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  • Prostate Cancer

Advanced Prostate Cancer: Overview of Unique Urology Practices in the US


Key opinion leaders in urology share their credentials and highlight the general structure of their institution in regard to prostate cancer management.


Paul R. Sieber, MD: Hello and welcome to the Urology Times® Viewpoints [program], Practice Management at Prostate Cancer Key Challenges and Practical Solutions. I’m Dr Paul Sieber. I’m a urologist in Lancaster, Pennsylvania, with Keystone Neurology Specialists and I’m excited this morning for [this] discussion. I have 3 friends and colleagues [joining] us: Dr Aaron Berger, Dr Richard David, and Dr Chris Pieczonka. And we’ll get to them in just a minute. We’re going to start talking about the challenges we all face because we all tend to be in a prostate cancer–focused practice and discuss some of our potential solutions and strategies we use in overcoming the challenges we face.…[Let’s] start off by all of us introducing ourselves to talk a little bit about our practice. I’ll start with myself. I’m the little guy. I have just a 9-man practice. I’ve got four APPs [advanced practice providers]. I’m in Lancaster, Pennsylvania. I practice in a suburban environment. I tend to do a lot of clinical trials, so I’m the small man on the show. And like I said, I’m on the East Coast but now I’ve got representatives from West Coast and Midwest and East as well. Aaron, if you could just introduce yourself and tell us a little bit about your practice.

Aaron Berger, MD: I’m Aaron Berger. I work in the southwest suburbs of Chicago. We have a 16-person group, all urology, so [a] single-specialty group, although we are part of Solaris Health Partners so a…larger entity as well. But I do the clinical research now, not nearly to the level of Dr Sieber, but hoping to get there at some point. And I do all the advanced prostate cancer for our practice and also serve as the chief medical officer.

Paul R. Sieber, MD: And…all 4 of us, I should say, are all involved with dispensing drugs. We all have in-office dispensaries, and we all have relatively large prostate cancer patient volumes that we manage. Correct?

Aaron Berger, MD: Yes. In our database, we have about 8,000 discrete prostate cancer patients. And in our advanced prostate cancer clinic, we have about 650 patients [who] we follow for metastatic disease, castrate-resistant disease, recurrent disease. Across the whole spectrum of prostate cancer, but total, we have 8,000 to 9,000 patients overall. So it’s pretty high volume.

Paul R. Sieber, MD: Richard, I’ll turn to you next. I think you’re the winner of the biggest group of all of us…you represent the West Coast. I’ll let you tell us your best estimates of where you stand today since you guys have such a moving target for your practice.

Richard David, MD, FACS: Thanks so much, Paul. The Genesis [HealthCare] partners in Southern California encompass San Diego…up to the Los Angeles County area. We are a group of about 150 multispecialty doctors. About 50 of us are urologists. We divide ourselves into different divisions, and I lead the Los Angeles division in our prostate cancer center. We have another center down in San Diego that does similar things. We…run the whole spectrum of prostate cancer care, everything from care management [to] nurse navigators. We dispense medications, we infuse medications. We try and treat patients from the beginning, from their diagnosis all the way until they’ve completed their care.

Paul R. Sieber, MD: Chris, I’ll bring you up…last, the other East Coast representative here, or semi–East Coast, we’ll say.

Christopher M. Pieczonka, MD: Thanks…for inviting me to this symposium. Chris Pieczonka, I practice in Syracuse, New York. The company I work for is Associated Medical Professionals. We’re part of, like Aaron, a larger private equity-based platform called US Urology Partners. I have the privilege of actually chairing our clinical trials working group at our corporate level. And…one thing that I think is interesting…about my demographics—we live in a smaller city, my 2 esteemed colleagues [and me]. And in order to get the same…volume, we have patients drive very far sometimes, so we go all the way up to the Canadian border. We have some patients who are driving 3 to 4 hours for their treatment. And I think that changes…how we manage these patients from…a virtual standpoint. The other thing that we’ve done within our organization is we’ve really ratcheted the set point for what we consider advanced prostate cancer to be. At one point it was bone health years ago, and then it was ADT [androgen deprivation therapy], and we’ve actually taken the move at the corporate level to say that anyone who’s not cured with prostate cancer, which has now come to the biochemical relapse patients, needs to be seen by one of our specialty providers within our practice. So we have really taken the approach that ADT is honestly a lot more complicated than we really always thought it would be. And we really move that to a couple of specialty providers inclusive of specialty nurse practitioners.

Paul R. Sieber, MD: Aaron, I’ll go back to you. Do you have a setup like that? Do you pretty much have everybody in the group coming to 1 or 2 providers? Is that similar for you as well?

Aaron Berger, MD: We’re not quite to the level of Dr Pieczonka’s group where we’re having all ADT patients seen by one of the prostate cancer specialists. At the moment, the last several years, pretty much 95% of the advanced prostate cancer metastatic, nonmetastatic CRPC disease, I’ve been managing. So to add in everyone on ADT, at least for me, that would be a bit overwhelming. Those patients who are not…metastatic or just getting ADT for radiation for a couple of years, I’m not currently seeing those patients, although that certainly could change down the road if we have more people who are really interested in managing some of the nuances of prostate cancer and ADT management and bone health and…all those kinds of things. But at the moment, we do have a pretty good setup as far as what Dr David was talking about earlier with nurse navigators and the IOD and keeping a pretty consistent experience for the patients. It’s pretty much all within our practice. The only time we refer patients out currently is if they do need chemotherapy and then we work with our medical oncology colleagues. But otherwise, we pretty much handle everything in-house from start to finish.

Paul R. Sieber, MD: Richard, I’ll bring you up last. Are you in more of the Berger model or the Pieczonka model in terms of super tight management or…a little looser management when it comes to ADT or advanced prostate [cancer]?

Richard David, MD, FACS: I think we’re in transition, Paul. I think we…started with a little looser arrangement and…the indications for a GnRH [gonadotropin-releasing hormone] antagonist or agonist alone, I think, [have] shrunk down to that period around radiation therapy. Many of those patients need more things that the average partner isn’t as familiar with, so we’re working toward shunting all those patients into our cancer centers.

Paul R. Sieber, MD: I think it’s intriguing as we see people change. I guess it was easiest for me because I came from only a smaller practice. Everything was easy to settle through a nurse practitioner to begin with.…[Our] APP saw everybody on ADT. And I think Chris…modeled his practice somewhat after ours to…grab them all. It was a little easier. I think, as your practices get bigger and bigger, it gets harder and harder to do that. I think it’s quite a feat … to…get that management. But it’s a challenge.

Transcript is AI-generated and edited for clarity and readability.

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