Preparing for the Future

Raoul S. Concepcion, MD

Editor-in-Chief of

Urologists in Cancer Care

Director of Clinical Research Urologic Surgeon Urology Associates, PC Nashville, TN

In attending the Society of Urologic Oncology’s annual meeting in Bethesda in early December, I was struck by the number of presentations focusing sharply on the burgeoning fields of biomolecular markers and immunotherapy and their application to urologic oncology. (In fact, one of the lead articles in the Wall Street Journal on Friday, December 5, was “How the Promise of Immunotherapy is Transforming Oncology.”)

A tremendous amount of science and research are being generated by the many labs across the United States and other countries that are working diligently in attempts to better diagnose and manage our cancer patients, all with the hope of potentially making it a chronic disease state and not a death sentence. At the meeting, I observed urologists, both young and old, feverishly scribbling notes, much like Sean Connery typing in his role as a writer in the movie “Finding Forrester,” so that they can hopefully make better sense of the new lexicon of terms that we are forced to understand: transcriptomics, checkpoint proteins/inhibitors, chaperone molecules, splice variants, and histone methylation, to name just a few.

With respect to the chronologic age of our colleagues, urologists are the second oldest amongst surgical specialists, just after cardiovascular surgeons. When we were in medical school, immunology was a fledging science and our understanding of the immune response, in retrospect, seems so rudimentary compared to where it has progressed. However, our field is rapidly evolving, especially in the world of cancer management. For us to deliver state-of-the- art care, we need to become physician scientists. It is imperative that we DO have a true working understanding of these concepts and mechanisms that we used to just memorize and discard after we passed our boards or recertification exams. This will be the future of medicine, and it is upon us, much faster than any of us ever thought possible.

For those of us years removed from our residency training, the constant challenge is how to stay abreast of this tsunami of information, given the limited number of hours we have to attend to all of our other obligations, both at work and at home. Luckily, there are myriad sources where we can obtain this information. No longer do we have to take time out of our practice to attend live meetings and conferences for educational updates. Webinars, video clips, print material, email blasts, and the entire digital world allow us, if motivated, to stay current and not fade into obsolescence. With the current payment-reform movement that is pushing all physicians to practice evidence-based medicine and begin to measure outcomes and metrics (even though these have not been truly defined), it is imperative to be motivated in order for our practices to remain viable.

But what is our obligation to those medical students, residents, and fellows training to join our ranks, given that we are a traditional surgical specialty and, for the most part, these newer targeted and immunotherapies in academic centers are primarily under the auspices of the medical oncologist? My concern is that they are not getting the adequate exposure to these newer treatments and biomolecular concepts, given the lure of robotic and open surgery. After all, the reason that all of us chose to be surgeons was to operate, not to administer drugs.

I have heard from many urologists around the country that we are not medical oncologists, and therefore lack the training to manage these patients. My counter argument is that we, as a specialty, are perfectly capable of mastering the utilization of these drugs. Many of us around the country have proven this to be a truism. The patients that we have diagnosed, treated, and followed have, for many years, put their trust in us. With the newer therapies in castrationresistant prostate cancer, now is not the time to abandon that relationship with the claim that we are just surgeons, and move their care elsewhere.

We need to figure out better models within our independent practices to provide the spectrum of care, including areas such as end of life and, yes, medical oncology. This would involve providing a complete multi-disciplinary team. More importantly, we need to continue, at every opportunity, to educate our medical students and residents in urology. They represent the future of our specialty and need to embrace the concept that managing our cancer patients goes well beyond surgery. Thus, in order to offer true personalized or precision medicine, they, like us, will need to learn (or relearn) the molecular basis of malignant transformation, its drivers, and how to best tailor therapies for each individual patient.