BERKELEY, CA (UroToday.com) - In this era of new options for the treatment of advanced prostate cancer, one large urology group practice has successfully evolved from providing bone health education to becoming an integrative ADT Clinic. At Lancaster Urology Cancer Center (Lancaster, PA), Paul Sieber, MD, urologist, is one of 12 physicians, and he is actively engaged in several clinical trials. He has been a champion of bone-health education, and in this interview, he addresses Lancaster Urology’s multi-disciplinary approach.
The Lancaster Urology Bone Health Clinic was established in 2007, and the ADT Clinic was added in 2010. At that time, the group practice had 7 urologists. By July, 2012 the practice had grown to 12 physicians, expanded with two satellite offices, and has integrated two physician assistants and a dedicated advance-practice nurse.
Dr. Sieber likes to start by putting this issue into perspective – recalling the prostate cancer treatment timeline. “Of all the decades, the 1940s, 1960s, and 2010s jump out as pivotal moments in the history of prostate cancer care. Great opportunities open the door for higher levels of physician, nursing and patient education on the issues.” That’s where our conversation took off.
According to Dr. Sieber, the Lancaster Urology vision includes utilizing advance-practice nurses to micro manage mCRPC patient care by instilling a higher level of patient education. Their multi-disciplinary team initiates preemptive bone-health education that relates the patient’s prostate health to one’s heart health and includes discussions about diet, cholesterol, and weight loss. At the end of the day it’s about emphasizing quality-of-life options. “It’s an exciting time to be a urologist – we have some significant treatment options to offer our patients,” says Sieber.
In November 2012, Dr. Sieber presented the practicalities of his ADT Clinic at the annual LUGPA meeting’s special all-day seminar on prostate cancer. A thousand miles away, his nurse, Leanne Schimke, CRNP, CUNP presented at the SUNA Annual Meeting on the same topic, albeit with a slightly different spin. Both shared the yin and yang of how to move the quality-of-life benchmark forward for these patients.
| Quick Review ADT Clinic & bone health – Where to start?
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Q. What cancer clinic models did you look to when planning for your ADT Clinic in Lancaster, PA?
Dr. Sieber: We don’t have many academic models that are a direct correlation to private practice. At Duke University, their cancer clinic model (as reported in the January 2012 issue of Journal of Urology) demonstrated a novel approach to comprehensive cancer care. The protocols and economics sound good on paper, but how do we pay for the expertise? In private practice, we can’t survive splitting a Medicare fee three ways. In an academic setting, these clinics may actually be a loss leader but generate downstream revenue from future care. That business model, however, doesn’t fit our group practice growth objectives. To complicate matters, the debated health-care delivery and belt tightening will continue to challenge us. We have these incredible new treatments and therapies, but can we effectively utilize them? The discussion needs be:
How can we be proactive?
How can we best integrate effective therapies that improve the patient’s quality of life?
I believe the answer lies, in part, in bone health.
Q. How have you adapted your ADT /bone-health clinic to balance the expertise and economics of delivery of care?
Dr. Sieber: We went from 7 to 12 physicians and added two satellite offices in the last year. It wasn’t hard to get buy-in from our physicians, nurses and PAs – 80 percent of our prostate cancer patients are seen in our Lancaster office. It’s pretty easy to move them through an ADT practice model. The challenge has been how to roll out this model to the satellite offices. The protocol for our mCRPC patients, with or without bone metastases, is the same. Our nurse practitioners micro-manage these patients so that education about bone health starts earlier.
Q: In this new era of PROVENGE®, Zytiga®, Xtandi® and other pipeline therapies, how does your group approach the sequencing of these treatments?
Dr. Sieber: 2010 represented a true kick-off into a new era of therapeutic treatments for castrate-resistant prostate cancer. We now have some really good options for prolonging life and preventing nasty side effects. In our group, we have taken the approach that bone health needs to be optimized. To that end, we can start running with PROVENGE®, and in the course of treatment, we sprint with Zytiga®. Obviously there are many more levels to that conversation, and, truthfully, our ADT Clinic model is evolving, but the process started by changing our internal structures.
Q: Have you set any benchmarks for your ADT clinic?
Dr. Sieber: Honestly, we don’t have a lot of people to talk to (such as Professor X or Y), so I tend ask the internists and radiologists to be my sounding boards. For each patient, evaluating bone density is an easy step. Our nurse practitioners take the lead on education and have significant conversations about the value of calcium and Vitamin D, as well as the role of diet, cholesterol, weight control, and alcohol. We are also paying more attention to the patient’s heart health and existing CVD. Since a majority of my colleagues reside in one office location, our sheer proximity increases the dialog on the subject of bone health. We also discuss how to better monitor these patients and ways to involve the patient’s family physician.
Q: You have a strong history of being a study site in numerous clinical trials. How do you manage this?
Dr. Sieber: I have often been asked how we manage a steady enrollment of our patients in various clinical trials. You might not think it’s possible with just a 12-person practice, but having a “captive” audience is an advantage to identifying potential patients and explaining the benefits of being involved in various studies. We seem to have a concentration of CRPC patients, so naturally it benefits our community for us to be focused, involved, and very proactive with clinical trials. As a champion for these studies, we all have special areas of interest (i.e. prostate cancer bone health), while others specialize in bladder or pediatric urology. So like an academic center with many specialists, we combine our expertise under one roof and those combined perspectives help us to be progressive.
Q. As for PSA and radiographic progression, what is on the horizon for continuity of care?
Dr. Sieber: It’s no secret that urologists view PSA as a vital piece of information; many of us grew up with PSA. It is part of our daily lives and integral to the guidelines for care. Yet, there are not a lot of guidelines for when to use imaging, what modality to use, and how often. These are all conversations that need to happen in scientific and academic meetings. But currently, in 2013, we don’t have a lot of guidelines.
As a urology group practice and cancer treatment center, it helps to have a process in place for when to use CAT scans and bone scans in the treatment regime. Now that we have stronger data supporting the involvement of an immunotherapy option (PROVENGE®) pre-chemotherapy, we are working to develop “next generation” practice protocols that focus on the sequencing of these new treatments with a strong emphasis on bone health education.
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About Lancaster Urology and Lancaster Urology Cancer Center: Twelve physicians, two physician assistants and a dual-certified family nurse practitioner and urology nurse practitioner have provided more than 60 years of urologic leadership in Lancaster, PA. This full-service urology group practice includes a clinical and pathology laboratories, CT, dual-energy X-ray absorptiometry (DEXA) and ultrasound imaging - offering state-of-the-art diagnosis and minimally-invasive treatments. This group continues to lead a nationally recognized clinical research program with outcomes well documented in the CaPSure database. The Lancaster Urology Cancer Center team treats all urologic cancers and includes a fellowship-trained uropathologist whose primary focus is urologic cancer. For more information, visit their website at http://lancasterurology.com .
About Paul Sieber, MD: Dr. Sieber received his undergraduate degree in biology from Purdue University, subsequently earning his medical degree from Indiana University. He completed his internship and residency at Penn State Milton S. Hershey Medical Center. His specialties include prostate and renal cancers as well as general urology and urologic surgery.
Interview conducted by Karen Roberts, UroToday.com medical editor.
