Burnout, biopsy, BPH, and more: Post-AUA review

I heard a lot of good lines at the AUA this year, including some with a unique Boston accent, but the best belongs to a friend from medical school.

It was 5:30 Sunday morning and I was sitting in the airport with a cup of coffee when I heard a familiar voice. Turning, I heard him say, “I guess I’m not the only person leaving early for Mother’s Day.” Seriously, I don’t know if I need to contact the AUA, but someone needs to make sure this conference is not on Mother’s Day weekend again.

OK, so the scheduling wasn’t great, but how was the content of the conference? First, let me report on my experiment to attend most of the conference virtually. Result? Not that bad, all of the plenary sessions were readily posted on the AUA website. The videos were crisp and easy to watch. Well done.

On the other hand, I was less impressed with the On-Demand Course Pass. I knew going in to the conference that I would not be able to attend most of these courses and, as I find them incredibly useful, I purchased this pass so I could watch them at home. Unfortunately, when I wrote this over a week after the conference, the website still read, "Coming Soon!" and my editor (who does a great job) says I have a deadline. I'll get back to everyone during the next blog about my experience with the On-Demand Course Pass.

Burnout is real

As with all AUA meetings, this year’s event provided some great teaching points. First, burnout is real. But what is burnout? The best definition is the original definition from 1974 that states that burnout is “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.” Depending on what study you want to believe, urology burnout is at between 40% and 64%-either number higher than I expected for a specialty like ours, which has always seemed to be low stress. But all is not lost; data was also presented that exercise is likely the best tool to prevent this problem and getting into better shape happens to be one of my goals this year.

Fusion biopsy and other new technology

One technology I was interested in learning about was shockwave therapy for erectile dysfunction. I thought Ranjith Ramasamy, MD, did a wonderful job explaining the basic science behind the technology in his point-counterpoint debate and had me leaving his lecture with great hope for the technology.

However, I think the case for shockwave for ED was best summarized by Irwin Goldstein, MD, who was presenting the pro side of the debate. At the end, he stated, “Shockwave therapy may be one day be considered as safe and effective disease modification strategy.” Not exactly a ringing endorsement and that was before Tom Lue, MD, started his con presentation.

The other major technology I was interested in exploring was the MRI-ultrasound fusion technology for prostate biopsy. I started with the technology hall and was duly impressed by the look and feel of the technology. I spoke with numerous other urologists including the attending from Iowa who taught me about prostate cancer, and everyone seems to be buying a device. I recently saw a European Urologypaper entitled, "Opening Our Eyes to Multiparametric Magnetic Resonance Imaging Before Prostate Biopsy" (in press) that further supports my developing opinion that I should start to use more MRIs in my practice (though if the Europeans know how I can get a private insurer to pay for a prostate MRI in a man who has not had a biopsy yet, I'm all ears).

Unfortunately, my plan to learn more about the state of the MRI technology and to settle on a plan for my practice didn't pan out. As noted, the On-Demand Course Pass videos aren’t yet live, so I have not watched either the courses of interest (Courses 042I on prostate cancer diagnostics and Course 047IC on MRI-US fusion biopsy). I'll get back to you with the next blog about my thoughts.

What I did learn, though, was that MRI-US fusion technology is not cheap. For a device that still does not have a unique CPT code, the costs are truly amazing. At approximately $140K plus disposables (yes, one of the manufacturers turned the needle guide into a disposable device) plus the cost of the CAD device the radiologists have to purchase, I’m amazed any small-town plumber can afford the device on their own.

I’m all for better diagnostic accuracy, but the only option I can find to pay for this device is to receive a portion of the downstream revenue associated with the diagnosis and treatment of prostate cancer (ie, pathology, the MRI itself, radiation, or surgery), which, as an independent single-specialty practice, I don’t have. When you consider the additional time it takes to perform an MRI-US fusion biopsy, I am becoming more frustrated that the government hasn’t added a specific CPT code for that procedure.

New drug treatments and guidelines

One of the exciting new treatments I learned about at the AUA was the new PD-1 checkpoint inhibitor, durvalumab (Imfinzi). This medication showed an overall response rate of 26.3% among patients with high PD-L1 scores who had already received first-line therapy for locally advanced or metastatic bladder cancer. For those curious about how this and other new immunotherapy agents work, I recommend a wonderful course, Chemotherapy and Immunotherapy Options for Genitourinary Malignancies, the video of which can be see here.

The only downside to this drug is that the wholesale price is $13,000 per month for a drug that needs to be given monthly for life. That translates to $156,000 per year. Given the prevalence of metastatic bladder cancer, I’m not sure how we, as a society, can continue to pay for drugs such as this even given its response rate.

While I did not attend any of the new guideline presentations at the AUA, I acknowledge the wonderful presenters and those who worked incredibly hard to draft these always useful statements. On the other hand, since leaving Boston, I have watched every presentation online and have read the guidelines in whole. For us small-town plumbers who strive to practice normal, boring, standard-of-care medicine, guidelines are gold. Here is a link to all five of the guidelines presented at the AUA: muscle-invasive bladder cancer, renal cell cancer, and localized prostate cancer (divided into low, intermediate, and high risk).

I was especially impressed with the guidelines on localized intermediate-risk prostate cancer, as that is the situation I find myself in most commonly. I thought the way the guidelines split this into favorable and unfavorable categories was very clever.

Highly useful BPH papers

Continuing the theme of uncool but incredibly useful information, I give credit to those researchers who presented new information on BPH. BPH is not as “trendy” as cancer, but when I look at my clinic schedule every day, the number of people I see with this condition dwarfs my prostate cancer volume. For example, there was an excellent poster by Joshua Cohn, MD, et al entitled, “Decision-making in men considering use of non-prescription tamsulosin for lower urinary tract symptoms,” which looked at whether men could appropriately self-prescribe tamsulosin for these symptoms. The answer is yes.

Another poster on BPH by Christopher Wallis, MD, et al entitled, “Surgical management of benign prostatic obstruction: 20-year population-level trends,” showed that not surprisingly, endoscopic laser procedures are becoming more popular. I also attended a wonderful moderated poster session where Alan Kaplan, MD, explained that patients receiving value-based care for BPH surgery do not experience worse clinical outcomes.

From the plenary sessions to the posters to the educational sessions, the AUA once again allowed me to catch up on a year's worth of urology in one short weekend (extended with the assistance of online access). I look forward to seeing everyone next year at the AUA in San Francisco. Thankfully, it's not over Mother's Day weekend.