Raoul Concepcion, MD, director of the Comprehensive Prostate Center, discusses the impending transition to a value-based model in urology.

The field is moving away from the traditional fee-for-service and many physicians have been hesitant to believe in the switch due to the high rate of tweaking and revising within the value-based system by the Centers for Medicare & Medicaid Services (CMS).

As per the CMS website, value-based programs are focused on paying providers based on the quality of care they give, not the quantity.

According to Concepcion, the way this transition plays out is vital to the future of way medicine is delivered.

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Dr. Concepcion on Transition to Value-Based Model in Urology

Raoul Concepcion, MD, director, Comprehensive Prostate Center, discusses the use of Eligard in the treatment of prostate cancer with 

Eligard, manufactured by Tolmar, is an LHRH agonist which overdrives the testical for a brief period of time, resulting in a castration level of testosterone.

What makes Eligard unique is its delivery system, Concepcion says. Eligard's Atrigel delivery system is a slow release, which results in lower, sustained levels of testosterone.

Raoul Concepcion, MD, director, Comprehensive Prostate Center, discusses the use of Eligard in the treatment of prostate cancer with OncLive during the LUGPA Annual Meeting.

Dr. Concepcion on the Use of Eligard in Prostate Cancer Treatment

	As we head into the sweltering days of summer, physicians—and urologists in particular&mdash;face a series of challenges that can potentially impact the way we practice and how we manage our patients. No faction is immune, academic versus independent, solo practitioner versus large group, employed versus self-employed urologist.

	At a national level, we are all anxiously waiting the Supreme Court ruling on the individual mandate that requires all citizens to purchase health insurance and the constitutionality of such a provision as set forth in Patient Protection and Affordable Care Act. If, in fact, this controversial amendment is deemed unconstitutional, then the court must decide if the law can stand if this portion of the legislation is stripped from the Act. With this issue looming in the midst of the Presidential election, inertia could possibly set in with no significant healthcare reform introduced, leaving many of us wondering what is next and having to grapple with the mounting pressure of diminishing reimbursement and rising overhead.

	Specific to the field of urology, we are all aware of the recent recommendation rendered by the US Preventive Services Task Force (USPSTF) downgrading the routine use of PSA in the early detection of prostate cancer. Without recapitulating all that has been published and submitted by various societies across the country, including the American Urological Association (AUA), Large Urology Group Practice Association (LUGPA), American Association of Clinical Urologists (AACU), and many patient advocacy groups, this single act threatens to roll back all the progress that has been made in reducing the mortality rate of prostate cancer over the past 20 years.

	In my mind, this is reprehensible. However, the good news is that as we go to press, a urology delegation from the AUA and AACU was successful in lobbying the American Medical Association House of Delegates, making note that the USPSTF failed to take into account public comments submitted by specialists and that there were no urologists or oncologists on the panel.

	Although opposed by certain primary care organizations, the tireless efforts of many of our peers resulted in a directive where the AMA encourages the USPTSF “to implement procedures that allow for meaningful input on recommendation development from specialists and stakeholders in the topic area under study.” Many thanks to Bill Gee, Willie Underwood, Aaron Spitz, and Roger Satterthwaite for their concerted efforts.

	Over the past few years, it seems that the urology community has been under constant attack from colleagues outside of our specialty. Physician ownership and over-utilization of advanced imaging and radiation therapy were the first issues to be brought into the public spotlight. The most recent salvo was delivered by a noted Washington, DC economist, hired by a subspecialty organization, questioning our standard of care and the use transrectal ultrasound guided needle biopsy of the prostate and the number of cores taken to make a determination of prostate cancer. Thanks to the efforts of LUGPA, with data input from many large integrated groups across the country, these arguments, based on faulty and suspect data, were summarily dismissed on The Hill.

	The field of medicine faces many challenges as we move forward in the 21st century. Given the economic situation and the rising national debt crisis in this country, many outsiders are looking at ways to stifle technology and limit or ration care. The rapid explosion of the new therapeutics for advanced prostate cancer will no doubt bring into question the potential rising costs to treat this disease.

	Given the lack of clear pathways and sequencing of these multiple agents, it seems prudent that we, as a specialty, begin to work cooperatively with our urologic peers to start the difficult and arduous task of data mining and collection. We need to determine the ideal patient profiles—irrespective of disease state&mdash;that will benefit from these new agents, and which therapies are clearly more efficacious and justify a higher price tag.

	Hopefully, a well-designed electronic health record will help facilitate such a project, which will take years and a commitment, both personal and financial, from all involved. However, if we, as the recognized experts and thought leaders in the field, do not take the initiative, it will be mandated by bureaucrats, which will more than likely result in suboptimal care for our patients.

	1. Urologists debunk misleading, grossly inaccurate prostate cancer biopsy study [press release]. Tallahassee, FL: Large Urology Group Practice Association; April 13, 2012.

Articles

As we head into the sweltering days of summer, physicians-and urologists in particular-face a series of challenges that can potentially impact the way we practice and how we manage our patients.

Urology Under Attack

	It is with great pleasure that I welcome you to the inaugural issue of 

. As all of us are so keenly aware, the beauty of our field is the diversity of patients who walk through our doors on any given day with a vast array of symptoms and disease states that we need to manage or diagnose. Whether our patients are male or female, adult or pediatric, symptom- or lab-driven or confirmed diagnosis, surgical or medical, we represent a true hybrid specialty that relies upon our cognitive and technical skills to adequately manage our patient population.

	With the exponential growth in research and technology, it becomes very difficult for the average urologist to keep current with all the new advances in the field. In years past, reviewing a handful of lab data and x-rays and possessing superior history/physical exam skills were all that were required to provide the limited treatment options that were available for our patients. That is clearly not the case today. In order to adequately deliver state-of-the-art medicine for every patient, there are literally hundreds of pieces of data that we need to collate and evaluate. To make matters more complex, this has to be accomplished in a limited time frame, as physicians are being forced to see more patients in order to keep their practices financially viable.

	It seems rather intuitive, then, that we—especially those who are in larger groups&mdash;encourage and promote an environment of subspecialization within practices, which in turn would foster the development of centers of excellence that optimize patient care. This model has been proven repeatedly in medicine (eg, Shouldice Hospital for hernia surgery) and in the business world (eg, Midas Mufflers). If you specialize in one thing and do it well, you become the recognized leader in providing these services, which should ideally result in higher patient satisfaction and superior clinical outcomes. Urologic oncology is an area that is perfectly suited for this type of specialization and represents an area of growing opportunity for urologists.

	For the most part, urologists have been buoyed by the treatment success in many of the malignancies that we commonly see, particularly localized prostate cancer, nonmuscle-invasive transitional cell cancer of the bladder, and early-stage renal cell carcinoma. In the metastatic arena, we have become accustomed to, and perhaps jaded by, the near 100% cure rate for most testicular carcinomas. Over the past few years, there has been a burgeoning of therapies, primarily aimed at patients in the advanced metastatic state. This is particularly true for renal cell carcinoma and metastatic castration-resistant prostate cancer (mCRPC ). As many of you are aware, we have seen an explosion of oncolytic therapies that are FDA-approved for mCRPC, and I anticipate many more to come over the next 12 to 24 months.

	What makes this particularly attractive for the urologist is the delivery of these agents. Some are administered orally, and others are injected subcutaneously or intravenously, with minimal side-effect profiles and are more efficacious than what previously had been available. These patients exist within our current practice—we have ushered them through diagnosis, definitive treatment, and are actively engaged in their follow-up. Most importantly, however, we now have therapies available that are superior and show documented survival benefits and better side-effect profiles that are better tolerated by the patient.

	With the rapid advancements in this area, it makes sense to identify a “physician champion” in your group, one who is well-versed in the data and understands the regulatory limitations of these agents. This is a very dynamic field, and sequencing of these drugs is yet to be defined.

	Although many challenges remain, the range of opportunities for urologists to expand our role in the treatment of patients with cancer is continually increasing. It is paramount for our specialty to become more active in identifying patients earlier in the course of disease and in helping to raise the quality of care for our patients. I am excited for this opportunity to be Editor-in-Chief of this new publication that will provide clinical updates and practical tools targeted specifically to urologists who treat patients with cancer. I hope that you will enjoy this first issue of 

, and certainly invite you to contact me with any comments or suggestions for future coverage.

	Finally, I dedicate this work to my father, a retired urologist and the first resident in urology at the Lahey Clinic, and to my late mother, who was perhaps my biggest fan. I am forever indebted.

It is with great pleasure that I welcome you to the inaugural issue of Urologists in Cancer Care.

Raoul Concepcion, MD

Articles

Dr. Concepcion on Transition to Value-Based Model in Urology

Dr. Concepcion on the Use of Eligard in Prostate Cancer Treatment

Urology Under Attack

A Word of Welcome