needs to be viewed in the context of the role of the urologist in prostate cancer in general. As we continue to move down the road of payment reform, it is incumbent upon us to be the lead physicians in diagnosis and management of the disease, both localized and advanced.
All of us are aware of these challenges:
Move beyond PSA to determine who needs a first biopsy.
Develop better technology when prostate biopsy is indicated.
Adopt better risk stratification tools for optimal patient management.
Be more cognizant of the nuances of disease progression once androgen deprivation therapy is instituted and identify the at-risk patient who will benefit from earlier treatment.
Have a working knowledge of all the therapies available for the correctly-indexed patient whose disease is metastatic.
Be willing and prepared to deal with potentially non- urologic issues (pain, end-of-life care) that traditionally has not always been within our domain or our comfort zone of practice
Our willingness to address all these issues and lead the efforts to find the solutions will serve our specialty well. It is still unclear to many if the Accountable Care Organization (ACO) model will be the ultimate winner in the primary care market. Regardless, management of elevated PSAs (or the next testing equivalent) and prostate cancer should default to the urology world, just like always. I hope to see that trend continue.