2022 Archives

Time to Cut Down the Phone Tree

Posted by Neil H. Baum, MD | Jan 2022

Grand Rounds in Urology Contributing Editor Neil H. Baum, MD, Professor of Urology at Tulane Medical School, discusses the problems with phone trees and gives suggestions for how medical practices can replace them. He observes that a telephone call is typically the first interaction between a patient and a doctor’s office, so the experience should be a good one. However, Dr. Baum argues, phone trees can make that first impression a negative one since phone trees can be difficult to navigate, can result in callers being on hold for a long time, may force callers to restart the lengthy process if the call is dropped, and may make it difficult for callers to leave a message. To determine whether a phone service is causing problems, Dr. Baum recommends conducting a survey of patients with questions about how quickly the phone was answered, how long callers were placed on hold, how difficult the phone tree was to navigate, and whether callers were able to speak to a human. He then gives three suggestions on how to cut down the phone tree including: conducting a telephone traffic study to determine when to make sure a greater number of people are available to answer the phone; increasing phone availability to include early and late hours when working people are available; and trimming or removing the phone tree to make the process simpler.

Semaglutide as a Game Changer for Weight Loss

Posted by Martin M. Miner, MD | Jan 2022

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, and Martin M. Miner, MD, Co-Director of the Men’s Health Center and Chief of Family and Community Medicine for Miriam Hospital, and Clinical Professor of Family Medicine and Urology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, discuss the potential benefits of semaglutide, a newly approved weight-loss drug. Dr. Moyad begins by summarizing the damage done by past weight-loss drugs, noting that they inevitably came with a huge catch and were never heart-healthy. He then introduces semaglutide, a recently-approved drug which has been shown to result in 15% weight loss over 2 years. Dr. Miner elaborates, explaining that there have been 4 studies of semaglutide featuring over 4500 individuals and that it is extremely safe. He highlights that the smaller dose in diabetics has also been shown to improve renal and cardiovascular outcomes, and that these outcomes are now being studied in non-diabetics. Dr. Miner argues that these results suggest semaglutide is a game changer. Dr. Moyad then discusses potential catches, noting that while the side effect profile seems good, the cost is very high at nearly $900 per month, and it is not covered by most insurance. Dr. Miner suggests that the price will go down once some time has passed from the initial approval. He does highlight as a negative the fact that semaglutide is given once per week as a subcutaneous injection, and suggests that it will be beneficial if the oral version currently under investigation is found to be effective. Drs. Miner and Moyad also ponder the long term impacts of semaglutide and sustained weight loss on testosterone levels, blood pressure, and depression. Dr. Moyad concludes by discussing his curiosity about the potential impact of semaglutide in a urologic setting.

Testosterone as a Fasting Blood Test?

Posted by Mark A. Moyad, MD, MPH | Jan 2022

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, and Martin M. Miner, MD, Co-Director of the Men’s Health Center and Chief of Family and Community Medicine for Miriam Hospital, and Clinical Professor of Family Medicine and Urology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, discuss recent guidance suggesting that a fasting blood test is needed for testosterone. Dr. Moyad begins by explaining that in 2018, the Endocrine Society Clinical Practice Guidelines included a recommendation of measuring fasting morning testosterone. He suggests that this is a logical recommendation since, in a subset of men, testosterone levels may be temporarily lowered by food intake, but notes that this guidance does not appear to be widely known or followed. Dr. Miner says that he actually does usually include testosterone with other morning fasting tests to meet the demands of insurance, although he argues that this may also result in inaccurate levels since testosterone is supposedly at its peak in the afternoon. He also mentions that the American Urological Association does not recommend getting testosterone tested in a fasting specimen, although he is unsure why this is. Dr. Moyad concludes that this is a topic that is just beginning to be explored and should be watched.

New Advances in Penile Implant Infections Detection in 2022

Posted by Gerard D. Henry, MD | Jan 2022

In conversation with A. Lenore Ackerman, MD, PhD, Assistant Professor of Urology and Director of Research in the Division of Female Pelvic Medicine and Reconstructive Surgery at the University of California, Los Angeles, Gerard D. Henry, MD, a urologist with WK Advanced Urology in Shreveport, Louisiana, and President of the Louisiana Urological Society, provides an update on his research into the detection of penile implant infections. Dr. Henry explains that bacterial infection is more common than urologists realized, noting how, 20 years ago, he and his colleagues found a biofilm on the penile implants of patients who appeared to just be experiencing mechanical failure. He then describes a study comparing next generation sequencing (NGS) versus traditional culture in penile implants and suggests that NGS might be the new gold standard for assessing penile implant infections since it can identify not only what bacteria are present, but also the abundance of bacteria. Dr. Henry highlights that NGS has demonstrated that the main form of bacteria affecting penile implants is not Staphylococcus epidermidis, as long believed, and that Escherichia coli and Pseudomonas are more common. He argues that by more specifically identifying these bacteria, urologists may be able to better treat patients and avoid having to remove implants. Dr. Henry then introduces a new, currently-recruiting, prospective, randomized study of next generation sequencing versus traditional cultures for clinically infected penile implants and the impact of culture identification on outcomes. The discussion concludes with a question-and-answer session in which Dr. Ackerman asks about outcomes in the upcoming trial, other potential applications of NGS in urology, and the potential source of the bacteria identified by NGS.

Point-Counterpoint: Management of mCRPC

Posted by Alan H. Bryce, MD | Jan 2022

Rana R. McKay, MD, Associate Professor of Medicine at the University of California, San Diego, and Co-Leader of the Genitourinary Oncology Disease Team at the Moores Cancer Center, and Alan H. Bryce, MD, Medical Director of the Genomic Oncology Clinic at Mayo Clinic Arizona in Scottsdale, debate whether to treat metastatic castration-resistant prostate cancer (mCRPC).

Taking the pro position, Dr. McKay presents on why physicians need to treat mCRPC, as well as come up with additional treatment options to help improve survival for mCRPC patients. She discusses the goals of mCRPC treatment, improved quality of life and overall survival, and displays a chart that summarizes the current landscape of treatment for advanced prostate cancer as she details how androgen receptor (AR) targeting agents are enhancing treatment. Dr. McKay reviews FDA-approved agents in mCRPC, stating that the vast majority both improve overall survival and quality of life. She specifically states that the agents, outside of pembrolizumab, rucaparib, and sipuleucel-T, can potentially increase overall survival by 53.6 months and improve cancer-associated pain, disease-related urinary symptoms, and symptomatic skeletal events. Dr. McKay then shows a graph displaying mCRPC treatment in a clinical practice, suggesting that mCRPC is grossly undertreated based on the vast majority of patients not going beyond first-line treatment. She states that there is little reliable data on the cost effectiveness of treatment and concludes that mCRPC should be treated based on data showing that treatments improve overall survival and quality of life.

Taking the con position, Dr. Bryce makes an argument against treating mCRPC based on the differences between trial and real-world populations, and the challenges of extreme treatments. Dr. Bryce cites quality of life post-treatment, financial toxicity, and patient-centric treatment as cons of mCRPC treatment. He shows a graph of mCRPC treatment management in clinical practice and states that the rapid drop off after first-line therapy could be caused by patient drop outs instead of undertreatment. Dr. Bryce discusses the mCRPC treatment process in detail, focusing on how after the first line of therapy, treatment options become much more extreme and mostly consist of chemo, and most patients only have about a year left to live if they are beyond second-line treatment. He uses a case study of a 73-year-old patient to show how real-world patients can differ from selected trial patients due to how patient selection leads to optimized outcomes. Dr. Bryce reviews data showing that 20% of patients report financial toxicity, something which is associated with anxiety and depression. He concludes that clinicians should exercise prudent judgment in deciding whether or not to treat patients with advanced cancer due to trials testing beyond third-line therapy not reflecting real-world patients and financial toxicity being a significant issue.