Combined urology-radiation oncology treatment for prostate cancer patients

MD Anderson Cancer Center
Date: 12-3-12


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Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin. Today, our guests are both from our department of Radiation Oncology, Dr. Benjamin Smith who is an assistant professor and Dr. Deborah Kuban who is a professor in Radiation Oncology, welcome to you both. Basically, what we're talking about today is an article that was in the International Journal of Radiation Oncology of which Dr. Smith was a coauthor and you were looking at urology practices that also had a radiation component. So tell me the basis of your study.

Dr. Benjamin Smith: Right, so in the last decade, there has been an increasingly common practice pattern of large urology practices acquiring their own radiation equipment and then offering patient's radiation treatment within the umbrella or the framework of the urology practice. This has been a very contentious issue with heeded debates between urologist and radiation oncologist as to the wisdom of this practice arrangement. But today, there's been very little actual science or study of these practices and how they may impact care or even just how frequently or commonly they're available in the community setting.

Lisa Garvin: Why are these cropping up?

Dr. Benjamin Smith: Well, that's a good question. So, in around 2000-2001, a new type of radiation called IMRT or Intensity Modulated Radiation Therapy was developed which is a really wonderful technology which improves our ability to spare normal organs but still treat the organ that contains the cancer. And so IMRT has become increasingly used for prostate cancer. IMRT itself especially in its early years was associated with a very favorable reimbursement rate and so that created quite a bit of interest in that technology both within radiation oncology and then in other specialties whose patients often received radiation.

Lisa Garvin: So you were looking in Texas alone is that correct?

Dr. Benjamin Smith: That's correct.

Lisa Garvin: What did you find with respect to these integrated practices?

Dr. Benjamin Smith: Yeah. So we found that these integrated practices are relatively common in the State of Texas. There are 12 such integrated practices in the states and 28 percent of urologists in the State of Texas are members of one of these practices. About one in three urologists is a member of such a practice. Their practices tend to be located in large urban centers and they tend to be located in places that already had other radiation therapy treatment facilities.

Lisa Garvin: 'Cause you found that in a lot of cases, the urology practice and the radiation oncology practice were not even in the same location.

Dr. Benjamin Smith: Yeah so that was a different issue. We were also interested in the structure of these practices. So what I mean by that is, were these practices set up so that it was just one big practice and one building with a bunch of urologist and then the radiation center within that same building or were the center is more geographically dispersed? And so on average, what we found is that the centers where urologist were seeing patients tended to be dispersed over a relatively large catchment area consistent with the idea of sending the urologist close to the patient so that patients wouldn't have to travel far to actually see their urologist and receive urologic care. But in contrast to that, the actual radiation therapy treatment facility owned by the urologic practiced tended to be in just one location and in a location different from where urologic care was provided. So that if you were a patient and you went to see your urologist and you had about prostate biopsy that diagnosed cancer, if the urologist referred you then to go drive from that clinic to the radiation therapy facility owned by the practice, on average, a patient would have to drive about 26 minutes to get to that radiation facility. In contrast, if the urologist sitting in the room with the patient were to refer the patient to the nearest radiation oncology facility, the patient would have to drive about 9 minutes.

Lisa Garvin: And Dr. Kuban, you would probably argue that MD Anderson has been doing this sort of multidisciplinary team approach all along.

Dr. Deborah Kuban: Yes, exactly. But I think we feel probably that we do it a bit differently. So we are all here in one place and we are really committed to giving the patient the best care from all specialties and in putting those specialist and specialty treatments together. So typically, in our multidisciplinary prostate cancer clinic which we hold multiple times a week, just about every day of the week when patients would come in, they would automatically see a radiation oncologist and a urologist. And if it's a more advanced cancer, then we would also bring in medical oncologists in the case if there were some drugs that were applicable to that patient. So here, it's always been a team approach and that's the basis for all of our treatment at MD Anderson. It's especially important for prostate cancer because in prostate cancer particularly, multiple treatment options are available and many times, just one treatment hasn't been proven to be far better than the others, the outcomes might be similar. They might have different complication profiles so we are really committed to giving patients all of their options and to try to lead them through those to find the one that may be best for them. So yes, that's always been our premise but it's sort of here all in the family, all among us, you know, we're all MD Anderson Faculty and we really try to take the best interest of the patients as first the consideration.

Lisa Garvin: And it sounds like there's kind of a business driver going on here and maybe patients would be pushed to a radiation facility even though that may not be their choice or that may not be the most optimal treatment. I know I'm treading a controversial waters here but it sounds like it's a funneling operation.

Dr. Benjamin Smith: Well, that's definitely the concern and so there's ongoing research to try to sort out is that what happens in real life or not and some of that research hasn't been published yet. So I think we kind of eagerly await that further research. But it certainly is a concern of whether or not these practice structures are organized to have the patient's best interest at heart.

Dr. Deborah Kuban: And so, you know, many times, we often wonder if the patient is getting the wrong impression that perhaps they're made to think that, you know, their cancer is so aggressive and so quickly progressive that they need to immediately go seek out the treatment that's being recommended instead of thinking about it, doing a little bit of research about it, perhaps getting another opinion and making sure that they get all of their option. So it is so important the patient knows what all of their choices are and not that they should rush to do just one thing that may or may not ultimately be in their very best interest.

Lisa Garvin: And I think prostate cancer in particular is unique because men do have a choice, you know, depending on you know, their PSA level and other diagnostic factor so they really do have more power to say I want this and this and not this.

Dr. Deborah Kuban: Absolutely and now, a choice additionally is not just which treatment but no treatment. So I'm sure you've heard, you know, all of the information very recently on active surveillance. We've always done this in the past, it was called watchful waiting. Now, it's actually a little bit more aggressive watching type approach called active surveillance where the patient is watched very carefully. But this is a topic of great discussion now because we know that there is a lot of over treatment of prostate cancer and that there are patients who were perhaps elderly, perhaps ill or perhaps have very slowly growing cancers who may never need treatment in their lifetime. And quite honestly, it just kills us to see patients come in and hear that they've been treated that--hear that they've been told that they need to rush very quickly to treatment when in fact, you know, it's our opinion that they may not need treatments ever at all.

Dr. Benjamin Smith: Yeah, I saw a patient for a second opinion who is an 82 year old man with the PSA of about 4 and a Gleason score 6 prostate cancer in 1 out of 12 course. So the lowest of low risk prostate cancer and he was receiving radiation therapy in the context of one of these 12 practices that we had identified in our study and you really wonder if that patient really needs radiation if there's any potential benefit for him or if there's only harm.

Lisa Garvin: So it sounds like, you know, obviously here, we're at a comprehensive cancer center. A lot of people come to us for treatment but out there in the world, it sounds like prostate cancer might be one of those lucrative cancers that people can really you know, rake in the box and the patients.

Dr. Deborah Kuban: That is so and you know, that's exactly what we were about. So, prostate cancer is, you know, very common cancer with several treatments and as you say, many of which have very good reimbursements. So, you know, we just have to I think be very careful that the right things are being done to patients for the right reasons.

Lisa Garvin: And Dr. Smith, what do you hope your study in your article will do? What do you hope to start?

Dr. Benjamin Smith: Yeah, so as far as I know, this is the first article in the academic literature to try to study this phenomenon and understand it. So, I hope that our research will add to a growing body of knowledge about this practice patterns and, you know, we want to keep an open mind so there may be strengths to the practice patterns and there maybe limitations. But this is kind of a first step of trying to develop a body of research to understand the strengths and limitations of these practice patterns and their impact on patients.

Lisa Garvin: In the nutshell, what would you tell obviously a driver for a lot of patients especially with radiation oncology because of all the treatments is convenience? So they maybe swayed by something that's in their backyard as opposed to driving to the medical center or one of our regional care centers. How do you overcome that?

Dr. Benjamin Smith: Radiation is the gift that keeps on giving ad the side effects of radiation can be with you for your entire life. Also, the benefits of radiation can be with you for you entire life so I think that convenience really needs to take a back seat to quality because you want to get the very best treatment because if there's something wrong with your treatment, you'll have to live with that for the rest of your life. So, you know, 8 weeks is a small price to pay for the next 20 years of your life.

Lisa Garvin: And Dr. Kuban, what would you say you have the multidisciplinary prostate clinic where you have like a treatment, like a decision tree where patients can use that. What would be your advice to a man who may be pushed by his urologist into a certain treatment? What would you tell them to do?

Dr. Deborah Kuban: I would certainly tell that patient that if that's the way he was feeling about the consultation and the opinion that he was getting to certainly seek out another opinion. And obviously, we're biased but, you know, I think that a clinic such as ours where the patient will not just get one opinion but an opinion from radiation oncology, urology which is the surgical opinion of course and also medical oncology and active surveillance. You know, that's the best of all worlds and that way, the patient can hear from the specialist why one treatment or another may be better or worse for him particularly 'cause there are so many factors that go into that decision. Typically, prostate cancer is not one of those very fast growing, vastly progressing cancer so that you can step back, think, regroup, get another opinion even if it takes a couple weeks to do that. That cancer is not going to be very much further along in that amount of time and it is certainly worthwhile to have the right treatment the first time. It's so critical so I would tell that patient just step back a minute, tell the doctor he's going to take time to think about it and really get some good advice.

Lisa Garvin: And Dr. Smith, what's your hope for these integrated practices. Are you looking for standardization, are you looking for guidelines, regulations?

Dr. Benjamin Smith: I conducted this as a descriptive analysis. There is a heated policy debate right now as to whether or not such practices, such practice arrangement should be considered legal or now. They're conducted under the--there is this Stark Law and there is an exemption to that for in-office ancillary services such as in radiation therapies included in that and blood draw, laboratory services or pathology services can fall under that framework as well. I think the hope in studying this phenomenon and developing literature about it is to help inform the policy decision of whether or not these arrangements really are in the best interest of our patients and then of our society's medical system. And so, you know, I think that the hard literature on that is still to be published and generated but the goal of such literature's to inform the policy.

Lisa Garvin: And do these integrated practices obviously prostate affects a lot of people? What about the other urologic cancers like bladder and penile and testicular? Are these also being seen in these practices?

Dr. Deborah Kuban: Not as much actually. So, prostate cancer is far more common than the other malignancies that you mentioned, the bladder, the penis and the testicle. They are also more difficult to treat. Very often, they're very complicated cases. And so, they're not as a sought after I guess we could say as something that can be treated easily and quickly and with very high reimbursement. So they typically to this point have not been problematic and we tend to see those type cases at you know, major medical centers and major cancer centers. So that hasn't been a problem with this type of practice to date.

Lisa Garvin: So it sounds like words to wise, do your homework, take a step back and get a second opinion and it sounds like you've injected a very interesting thing into the debate. So we'll--it'll be interesting to see how it turns out. Great! Thank you both. If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789 or online at [Background Music] Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.

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