The question of what role urologists should play in managing hormone-resistant prostate cancer is "controversial," says Kenneth Jacobsohn, MD.
“That’s a tough question, and a controversial one. It depends on everybody’s background and subspecialty. These patients are very complex; a lot of new drugs are coming out, seemingly by the minute, so it depends upon a particular urologist’s practice patterns. Either a urologist is going to take it on for every patient, or pass it on to somebody who subspecializes in it.
For urologic oncologists, either fellowship trained or practice emphasis, it’s perfectly appropriate. For the general urologist, if they’re going to stay nuanced with the drugs, it’s fine. But five new drugs in a short period of time-and how many more are coming out? If you don’t see a lot of that in your practice or have a particular interest in it, that’s probably the time you should partner with medical oncology colleagues. It’s good for urologists and oncologists to work together because patients are going to continue to have urologic concerns for a variety of reasons, so passing patients on entirely isn’t appropriate. This is still a disease that we understand as well as anybody. So urologists should remain involved.
We have to do what’s best for patients. Whether having one doctor or multiple doctors is best, probably depends on their expertise. It would be better to have multiple doctors if that’s how you get the expertise. It’s a balance.”
Kenneth Jacobsohn, MD
“I’m in solo private practice, so I send patients who become hormone refractory to medical oncology as soon as that happens. Medical oncologists have better protocols set up to follow patients long term, in terms of complications from therapy. I definitely stay involved and continue to manage patients who stay on their Lupron or other anti-androgens, and let the medical oncologist take over further therapies-kind of the second- and third-line agents. We’re in a small town and we have a good relationship.
If I were part of a big multispecialty group with multiple urologists and could focus on this, I could figure it out and make it work. But I don’t have the resources to follow up on patients for thrombocytopenia and skin rashes and all complications that come with these additional medicines.
But as a single urologist in a busy clinical practice, I would worry I could drop the ball on managing some of these medicines I use a lot less frequently.
I’ve been to conferences with one of the huge advocates for urologists running their own medical oncology and not sending patients away. In theory I agree, but in practice it’s unrealistic for me to give this the attention it deserves when eight new meds are coming in over a 1- or 2-year period.”
William J. Badger, MD
“After 30 years in urology, my focus has shifted a lot toward preventive medicine. I think a lot of the same philosophy holds for both prevention and treatment of disease. Urologists should absolutely be involved with patients who have hormone-resistant prostate cancer because there are so many nuances that go beyond the androgen deprivation therapy.
In terms of the chemotherapy, that’s obviously in the field of medical oncologists. But there are a lot of other strategies that can play a role, in terms of intermittent androgen blockade; I think you can boost the immune system. There are also other urologic issues that come along, in terms of issues like voiding dysfunction that need to be managed.
The medical oncologist is critical to the whole thing because they have a different perspective. They know the toxicity of the drugs. There are so many new drugs in combination therapies that are really very good for hormone-resistant prostate cancer.
But my focus is definitely on whole health now, because I’ve had patients with hormone-resistant prostate cancer who should have died years ago who are fine. They may still have disease but their disease is really quite well-controlled, with intermittent Casodex, because there are also factors that boost their immune system.”
Kenneth Janson, MD
Lake Forest, IL/Boca Raton, FL
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