Video Archives

Patients Come Second

Posted by Neil H. Baum, MD | May 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, argues that the best way to make a medical practice more successful is to focus on improving the experience of the employees, putting their needs ahead of patients and finances. He explains that while the “knee-jerk reaction” to the erosion of a practice’s bottom line is to cut staff, equipment, resources, and investments, putting employees first actually leads to greater financial success, since happier employees will take better care of patients. In turn, these satisfied patients will leave positive reviews, driving new patients to the practice and increasing productivity and profitability. Dr. Baum gives several suggestions on how to put employees first, recommending that practice owners start by measuring employee engagement and employee satisfaction with surveys. He concludes by saying that practice owners should “forget employee of the month” and instead try to praise and compliment their employees every day.

Industry Perspective: AR-V7 Testing for Men with Advanced Stage Prostate Cancer

Posted by Daniel Shoskes, MD, FRCSC | May 2022

Daniel Shoskes, MD, FRCSC, Medical Director in Medical Affairs for Urologic Oncology at Exact Sciences, and Emeritus Professor of Urology at the Cleveland Clinic, discusses AR-V7 testing for men with metastatic castrate-resistant prostate cancer (mCRPC). He begins by noting that mCRPC cannot be cured, but patients with mCRPC often benefit from multiple lines of sequential therapy. Dr. Shoskes explains that when one therapy fails, choosing the next therapy can often be difficult, in part because patients often prefer AR-targeted therapy over taxanes due to the less burdensome side effect profile of AR-targeted therapies. As a result, even though secondary AR-targeted therapy is only effective 22-46% of the time, AR-targeted therapies are administered back-to-back up to 60% of the time. Dr. Shoskes observes that AR variants are a common cause of AR-targeted therapy resistance, and of those variants, AR-V7 is one of the most common and best understood. He defines AR-V7 as a splice variant of the androgen receptor protein which is active without the ligand binding domain, making it resistant to abiraterone, enzalutamide, and apalutamide. Dr. Shoskes then introduces the Oncotype DX AR-V7 Nucleus Detect assay, which he argues can help clinicians quickly direct their mCRPC patients toward the right treatment. He explains that the Nucleus Detect assay detects the AR-V7 protein in the nucleus of circulating tumor cells, is predictive of resistance to AR-targeted therapies, provides easy-to-interpret and actionable results, and only requires a simple blood draw. Dr. Shoskes highlights that the Nucleus Detect assay has been validated in three independent studies, all of which found that it to be predictive of non-response to AR-targeted therapy. He concludes by discussing outcomes, noting that in the validation studies, AR-V7+ patients experienced a 76% survival benefit from being placed on taxane therapy versus AR-targeted therapy.

Updates in Treatment Using ADT and Anti-Androgens

Posted by E. David Crawford, MD | May 2022

E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, discusses the state of androgen deprivation therapy (ADT) and anti-androgens as treatment methods for prostate cancer (PCa). He describes the mechanism of action of anti-androgens, stating that while they should be the best treatment for prostate cancer based on their ability to block tumor development without lowering testosterone levels, anti-androgens have some flaws. Dr. Crawford goes over the history of anti-androgens, beginning with Huggins demonstrating the efficacy of androgen ablation in 1941 and ending with apalutamide’s demonstrated efficacy in 2018. He suggests that anti-androgens are the backbone of treatment. Dr. Crawford discusses the safety of novel hormonal therapies based on data from PROSPER, SPARTAN, and ARAMIS that show adverse effects leading to death and discontinuation never increased by more than 8% relative to placebos. He then reviews discussions from the RADAR V group on how the transitional state from biochemically recurrent disease to advanced disease needs to be identified and managed in order to create better outcomes. Dr. Crawford also discusses the PEACE-1 trial which emphasized that combination therapy is key to treating specific forms of disease, as well as the SWOG S1216 trial which found that overall survival in the ADT treatment arm did not surpass the control arm’s overall survival of 70 months. Dr. Crawford concludes that anti-androgens are here to stay.

High Intensity Focused Ultrasound for Prostate Cancer

Posted by Hao G. Nguyen, MD, PhD | May 2022

Hao G. Nguyen, MD, PhD, Associate Professor of Urology at the University of California, San Francisco, reviews high intensity focused ultrasound (HIFU) for prostate cancer, discussing its basic principles, historical development, current role, and outcomes. He begins by describing HIFU as a non-invasive approach that uses precisely delivered ultrasound energy to a deep tumor necrosis while minimizing side effects, specifying that its success depends on careful patient selection and lifetime surveillance. Dr. Nguyen outlines the history of HIFU from the first prostate cancer treatment with HIFU at Lyon University Hospital in 1993, through 2022. He reviews the NCCN, AUA/ASTRO/SUO, EAU, and DGUS3 guidelines, all of which suggest that HIFU is an option for prostate cancer treatment, but not yet standard care. Dr. Nguyen discusses how focal therapy can work to fill an important treatment gap in prostate cancer, between active surveillance and radical therapy, due to the oncological control with minimal side effects that HIFU provides. He summarizes data on upgrade-free survival during active surveillance that found high rates of overall survival, prostate cancer specific survival and metastases-free survival. Dr. Nguyen also considers data on the role of focal therapy in active surveillance which demonstrates that 70% of FT candidates remain favorable for hemiablation based on biopsy. He then discusses four ways that HIFU can fail: the heat-sink effect wherein cancer vessels wash heat in or away; the margin effect which signals a missed satellite cancer area; the staging effect wherein micromets or clinically significant cancer is missed; and the field effect which is the progression of low-risk cancer or a pre-cancerous area. Dr. Nguyen concludes that HIFU has promising oncological data and could be shown to be an effective option for patients who don’t want active surveillance or radical therapy.

Practice Evaluation

Posted by Neil H. Baum, MD | May 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, goes over four steps to conduct a medical practice evaluation in order to help improve a practice’s efficiency or prepare it for sale or merger. He begins by observing that the road to success in healthcare has become increasingly complicated as regulation and costs have increased, and technology has developed. Dr. Baum then introduces the first step in performing a practice evaluation: identifying long-term goals and motivation behind the practice. He explains that the doctor/owner must ask themselves where they are in their career and consider whether they plan to sell or merge in the near future. The answers to these questions may lead to further questions about how sustainable the practice is without the full time involvement of the doctor, or about how the doctor/owner can make the practice more attractive to potential buyers. Dr. Baum then moves on to the second step: evaluate practice essentials. These essentials include profit/loss statements, patient volume, status of competitors, patient satisfaction, the status of accounts receivable, and more. Dr. Baum follows this with the third step: measurement of provider productivity. He explains that practice owners should determine how productive doctors in their practice are by looking at the number of patients seen per provider during each half-day session. He suggests that once they have gathered this data, practice owners can determine how to make the lower producers more productive. Finally, Dr. Baum goes over the fourth step: evaluate team talent and morale. He observes that staff salaries represent a practice’s largest expense, and he notes that staff are largely responsible for patient satisfaction. Dr. Baum recommends having an employee review every quarter while also holding regular staff meetings and conducting employee engagement surveys.