For a urology practice to thrive, its physicians, nurses, and administrators need to be unified in providing advanced prostate, kidney, and bladder care, said Basir U. Tareen, MD, a urologist at Metro Urology of Minneapolis. At Tareen’s practice, urologists are at the forefront of introducing new techniques and technology, especially with respect to advanced prostate cancer care.

“As a specialty, we need to be the experts in prostate cancer by offering all aspects of care, from the initial diagnosis, offering curative treatments, and providing late-stage therapies that include infusions and oral oncolytics.” said Tareen. “We want to provide the best, most up-to-date care to our patients.” In many cases, better scanning techniques and the use of advanced prostate cancer care clinics have significantly improved urologists’ ability to manage the disease.

Tareen’s group of 26 physicians was founded in 1994 and is now is the largest, independent urologic specialty practice in Minnesota.

Significant medical advancements have made it possible for Metro Urology to improve the quality of its care. Tareen noted that in 2013 the introduction of MRI-guided biopsies in prostate cancer was “practice changing.” Biopsies that use MRI-guided technology are much more accurate than the traditional ultrasound-guided biopsy and “increase the chance of finding tumors that may have otherwise been missed.”

In particular, Tareen noted the emergence of MRI-ultrasound fusion biopsy and the excitement it has generated among urologists. Clinical trials have suggested that the combination of this type of biopsy with a multiparametric MRI was more effective at detecting aggressive prostate cancer compared with either procedure alone.1 “Many urologists are describing this technology as revolutionary in terms of prostate cancer diagnosis and eventually treatment.”

Using the MRI-guided approach, urologists can more accurately locate the tumor. “This opens up the door for focal therapy,” said Tareen. He explained that MRI technology allowed his group practice to develop a focal therapy program, which was one of the practice’s short-term goals. “We are currently evaluating ablative techniques such as high-intensity focused ultrasound, cryotherapy, and laser therapy.”

Focal therapy is a general term for a variety of noninvasive techniques for destroying small tumors inside the prostate while leaving the gland intact and sparing most of its normal tissue. In appropriate situations, focal therapy can offer several advantages for men with early prostate cancer:

		It can effectively destroy specific areas of cancer within the prostate while preserving normal prostate tissue and function.

		Side effects, including changes in urinary and sexual function, are often temporary and may be less severe than those associated with radical treatments.

		Because it causes minimal injury to the prostate gland, it does not prevent further treatment with radical prostatectomy, radiation therapy, or additional focal treatment to another part of the gland, if necessary. Cancer that returns after radiation therapy may be treated with focal therapy.

		It can be performed on an outpatient basis or with a single overnight hospital stay.

“I rarely perform standard biopsies anymore,” added Tareen. “It’s a big change in the standard workup. The real potential benefit of it is once you have the results, you can go back and know exactly where your biopsies were positive. You can use that information to focally target lesions.”

Another innovation in practice management that Metro Urology has initiated is the creation of a joint cancer clinic in which the urology practice partners with a local, large medical oncology group. “Some urologists might not be comfortable administering cytotoxic chemotherapy such as Taxotere (docetaxel),” he said. When the joint cancer clinic was originally initiated, a medical oncologist would consult and meet with urologists once a month at the urology practice. “There’s a lot of different models that groups use, but we highly recommend doing something like this. It’s been very successful for us.”

Rather than have the patient go to the urology office, then drive across town to a second appointment with a medical oncologist, we go to the patient, said Tareen. “If I have an advanced prostate cancer patient who I think will need chemotherapy, I will schedule the patient to come in when both the medical oncologist and I are in the joint clinic. It’s great for continuity of care because everybody is on the same page.”

It has been more than a few decades since there has been a major advance in bladder cancer, and Tareen noted the excitement surrounding checkpoint inhibitors in the second-line setting. An approval for use in everyday practice, though, is at least one or two years away, he said.

Meanwhile, chemotherapy offers another viable treatment option and is best utilized through the joint cancer clinic, said Tareen. It is a challenge to treat these patients who require neoadjuvant chemotherapy. “Ideally, if somebody has muscle invasive bladder cancer, we treat with neoadjuvant chemotherapy followed by radical cystectomy. Using the joint cancer clinic has made it a lot easier for us to coordinate chemotherapy schedules.”

Tareen also sees greater use of the joint cancer clinic in kidney cancer because of the chemotherapeutic agents currently available. “We don’t write a lot of prescriptions for chemotherapeutic agents, but we do work closely with the medical oncologist in the joint clinic who often takes the lead.”

Another advancement to help urologists is the increased use of robotics during surgery, said Tareen. In particular, for bladder cancer, Tareen has witnessed the growing use of robotic cystectomies. “Traditionally, we have performed these as open cystectomies, but we have gradually transitioned, with close to 90% of our cystectomies performed robotically. A few urologists also perform intracorporal bowel surgeries, as well.”

The emergence of robotic technology in surgery has also been extended to partial nephrectomies, said Tareen.

Tareen attributes much of the success that the group practice has experienced to strong group leadership. “One of the biggest challenges with any new technology in a large group is getting a ‘buy-in’ from all the partners,” said Tareen. “The committee chairs for castrate-resistant prostate cancer and focal therapy, for example, serve as physician champions for a particular practice area. They are encouraged to communicate with everyone in the group.”

	1. Filson C, Margolis D, Huang J, et al. MR-US fusion biopsy to diagnose prostate cancer: first 1000 men at UCLA. Presented at: 2015 AUA Annual Meeting; 2015 15-19; New Orleans, LA. Abstract PD30-01.

Articles

At Metro Urology of Minneapolis, urologists
are at the forefront of introducing new
techniques and technology, especially
with respect to advanced prostate
cancer care.

Partner's Buy-In Key to Minneapolis Urology Group's Success

The practice of urology finds itself at an interesting point in history. With new therapies in prostate, kidney, and bladder cancer on the horizon and tightening regulatory and reimbursement restrictions in place, urologists need to adapt to a quickly changing landscape. And this change cannot happen soon enough.

Group practices, the lifeblood of urologic practice, are trying to find a steady foothold, and many practices find themselves adapting to care and practice management models that incorporate a unified approach in order to survive and thrive in the current reform environment. That unified approach involves the clinical and administrative champions within the practice coming together and working towards the common goal of providing expert and compassionate patient care, without incurring excessive use of medical resources.

The Large Urology Group Practice Association (LUGPA) is trying to train and equip its members to embrace these new models during a spring meetings rollout. The meetings focus on 3 broad categories: the establishment of an advanced prostate cancer clinic, practice management tips, and the integration of clinical and business challenges. Gary Kirsh, MD, president of LUGPA told us that some large groups have successfully adopted this model, but others have not. He said that by and large, the groups understand, from an intellectual standpoint, the importance of creating an integrative group practice that accounts for these categories, but that the steps to implement these changes can prove challenging. He pointed out that many large groups started out as smaller groups that were initially cobbled together, before healthcare reform and other changes that we see today. They are finding themselves somewhat adrift.

In keeping with our practice management theme, our Practice Profile column this month highlights Minnesota’s largest private urology practice, Metro Urology. The 26-physician practice was founded in 1994. We interviewed Basir U. Tareen, MD, who highlighted many advances that have him excited, notably, the emergence of MRI-guided biopsies and greater use of joint cancer clinics, in which urology practices partner with medical oncology practices to treat and manage prostate, kidney, and bladder cancer patients.

This collaboration with medical oncology practices enhances the continuity of care that is so important for patients on their cancer journey.

In discussing the use of MRI-guided biopsies in prostate cancer, Tareen called these advances “practice changing” because of the greater accuracy MRI-guided technology provides over traditional ultrasound-guided modalities. In addition, the greater use of robotic technology to hone the surgical skills of urologists when performing cystectomies or nephrectomies adds to their expertise.

In this month’s issue, we also bring you coverage from the New York GU™: 9th Annual Interdisciplinary Prostate Cancer Congress® and Other Genitourinary Malignancies held on March 19 in New York City. The congress is an intensive, interactive, one-day educational program that brings together renowned national experts in the fields of genitourinary malignancies treatment.

Daniel P. Petrylak, MD, a leading expert in the field, provided a broad overview of the development of new therapies to treat patients with bladder cancer, which has been lagging behind other genitourinary malignancies for at least 30 years. In particular, Petrylak focused on the PD-1/ PD-L1 pathway highlighting clinical trial results involving atezolizumab, pembrolizumab, nivolumab, and durvalumab, and even explored the potential preclinical research involving the vascular endothelial growth factor (VEGF). In particular, Petrylak reported results of a three-arm phase II study that evaluated docetaxel with or without ramucirumab or icrucumab, a VEGFR-1—targeting agent, among 139 patients with urothelial transitional cell carcinoma following progression on or after first-line platinum-based therapy.

Also during the conference, Robert Dreicer, MD, MS, associate director for Clinical Research and deputy director of the University of Virginia Cancer Center, discussed androgentargeting strategies in metastatic prostate cancer. Although some recently approved agents have improved outcomes for men with metastatic castration-resistant prostate cancer (mCRPC), significant questions linger about how to tackle resistance to the therapies, whether there is cross-resistance in sequential paradigms, and what predictive biomarkers can be identified. Read all about these topics—and more&mdash;in this month’s 

With new therapies in prostate, kidney, and
bladder cancer on the horizon and tightening regulatory
and reimbursement restrictions in place, urologists need
to adapt to a quickly changing landscape.

April 2016 | Oncology Live Urologists in Cancer Care®

Partner's Buy-In Key to Minneapolis Urology Group's Success

Urology Practices Thrive When Administrative and Clinical Champions Emerge