Washington, DC (UroToday.com) The Huggins medal is given annually at the Winter meeting of the SUO in recognition of a major contribution and/or lifetime achievement in research and/or clinical practice that has contributed to the progress in the treatment for patients with genitourinary neoplasms. This year’s Huggins medal was awarded to Dr. Joseph A. Smith.
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Dr. Smith addressed a packed ballroom and began by reflecting on Urologic Oncology and how he first became interested in the field. Dr. Smith was the first in his family to go to college and almost immediately upon entering medical school knew that he wanted to be a surgeon. As a surgical intern at UT southwestern, he rotated in cardiac surgery, neurosurgery, and trauma surgery before being assigned a rotation in urology with Dr. Paul Peters. The first urologic operation that he saw was a radical cystectomy. He quickly determined that this was the most challenging operation he had seen. His commitment to urologic oncology has never waivered – but as he admits, the field of urologic oncology has.
Thus, Dr. Smith asked, will the urologic oncologist of the future be a surgeon? And if so, what kind of surgeon will she/he be?
He commenced by highlighting the historical evolution of cancer surgery. Greek surgeon, Galen, commented that even it a growth is removed, it will consume the patient. Roman physician, Celsus, added that after excision, even if a scar is formed, the disease will return. Halstead posited the notion that cancers do not spread by the blood stream and thus require wide surgical excision. Finally, he attributed the seed and soil theory of metastasis to Paget. Even historically, surgery has changed.
Willard Whitmore was Dr. Smith’s fellowship director at Memorial Sloan Kettering in New York and is widely considered the father of urologic oncology. One of his famous commentaries or “Whitism” was that when a patient does well after surgery and does not experience recurrence, the surgeon says we did a great job. When patient does poorly, however, the patient had bad disease. Truly it depends on the tumor and its inherent biology.
Dr. Smith referenced a poll-the-audience result from a previously asked audience of general urologists. He asked for a response to the following question: five years from now how often will radical prostatectomy (RP) be performed? Two-thirds of the audience agreed that RP would be performed less often. There are multiple reasons for this including decreased screening which results in prostate cancer being detected less frequently (Barocas et al, J Urol 2015).
There is evidence that the indications for RP have changed over time. In earlier editions of Campbell’s Urology, the following statement was written: “the best candidate for RP is a man with at least a five year life expectancy and a low grade tumor clinically localized to the prostate.” In contrast, Heidenreich et al (J Urol 2015) have recently published data looking at the role of primary debulking RP in metastatic prostate cancer and there are clinical trials accruing that seek to answer this very question (NCT01751438).
According to Dr. Smith, ten years from now open surgery for prostate cancer will never be done, for bladder cancer open surgery will be seldom performed, and for kidney surgery open surgery will be reserved for level IV thrombi and locally invasive disease. He hopes that these decisions will be informed by high-level evidence-based medicine (http://hsls.pitt.edu/resources/ebm).
Dr. Smith concluded his remarks by stating that the future of urologic surgery will be more refined, applied more selectively, and will require advanced technical skill. He believes that the options to care for patients will expand to permit true multidisciplinary management. Finally, he noted that being a technician will not be enough – in truth, it never has been.
Joseph A. Smith, MD
Vanderbilt University Medical Center
Benjamin T. Ristau, MD from the Society of Urologic Oncology Meeting - December 2 - 4, 2015 – Washington, DC.
Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA