Practice in South Texas Offers Vertically Integrated Cancer Care

Alan D. Winkler, MHSA, FACMPE

Providing comprehensive, compassionate, cost-effective care has been the guiding principle of Urology San Antonio (USA) from its beginning in 1996. Those same attributes have been integrated into the innovative cancer care program offered by this medical practice that treats all aspects of prostate cancer from diagnosis to end-of-life care, including an in-house pharmacy, catheter service, disease-specific nurse navigation, and clinical trials division.

With a team of 26 urologists, 8 advanced practice providers, and 2 pelvic floor physical therapists, the practice manages over 200,000 visits and establishes relationships with more than 22,000 new patients each year. Four additional urologists and the practice’s first urologic-oncologist will join the care team at USA later this year.

Coordinated care does not happen by accident. The practice offers a wide range of services along a continuum of care overseen by a team of subspecialists across 9 locations. From cutting-edge diagnostics including biomarkers to guided targeted biopsy services, genomic testing, and multiparametric MRI fusion biopsy services, the practice designed and follows clinical pathways for active surveillance and prostate and bladder cancer treatment. As a result, the physicians have attained a 58% positive biopsy rate with a healthy distribution across treatment modalities that meets or exceeds national averages: 35.2% of men in active surveillance, 27.3% in intensity-modulated radiation therapy (IMRT), and 23.5% selecting prostatectomy.

Robust data analytic tools managed by disease-specific nurse navigators help identify patients for life-saving treatment modalities and potential participation in clinical trials. Chronic care management of patients with prostate cancer continues to expand with over 100 patients in active management currently through the prostate cancer Chronic Care Management program.

“The Advanced Therapeutics Clinic opened in 2011 and currently manages more than 300 patients. Identifying who is appropriate for active treatment versus active surveillance has been crucial to our success,” Daniel Saltzstein, MD, explained. By using biomarkers and offering new diagnostic imaging modalities that might someday replace MRI, the practice individualizes advanced cancer therapies while offering companion therapies such as PARP inhibitors.

In-house pathology services enhance the consistency and timeliness of diagnosis and treatment. Patients have access to immunotherapy, secondary hormonal therapy, agents to manage bone health, and radiopharmaceuticals. Currently, physicians like Saltzstein, the practice champion for Advanced Prostate Cancer Care, are investigating the potential of new oral antagonists and considering incorporating FDA-approved adrenal biosynthesis inhibitors and second-generation androgen—receptor signaling inhibitors earlier in the prostate cancer treatment paradigm.

The Reyna Cancer Center was added in 2005 and provides IMRT to 80 men per day in addition to offering conventional radiation treatment for a variety of cancers.

Diagnostic and treatment services are augmented by an in-house retail pharmacy that allows USA to manage 80% of its patients started on all 3 oral agents for advanced prostate cancer care, as well as provide many medications for the patients’ other urologic needs. In fact, the pharmacy fills almost 1000 prescriptions per month for a variety of urologic issues.

USA’s robust clinical trials division, with 8 current prostate cancer trials in addition to its work in medical devices and other disease processes such as bladder cancer, allows USA’s caregivers to accompany the patient and his family along the cancer journey. USA is preparing to launch its end-of-life program now to support the patient and his family and caregivers in dignified, informed decision-making.

USA is governed by a board of 5 physicians who work with an executive director. The practice employs 288 individuals located in 7 clinics, a radiation cancer center, and a specialty ambulatory surgery center.