The arrival of spring generally heralds a sequence of significant events that most of us look forward to in some form or fashion as we hopefully jettison the doldrums of winter. The NCAA Final Four basketball tournament, the Masters, Opening Day in Major League Baseball, the Stanley Cup playoffs, both Easter and Passover, and yes, the annual meeting of the American Urological Association (AUA), which convened in Boston over May 12 to 16.

It was 30 years ago that I was preparing for my first AUA meeting, also that year in Beantown, having had 3 presentations accepted as a reward for toiling away in the research lab at Vanderbilt, monitoring and operating on hundreds of rodents and canines (developing a significant allergic cross reactivity to feline dander along the way). The preparation time for podium presentations and posters was much more laborintensive than what is currently required today. Slides were either black and white, or blue and white. Harvard Graphics was considered state-of-the-art, not PowerPoint. We loaded slide carousels, not portable thumb drives. Illustrations were drawn by hand, unless you had personal access to the equivalent of physician-artist Frank Netter.

What made this particularly exciting for yours truly, besides being my first national meeting, was that my father and mother were also going to attend. The late Joe Dowd was president of the AUA, chairman of urology at the Lahey Clinic, and was presiding over the meeting. My dad, one of the first residents in the fledgling urology program at Lahey in the late 1950s, decided not to stay on staff, and they hired Dr Dowd.

My father notified Dr Dowd that he would be attending the AUA meeting to support his youngest son. It was a true privilege as a junior resident to be able to spend time with the AUA president one late evening, listening to the history of our specialty as he, my dad, and colleagues regaled one another with stories of times past.

Two years later, I was finishing my chief residency year and my father was going to retire from active practice on his birthday, March 15, the Ides of March. I made it a point to be present on that day with him and my brother Bob, also a urologist and my dad’s partner. The torch had been passed, and I could sense an immense feeling of pride, and a hint of sadness, as the family patriarch walked away from the operating room for the last time, both his sons on either side, sharing the moment. Even in retirement, and until his passing, he remained very inquisitive about the advancement of the specialty, and marveled at the technologic advances, knowing that he played a significant role in our careers, and the field in general. The urologic bond was always present amongst the 3 of us.

My bias is obvious, but it seems we have a significant number of parent-child urologists in the United States. I can probably list at least 20 surnames without much effort, and if given the time, that number would at least quadruple. Is it a function of the specialty, the personality of the individuals, exposure at an early age, a “urology gene” that draws us? (Maybe we should do next-generation sequencing on all urologists.)

Whatever the reason, I have always smiled and rejoiced when I heard of or met a future urologist starting his/her residency whose father is one of us. For me personally, getting the opportunity to engage with the true giants of the field— whether through my father or visiting professors during training&mdash;has given me a much deeper appreciation of how great urology is as a specialty.

With only months away before I officially become a sexagenarian, my concern is whether the younger physicians, either in those training or matriculating into practice, will appreciate, or even know, the names and contributions of the physicians who have paved the way for them. Young, Millin, Leadbetter, Huggins, Goodwin, Kaufman, Flocks, Hendren, Donohue, Stamey, Nesbit, Walsh, and Chaussy, to name a few.

The vision and dedication to training future urologic surgeons and advancing care by these giants of urology should never go unrecognized, underappreciated, or forgotten. We need to continue in this tradition, lest we forget our roots.

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The vision and dedication to training future urologic surgeons and advancing care by these giants of urology should never go unrecognized, underappreciated, or forgotten.

It's a Family Affair

Jerri Wilson, CEO of Urology Clinics of North Texas (UCNT), said it was last summer that payers started making it more difficult to gain payment approvals. “We saw an increase in demand for records and more scrutinizing of notes and data,” she said. More patients were being denied for coverage for tests and procedures. The practice was feeling the effects of a payer backlash against the rising costs of care. As manufacturers charge increasingly higher prices for new therapies and even well-established agents, payers have responded with pressure on practices to justify every cost, and UCNT, like many other independent practices, is caught in the middle.

Matthew Shuford, MD, president of the Board of Directors at UCNT, agreed. “People always have trouble paying for things, and certainly insurance is the biggest determinant of that, or lack of insurance, or maybe inadequate insurance,” he said. However, Shuford noted that “even in areas where a practice would traditionally see an approval for certain cancer medications or necessary scans, the amount of prior authorization or peer-to-peer review needed has risen dramatically.”

The added difficulty in gaining approvals has placed an extra burden on the practice. Not only is it more difficult to gain payer approval, some claims are no longer being accepted at all. “It’s become quite costly to our organization to have staff to cover the increase in demand from the carriers,” Wilson explained. “For instance, for our male patients, testosterone treatment is an example of a type of service that carriers are now denying, or they’re limiting the service.”

Despite these payer challenges, UCNT has found ways to thrive and grow, both by building up its in-house offerings and by collaborating with outside providers to improve coordination of care and quality of service to patients.

In the Dallas-Fort Worth metro area, UCNT is a large, multilocation practice that covers the gamut of urologic care. Practice administrators said they are fortunate in that in their market, they have little competition. The hospitals in their area don’t hire urologists. Consequently, UCNT has seen tremendous growth since it was founded in 1999. Along the way, it has upgraded its operations by coordinating care with outside specialists, bringing more care options in-house, and employing data analytics to track patient care and to improve efficiency and outcomes.

Although not the largest urology group in northern Texas, UCNT has a broad reach, with 16 locations that cover about half of the Dallas-Fort Worth metro area, Shuford said. The practice started with a merger of 3 smaller practices 18 years ago. The physicians sought growth and an improved payment structure. In 2005, the practice expanded again to broaden its offerings, improve performance measurement, and upgrade services. Now, in 2017, UCNT has a total staff of about 270 employees. Among its providers are a radiation oncologist, 3 pediatric urologists, and 35 adult urologists.

The doctors anticipate further staff growth this year. “Most of that growth is because this is 1 of the fastest-growing areas in the country. We’re growing out into the suburbs and areas that we presently don’t cover,” Shuford commented. To keep that rapid growth going, the physicians have created infrastructure that will enable them to add types of patient care that they don’t presently offer.

The practice’s immediate goal has been to prepare for any value-based changes required by commercial payers or under the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015, which is nudging all practices towards an incentivized payment structure that rewards and penalizes based on quality-improvement measures. “That’s been our focus here in the last 6 to 8 months—how we can improve the care we deliver, in terms of reduced costs and better value, both for the patient and the payers,” Shuford said.

The physicians are also trying to improve the quality of care and to grow by coordinating care with subspecialists in their geographic area. UCNT is working to combine its relationships with nephrology and cardiology subspecialties, among others, into an accountable care organization (ACO). They’ve been collaborating with these groups for about a year.

The attempt to create an ACO represents the practice’s largest partnering effort so far. What the doctors are trying to create through these collaborations is a “specialist ACO.” Shuford said that while most ACOs are centered around primary care, UCNT wants to create an ACO centered around urology, for a greater benefit to their patients.

The practice has a research department that always has clinical trials running. According to Shuford, it currently has trials for bladder cancer, overactive bladder, and both early-stage and advanced prostate cancer. UCNT has started using data analytics programs to search its medical records to find patients who meet certain criteria for treatment. The practice also uses data analytics to find patients whose treatment or adherence may have lapsed, such as those with missed appointments, which allows providers to ensure that patients are complying with their treatment. This improves care quality and helps the practice keep track of many different cases.

Trends in Prostate Cancer Care Include Later Referrals

The practice also has an online patient portal, available through its website, for patients to stay in contact with their physicians, and vice versa. Patients can also use the portal to receive their lab results, request appointments, access their own health records, and pay their bills.

Shuford and others at UCNT have noticed a trend of fewer referrals for elevated prostate-specific antigen (PSA) levels and, consequently, fewer biopsies and diagnoses for prostate cancer. They attributed this to recommendations against PSA screening from the US Preventive Services Task Force in 2008. Shuford predicted that eventually there will be a reckoning, when patients whose cancer could have been flagged by early screening show up later with advanced disease. “I think we’re going to see an increase in the rise of advanced-stage diagnoses of prostate cancer. Nationally, we’ve started to see those trends,” he noted. “I think we will see over the next 5 years that people at the time of diagnosis will be more advanced then they have been [in the past].” In May, the USPSTF changed their guideline statement to open PSA testing to men aged 55 to 69 (full story on page 9).

UCNT prides itself on offering comprehensive services, Shuford said, explaining, “It’s a pretty broad spectrum from initial diagnosis and local cancer care to the more advanced care.” Patients may be referred, depending upon their urologist’s initial thoughts, to someone who focuses more on surgery. The practice has a radiation oncologist and offers such treatments as cryotherapy and high-intensity focused ultrasound, Shuford said. The practice also offers medication management for androgen deprivation therapy, including enzalutamide (Xtandi) and abiraterone acetate (Zytiga).

Most recently, the practice has added MRI fusion biopsies as part of its cancer diagnosis technology. It also has a program for patients with advanced prostate cancer. These patients are referred to other physicians within the practice if their own doctor does not feel equipped to treat their disease. This way, UCNT can continue to provide the appropriate standard of care for all patients without having to send them outside the practice.

Shuford has noticed that at his practice, these days, more patients with prostate cancer seem to prefer active surveillance (if they are appropriate candidates) over interventional treatments. In the advanced setting, Shuford noted patients don’t tend to have a single treatment preference, so the team guides them through the best options.

UCNT does not currently have a medical oncologist on its team, so when a patient requires chemotherapy, that case is referred out. Eventually the practice may decide to hire such a specialist, Shuford said. Because the practice covers a wide geographic area, it refers patients to oncologists based on where the patients live. One of the referral practices is a large oncology group that employs many of the state’s medical oncologists and has also recently started employing urologists.

For patients with renal and bladder cancers, Shuford noted, “There really haven’t been any significant changes [in renal and bladder cancer treatment]. I think surgically, you’re seeing more use of minimally invasive or laparoscopic or robotic surgical techniques, as opposed to the traditional open techniques. We’re also seeing more emphasis on partial nephrectomies as opposed to radical nephrectomies, when appropriate.”

When Shuford and his colleagues look back, they realize that the best advice they can pass on to other independent urology practices is to have a defined vision of the practice from the beginning. “If you’re going to set off early, have a better vision of standardization and uniformity right from the beginning. Understand that if you’re going to be 1 group, you need to be 1 group, with a single pay model and a single expense structure. Also, you should start thinking about how referrals and coordination between the divisions are going to look,” Shuford said.

There will be growing pains as any practice grows, but Shuford noted that it’s better to go through those challenges early, rather than when the practice has doubled in size. “That’s the biggest thing we’ve learned over time,” he said. The benefits of meeting challenges head-on with wise management pay off in terms of a practice that is better able to manage its own caseload and deliver on quality, Shuford said. “We’re seeing the results of that, with less referrals outside our group, and the ability to give specialized care for some of the more advanced things like prostate cancer,” he said. “We will coordinate those into fewer people’s hands, and we’ll do it well, which provides better care for the patients, and helps the practice as a whole.”

As manufacturers charge increasingly higher prices for new therapies and even well-established agents, payers have responded with pressure on practices to justify every cost, and Urology Clinics of North Texas, like many other independent practices, is caught in the middle.

How Urology Clinics of North Texas Is Overcoming Payment Challenges

A recent nationally representative study published in 

 found that previously reported declines in prostate-specific antigen (PSA) testing have not continued in recent years, and that approximately one-third of men age 50 years or older still receive routine PSA tests.

In 2008, the US Preventive Services Task Force (USPSTF) recommended against routine PSA-based prostate cancer screening among men 75 years or older, and in 2012, they recommended against routine PSA testing for men of all ages. As a result of these recommendations, PSA screening rates declined from 37.8% in 2010 to 30.8% in 2013 among men 50 years or older, resulting in substantial declines in reported prostate cancer incidence.

Another recent study reported a modest short-term (from 2011 to 2013) increase in the incidence of metastatic prostate cancer among men 75 years or older. This study found that in men younger than 75 years, there was an increase in the proportion of men presenting with distant metastases from 2.7% (95% CI, 2.5%-2.9%) to 4% (95% CI, 3.8%-4.2%) and in the proportion presenting with intermediate- and highgrade prostate cancer from 46.3% (95% CI, 45.9%-46.9%) to 56.4% (95% CI, 55.9%-56.9%) (

This study demonstrated a significant increase in distant metastases at diagnosis in men 75 years or older, and notes that this may be a result of the 2008 and 2012 USPSTF recommendations against prostate cancer screening in this patient population.

 study, investigators gathered data on 19,690 respondents who were 50 years or older from the 2010, 2013, and 2015 National Health Interview Survey (NHIS) database, with response rates of 60.8%, 61.2%, and 55.2%, respectively. A total of 16,196 men were included in the analysis, after those who reported a history of (or were missing data on) prostate cancer diagnosis (n =1115) or PSA testing (n=1574) or who had PSA testing for nonscreening reasons (n=805) were excluded.

Of the 16,196 respondents, more than half (59%) were age 50 to 64, 26% were age 65 to 74, and 15% were older than 75. While data was missing for 10 respondents, 75% had visited a primary care physician in the past 12 months. Among men 50 years or older, unadjusted PSA testing rates for routine reasons in the past year decreased from 38.3% in 2010 to 31.5% in 2013 (P <.001) and remained stable at 32.1% through 2015 (

Adjusted analyses were similar, where PSA testing in the past year was significantly lower in 2013 than in 2010 (screening rate ratio [SRR], 0.83; 99% CI, 0.77-0.89), but was not significantly different between 2015 and 2013 (SRR, 0.99; 95% CI, 0.91-1.08). The pattern of declining PSA testing between 2010 and 2013, but not between 2013 and 2015, was similar across age groups.

Thus, the study concluded that previously reported declines in PSA testing have not continued in recent years, and approximately one-third of men 50 years or older still receive routine PSA testing. Previous declines in routine PSA testing between 2010 and 2013 did not continue in the most recent time period analyzed (between 2013 and 2015).

The study noted that continued evaluation on how testing patterns influence prostate cancer outcomes over the long term are still needed.

Fedewa SA, Ward EM, Brawley O, Jemal A. Recent patterns of prostate-specific antigen testing for prostate cancer screening in the United States. 

Published online April, 24, 2017. doi: 10.1001/jamainternmed.2017.0340

Jemal A, Fedewa SA, Ma J, et al. Prostate cancer incidence and PSA testing patterns in relation to USPSTF screening recommendations. 

2015;314(19):2054-2061. doi: 10.1001/jama.2015.14905

Hu JC, Nguyen P, Mao J, et al. Increase in prostate cancer distant metastases at diagnosis in the United States. 

 Published online December 29, 2016. doi: 10.1001/jamaoncol.2016.5465.

A recent nationally representative study published in JAMA Internal Medicine found that previously reported declines in prostate-specific antigen testing have not continued in recent years, and that approximately one-third of men age 50 years or older still receive routine PSA tests.

Recent Patterns Indicate PSA Testing Halt in Decline

Although the past few months have seen several androgen receptor (AR) resistance, and described drug approvals for bladder cancer therapies, a wealth of research also is moving the field of prostate cancer forward, since gaining a better understanding of the disease is the best way to find out how to optimally treat—and perhaps ultimately cure&mdash;prostate cancer.

In our feature article for this issue, “Novel Imaging Agent May Improve Prostate Cancer Detection,” we report on the ongoing OSPREY clinical trial, a phase II/III study investigating a radiotracer that targets prostate-specific membrane antigen. This radiotracer, 18F-DCFPyL, is being tested in patients with high-risk, recurrent, or metastatic prostate cancer, a patient population that needs better imaging and screening methods.

These patients often have cancer that has spread outside of the prostate, and should the OSPREY trial prove positive, there will be a much more effective way to identify and manage them. According to Kenneth J. Pienta, MD, the preliminary data are already looking promising, and he and his colleagues are running this trial with the hope that it could lead to an approval by the FDA. In terms of not only identifying, but also treating patients with prostate cancer, our cover story, “Next-Generation Therapies in CRPC Take Aim at AR Resistance,” we report on a presentation from Robert Dreicer, MD, MS, delivered during the New York GUTM: 10th Annual Interdisciplinary Prostate Cancer Congress® and Other Genitourinary Malignancies.

Dreicer detailed the various mechanisms of strategies for treating patients with AR resistance. Currently, initial management of a patient with metastatic castration-resistant prostate cancer (CRPC) includes assessing the duration of response to androgen deprivation treatment, and then administrating AR-directed therapy. Physicians can choose between the AR inhibitors abiraterone acetate (Zytiga) and enzalutamide (Xtandi), and monitor patients for response to the initial agent. However, 15% to 25% of patients experience de novo resistance to AR inhibitors. We must nd therapies that counteract this resistance, so patients can be treated without encountering this obstacle. Fortunately, there are agents undergoing development to treat CRPC with AR resistance. However, a challenge for these new agents, as Dreicer noted in his presentation, is that they are not being studied comparatively.

We must push forward with these investigations, and make sure the research is giving enough meaningful data to truly help these patients. I am confident that the distinguished researchers and dedicated practitioners who care for patients with prostate cancer will find more answers.

We will continue to follow the development of research in these areas with great interest and diligence. Thank you for reading.

Although the past few months have seen several androgen receptor resistance, and described drug approvals for bladder cancer therapies, a wealth of research also is moving the field of prostate cancer forward, since gaining a better understanding of the disease is the best way to find out how to optimally treat&mdash;and perhaps ultimately cure&mdash;prostate cancer.

June 2017 | Oncology Live Urologists in Cancer Care®

It's a Family Affair

How Urology Clinics of North Texas Is Overcoming Payment Challenges

Recent Patterns Indicate PSA Testing Halt in Decline

Deeper Understanding Leading to Better Care for Patients With Prostate Cancer