What new clinical guidelines would you like to see?

April 1, 2018

"One thing I would like to see some guidance on is what to do about patients who use marijuana recreationally," says one urologist.

Urology Times reached out to three urologists (selected randomly and asked them each the following question: What new clinical guidelines would you like to see?

"I’d like to see new guidelines on the management of advanced prostate cancer. Right now, there’s kind of a gap in the treatment of advanced prostate cancer once patients have become hormone refractory. Some of the medications are only FDA approved if patients have proven metastatic prostate cancer. So we have some men who are in a gap where their PSA is rising, but they don’t necessarily have a treatment for that.

Even though these treatments would be beneficial for before metastasis, they aren’t necessarily used off-label because insurance companies won’t pay for them and they cost $4,000 to $5,000 a month. If the AUA came up with practice guidelines on when and how to treat men with advanced prostate cancer as they progress, those medications could then potentially be covered by insurance.

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It’s a work in progress because there are newer medications that have been developed and released in the past 6 months that are FDA approved for that indication but the AUA has not endorsed them. So whether they are FDA approved or not, they need to be considered by the AUA. I’d like to see the treatments that are FDA approved added to the AUA guidelines.

And I think it would be beneficial to get AUA guidelines for earlier use of the newer agents for advanced prostate cancer, that are not FDA approved for those nonmetastatic patients. That could help them get the FDA approval sooner.”

Rodney Smith, MD

Charlotte, NC

Next: "I feel that there already exists plenty of guidelines for most of the things I deal with in urology"

 

“The answer, to be honest, is no, not really. I feel that there already exists plenty of guidelines for most of the things I deal with in urology. So I’m really not looking for any new guidelines.

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I’m familiar with a number of the guidelines and there are a lot of them out there, but I don’t look at a whole lot of the guidelines.

I use guidelines for cancer, but there I use the National Comprehensive Cancer Network [NCCN] guidelines. I don’t know why; that’s just what I do. When I’m dealing with cancer, I go to the NCCN websites for those.

When it comes to the benign processes like BPH and incontinence, I don’t use a lot of guidelines. I rely more on my experience.

I am still glad the guidelines are there. I’ve been doing this for 20 years and I’m kind of set in my ways. I think my management protocols are pretty consistent with the guidelines; at least I’m pretty sure they are any time I see the guidelines.

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If the AUA does come up with new guidelines, I may take a look at them, but I don’t expect there to be anything there that I’ll really need.”

James Kelly, MD

St. Louis

Next: "I would like to see some guidance on is what to do about patients who use marijuana recreationally"

 

“A couple of things come to mind. One thing I would like to see some guidance on is what to do about patients who use marijuana recreationally. What are guidelines for saying it’s a problem or not a problem with surgery, anesthesia, consent, and compliance? Like the statement on medical marijuana-related things, I think we need something on recreational marijuana.

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I practice in Washington, so it does come up more often now. And more states are adopting legalized recreational marijuana, so it would help to have something kind of defining our role.

There is the also the opioid crisis and uses specifically in urology. Where can we use more alternatives like ketorolac for ureteral colic, and initial IV doses then switching to oral equivalents?

So marijuana and opioids-those are two areas where it would be good to have AUA guidelines.”

William Heaton, MD

Spokane, WA

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