BERLIN, GERMANY (UroToday.com) - EAU 2007 - Professor Kurt Miller, Berlin Germany chaired this discussion on "Systemic Treatment of Urologic Cancers: Who Should Treat the Patient?". Professor Miller began by highlighting that between 44,000 and 98,000 patients die each year in the US as a result of medical errors. Urology specific outcome data is not available. In Germany, a significant number of urologists provide systemic therapy for patients and are reimbursed for it. This requires that office urologists document that they have given >200 cycles of systemic chemotherapy in their training. New guidelines require that >300 cycles must be demonstrated by urology departments.

Professor Mulders, Nijmegen, The Netherlands debated that the urologist should manage these patients. The patient does not consider what type of physician administers the care, as long as they are qualified and skilled at it. Urologists treat a variety of urologic diseases with systemic therapy such as OAB, stone disease, malignancies, etc. Dr. Huggins, a urologist by training founded the basis of systemic therapy for prostate cancer in 1944. This established the precedent for the role of the urologist, according to Professor Mulders. In addition, intravesical therapy for bladder cancer has been developed and optimized by urologists. In testicular cancer, urologists in the EORTC enrolled patients and were responsible for advancements using chemotherapy in Europe. These results were clearly better in high volume centers as supported by the outcomes data. While systemic chemotherapy for androgen-independent prostate cancer was primarily spearheaded by medical oncologists, urologists understand the patient and their history far better than the medical oncologist. The oral agents for renal cell cancer are best administered by urologists he said, and toxicities are relatively mild and easily managed.

Professor Bellmunt, Barcelona, Spain argued that the oncologist should care for these patients. He cited a paper by Dr. David Crawford that surveyed urologists about their interest in learning about administering chemotherapy. 21% responded to the survey and 95% did not give chemo to AICaP and only 2-4% gave IV chemo. In addition, only 38% of urologists even referred patients for systemic chemo for CaP. 45% expressed interest in acquiring training to give chemo. In the US, 80% had a medical oncologist in their group to rely upon for giving chemo. Even among fellowship trained urologic oncologists, only 25% received training in systemic chemo. Professor Bellmunt informally polled urologists in Europe, which led him to the conclusion that urologists will separate into surgical urologists and medical urologists. The latter group would potentially give chemo. In several countries, such as Austria and the UK, physicians stated that urologists and oncologists both provide this care to patients. His personal view is that he went into medical oncology as others were not interested in treating these patients. He felt that urologists primarily focus in the operating room and just because oral agents are available for the treatment of renal cell cancer, does not mean that any doctor who can give them is now a renal specialist. Oral drugs should not be mistaken for being without toxicity. Medical oncologists are most versed at managing complications, but if urologists want to get involved, they should undertake adequate training and gain substantial experience. Ultimately, in the end it is the degree of experience that is most important, not the type of specialist.

Professor Mulders countered that medical errors are prevalent with medical oncologists as documented in a study reporting 17 of 172 children treated with chemotherapy for acute lymphoblastic leukemia suffered medical errors. It is not the toxicity, rather the understanding of the disease course and necessary timing of treatments that is important. At the very least, coordinated treatment between the two specialists is important.

Professor Bellmunt finished by stating that as disease stage advances, the role of the urologist has historically decreased as other specialties assumed the care. Both specialists can treat the patient, as long as training is thorough and interaction between the groups well established. As a result, patients will remain at the center of care and benefit from the expertise of the medical professional.

EAU 2007 Conference Coverage on UroToday.com

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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