The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, February 11, 2014

I Am Not a Urologist


In February, while attending the tenth annual GU-Oncology meeting, I was surprised to see my name listed on large posters around the meeting hall (along with about 30 other physicians).  The hosts of the meeting were honoring a very small group of doctors who have attended every single American Society of Clinical Oncology Genitourinary (ASCO-GU) meeting since the meeting’s inception 10 years ago.

A Prostate Cancer World Populated by Surgeons
It’s not surprising that at a meeting of 2,500 attendees, only 30 doctors were honored. This was not a urology meeting, as is typical with most prostate cancer meetings. This meeting was hosted by the American Society of Clinical Oncology*, an association of medical oncologists. Only 30 doctors were on the list because medical oncologists who consistently attend meetings focused on prostate cancer are rare. The prostate cancer world is run by urologists, who are surgeons. Urologists have dominated prostate cancer for 100 years, dating back to when surgery was the only effective cancer treatment available.

What is a Medical Oncologist?
I tend to assume that all my patients know that I am a medical oncologist, not a urologist. However, when I speak to patients, I frequently discover that men fail to understand the difference. The following short list might be help helpful.

Medical Oncologists:  

1.    Take leadership of a medical team comprised of medical doctors from various specialties

2.    Are trained to manage all types of cancer

3.    Supervise multimodality therapy (surgery, radiation, immune, hormonal and chemotherapy)

4.    Are board certified in internal medicine as well as medical oncology

5.    By observing patient outcomes, learn through first-hand experience which surgeons and radiation doctors are the most skilled

6.    Are trained in how to administer multiple different types of medications—both for cancer treatment and for overall health needs—safely, in combination

7.    Have no innate preference for surgery over radiation, since they perform neither

1.    Are trained first and foremost as surgeons

2.    Are trained to care of numerous noncancerous maladies of the genitourinary tract (kidney stones, erectile dysfunction, bladder infections, prostate enlargement, vasectomies, repair of congenital anomalies, urinary leakage, etc.)

3.    Have no internal medicine training

4.    Have a rudimentary understanding of cancer treatment (outside of doing surgery)
Let’s take up the issue of leadership. In this complex modern era, good medical outcomes require a coordinated team effort that maximizes the participation of all the different medical specialties. Five specialties commonly participate in prostate cancer management: urology, radiation oncology, radiology (reading scans), pathology (reading biopsy specimens under the microscope) and medical oncology.  Obviously, any kind of team, medical or otherwise, performs best with knowledgeable and experienced leadership. With almost every other type of cancer (besides prostate cancer) medical oncologists take the lead.

Longstanding Tradition Makes Prostate Cancer the Exception to the Rule
It’s surprising to most people that university medical oncology fellowship programs (like USC, where I trained) offer no training in the management of early-stage prostate cancer. This role has been totally abdicated to the urologists. While advanced-stage prostate cancer patients do transfer their care to oncologists somewhat more frequently, this happens in only half the men with advanced disease.

Studies show that 50% of men with advanced prostate cancer who succumb to progressive disease die without ever consulting with a medical oncologist!  This practice of urologists holding onto their patient to the bitter end may have been defensible back when the effective treatment options for advanced disease were limited to Lupron, Casodex and palliative spot radiation to the bones. However, forgoing oncology consultation in this modern era of Provenge, Zytiga, Xtandi, Xofigo and Jevtana, all of which are proven to prolong survival, borders on lunacy.

Yet despite there being over two million prostate cancer survivors in the U.S., less than a one-hundred (100) medical oncologists who actually specialize in prostate cancer, and almost all of these are in academia doing clinical or laboratory research. Outside of academia less than ten (10) medical oncologists specialize in prostate cancer fulltime. Three of these are in my office in Marina del Rey. The other free-standing medical oncology clinics that specialize in prostate cancer are listed at

Practice Makes Perfect
Real day-to-day clinic experience treating large numbers of men with one disease—in this case prostate cancer—improves the skill level of the practicing doctors. Skillful doctors are of great value because new medicines are being approved at an ever faster pace. Familiarity with their use can only be achieved at a high-volume prostate cancer clinic. A fulltime prostate oncologist gains practical experience that takes years to appear in textbooks.

Furthermore, prior to FDA approval, new drugs can only be obtained by participating in clinical trials. But it’s dangerous to conclude that every agent under clinical investigation will provide meaningful benefit. While there is no absolute inside information, most of the prostate oncologists in the country know each other so “inside information” can be learned from a simple phone call or a chance meeting at one of the various prostate meetings that occur throughout the year.

Finally, doctors who are involved in managing large numbers of men with prostate cancer also gain experience with the relative skill levels of other physicians on the medical team; the surgeons, pathologists, radiation therapist and the radiologists. Improved patient outcome is not simply the result of picking the right treatment.  You also have to select a doctor with special talent to administer it.

Don’t make the common mistake that urologists and medical oncologists are inter-changeable.  Having a highly trained and skilled surgeon can be lifesaving—when surgery is truly indicated.  However, in this modern era, radical prostatectomy should be the first choice in relatively few men. And even when surgery is the preferred approach, having a surgeon as the overall leader of your team is no longer ideal.

P.S. My apologies for radically digressing from the exciting information shared at the meeting.  My frustration with a world dominated by urologists clearly got the best of me.  I’ll take up the meeting highlights in my next blog (and in even greater detail in the next issue of PCRI Insights).

* As an aside, the acronym, ASCO, in Spanish means nausea, a name some consider apropos since oncologists are the main purveyors of chemotherapy.

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