A very interesting post by Dr. Scholz

i like a doctor with swagger

ed

The link is not working.

Let me just paste it:

(Moderators: I hope this is allowed, if not then delete it)

>>>>>>>>>>>>>>>>>>>>

I Am Not a Urologist

Posted: 12 Feb 2014 08:34 PM PST

BY MARK SCHOLZ, MD

In February, while attending the tenth annual GU-Oncology meeting, I was surprised to see my name listed on large posters around the meeting hall (along with about 30 other physicians). The hosts of the meeting were honoring a very small group of doctors who have attended every single American Society of Clinical Oncology Genitourinary (ASCO-GU) meeting since the meeting’s inception 10 years ago.

A Prostate Cancer World Populated by Surgeons
It’s not surprising that at a meeting of 2,500 attendees, only 30 doctors were honored. This was not a urology meeting, as is typical with most prostate cancer meetings. This meeting was hosted by the American Society of Clinical Oncology*, an association of medical oncologists. Only 30 doctors were on the list because medical oncologists who consistently attend meetings focused on prostate cancer are rare. The prostate cancer world is run by urologists, who are surgeons. Urologists have dominated prostate cancer for 100 years, dating back to when surgery was the only effective cancer treatment available.

What is a Medical Oncologist?
I tend to assume that all my patients know that I am a medical oncologist, not a urologist. However, when I speak to patients, I frequently discover that men fail to understand the difference. The following short list might be help helpful.

Medical Oncologists:

1. Take leadership of a medical team comprised of medical doctors from various specialties

2. Are trained to manage all types of cancer

3. Supervise multimodality therapy (surgery, radiation, immune, hormonal and chemotherapy)

4. Are board certified in internal medicine as well as medical oncology

5. By observing patient outcomes, learn through first-hand experience which surgeons and radiation doctors are the most skilled

6. Are trained in how to administer multiple different types of medications—both for cancer treatment and for overall health needs—safely, in combination

7. Have no innate preference for surgery over radiation, since they perform neither

Urologists:

1. Are trained first and foremost as surgeons

2. Are trained to care of numerous noncancerous maladies of the genitourinary tract (kidney stones, erectile dysfunction, bladder infections, prostate enlargement, vasectomies, repair of congenital anomalies, urinary leakage, etc.)

3. Have no internal medicine training

4. Have a rudimentary understanding of cancer treatment (outside of doing surgery)

Let’s take up the issue of leadership. In this complex modern era, good medical outcomes require a coordinated team effort that maximizes the participation of all the different medical specialties. Five specialties commonly participate in prostate cancer management: urology, radiation oncology, radiology (reading scans), pathology (reading biopsy specimens under the microscope) and medical oncology. Obviously, any kind of team, medical or otherwise, performs best with knowledgeable and experienced leadership. With almost every other type of cancer (besides prostate cancer) medical oncologists take the lead.

Longstanding Tradition Makes Prostate Cancer the Exception to the Rule
It’s surprising to most people that university medical oncology fellowship programs (like USC, where I trained) offer no training in the management of early-stage prostate cancer. This role has been totally abdicated to the urologists. While advanced-stageprostate cancer patients do transfer their care to oncologists somewhat more frequently, this happens in only half the men with advanced disease.

Studies show that 50% of men with advanced prostate cancer who succumb to progressive disease die without ever consulting with a medical oncologist! This practice of urologists holding onto their patient to the bitter end may have been defensible back when the effective treatment options for advanced disease were limited to Lupron, Casodex and palliative spot radiation to the bones. However, forgoing oncology consultation in this modern era of Provenge, Zytiga, Xtandi, Xofigo and Jevtana, all of which are proven to prolong survival, borders on lunacy.

Yet despite there being over two million prostate cancer survivors in the U.S., less than a one-hundred (100) medical oncologists who actually specialize in prostate cancer, and almost all of these are in academia doing clinical or laboratory research. Outside of academia less than ten (10) medical oncologists specialize in prostate cancer fulltime. Three of these are in my office in Marina del Rey. The other free-standing medical oncology clinics that specialize in prostate cancer are listed at www.goo.gl/hfFt3F

Practice Makes Perfect
Real day-to-day clinic experience treating large numbers of men with one disease—in this case prostate cancer—improves the skill level of the practicing doctors. Skillful doctors are of great value because new medicines are being approved at an ever faster pace. Familiarity with their use can only be achieved at a high-volume prostate cancer clinic. A fulltime prostate oncologist gains practical experience that takes years to appear in textbooks.

Furthermore, prior to FDA approval, new drugs can only be obtained by participating in clinical trials. But it’s dangerous to conclude that every agent under clinical investigation will provide meaningful benefit. While there is no absolute inside information, most of the prostate oncologists in the country know each other so “inside information” can be learned from a simple phone call or a chance meeting at one of the various prostate meetings that occur throughout the year.

Finally, doctors who are involved in managing large numbers of men with prostate cancer also gain experience with the relative skill levels of other physicians on the medical team; the surgeons, pathologists, radiation therapist and the radiologists. Improved patient outcome is not simply the result of picking the right treatment. You also have to select a doctor with special talent to administer it.

Conclusion
Don’t make the common mistake that urologists and medical oncologists are inter-changeable. Having a highly trained and skilled surgeon can be lifesaving—when surgery is truly indicated. However, in this modern era, radical prostatectomy should be the first choice in relatively few men. And even when surgery is the preferred approach, having a surgeon as the overall leader of your team is no longer ideal.

P.S. My apologies for radically digressing from the exciting information shared at the meeting. My frustration with a world dominated by urologists clearly got the best of me. I’ll take up the meeting highlights in my next blog (and in even greater detail in the next issue of PCRI Insights).

* As an aside, the acronym, ASCO, in Spanish means nausea, a name some consider apropos since oncologists are the main purveyors of chemotherapy.
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see, all the "big guns" use marketing and sales tactics and take advantage of the role social media plays in our lives to do so.

I think some of what he says is not detailed enough and designed to sway opinion if not create fear. When he says urologists "Have a rudimentary understanding of cancer treatment (outside of doing surgery) he failed to mention that there are board certified urologic oncologists who do specialize in specific cancers and have an amazing understanding of that cancer.

I don't have a problem with his article, this is America and it's all about generating business for everyone.

btw, $1200 consultation is definitely steep. God bless him.

Mel,

To some extent the good doctor may be undermining his own message in the paragraph you highlighted. His main point is that more men with prostate cancer should seek the advice of a medical oncologist rather than relying on a urologist, especially for advanced cancer where a urologist may be out of his depth. But then he goes on to complain that there are so few medical oncologists available who meet his ideal standard, rather giving the impression that adequate medical oncologists are only available for high-roller patients who can afford to travel and to pay out of pocket.

Elvis is dead, Springsteen and Joel are semi-retired but if you want music for your party you can do better than hiring the teen-aged DJ you met at Chuck E Cheese.

John T:

I agree with you 100%. I am so pleased with the care and knowledge of both Scholz and Lam. I have some local doctors that are very caring and "nice," but they are certainly not at the level of competence that I desire.

(Oh, and I found Lam and Scholz to also be quite compassionate).

However, I still sense a bit of self-aggrandizement in the article!

DavidG-- Regarding the $1200 figure? I don't recall it being even half that much when I first consulted with Dr. Scholz about 3 years ago. I do know that Snuffy Myers is extremely expensive. But, then again, you get what you pay for. I think when dealing with a life-threatening emergency, if you can afford it, you MAY have gotten the best buy out there!

You know...cheap at twice the price and you can't take it with you.

Incidentally, PC has caused me some financial discomfort in an indirect way. We have a certain chunck of funds that I would like to use in a certain way. Instead, I'm just letting it accumulate. That will be my stash to pay for expensive tx. not covered by any kind of insurance. Hopefully, I'll never get to that stage. But it's certainly a consideration. In fact, that is an interesting topic in itself. I think I'll start a discusion on that.

Mel

You know, the difference between a .300 hitter and a 0.275 hitter is actually very little -- maybe an extra 10 or so hits in a year (one a week, more or less). Yet the end result is very significant. I think that's probably the difference between your very top doctors and the really good ones. Your best doctor sees a SE and has dealt with many many patients with the same disease, so he might immediately know what to do (I had this when my liver enzymes suddenly went haywire -- my local doctor shrugged and Lam said "stop the Casodex").

about 30 years ago I was having major intestinal issues (Crohn's Disease dx.). I was on a drug that was causing additional major issues. GI expert locally said get off the medication immediately. I ended up at the Cleveland Clinic, one of the leading Crohn's Disease places. Their expert said that this SE was an unusual one but they knew it would go away. I ended up back on the medication. SE returned and then went away just as he said. As I said, small difference due to the doctor being a true expert and also dealing with (and learning from) lots of patients.

Incidentally, I've been lucky with the Crohn's as the course of my disease has been mild with occassional flareups. It has basically been a non-issue for me.

I apologize if it sounds like I am proseletyzing. But I remember a few years ago when I started searching for the best practitioners, I was skewered for "putting down" local doctors. I was really stunned by those remarks, as that was not my point at all. There are many fine experts. But when PC becomes advanced/incurable, while I would like a kind compassionate expert, I'll take extreme competence every time.

Mel

that's a good analogy Mel.

ed

I was away a couple days and only came across this very insightful thread when the duplicate one was locked.

As I was reading through that one, could nto figure out why it had been locked til I got to post that said it was a duplciate.

So, bump for guys who may have missed it.

LupronJim

Mayo is like a large machine in which all the parts fit in for the benefit of its patients. It probably operates differently than most other medical facilities.

I don't know exactly how this works with the medical oncologists, but the system Mayo uses probably does much the same thing, but with a different approach.

As one of the leading medical icons in the world, I suppose they have their reasons for how they do things. Their success certainly shows that their system works very well.

I don't know if the following will help, but the rest of this post is a copy-paste from the Mayo website at http://www.mayoclinic.org/departments-centers/oncology/minnesota/overview


Overview
By Mayo Clinic Staff
The Department of Oncology has one of the largest, most comprehensive cancer diagnosis and treatment programs in the world. It is closely aligned with the Mayo Clinic Cancer Center, designated by the National Cancer Institute as a comprehensive cancer center. The Mayo Clinic Cancer Center ranks in the top tier of cancer centers in the United States for cancer research, treatment, and education. The Department of Oncology works in collaboration with other departments and divisions at Mayo Clinic to provide patients with all aspects of cancer care.

Each year at Mayo Clinic in Minnesota, more than 12,000 patients are diagnosed and treated for 200-plus different types of cancer. Adults with cancer of the colon and rectum, breast, prostate, and lung comprise the largest number of patients seen at Mayo Clinic's Oncology Department. Specialists at Mayo Clinic also have extensive experience in the diagnosis and treatment of every kind of cancer, including:

Brain tumors
Head and neck tumors
Sarcomas
Melanoma
Kidney cancer
Ovarian cancer
Other gynecological cancers
Hepatoma
Biliary cancers
Pancreatic cancer
Neuroendocrine cancers
Novel drug, immunologic, and biological targeted therapies and gene therapies are being studied intensively within the department to determine their potential for cancer treatment. This clinical expertise aligns strongly with the research programs of the Mayo Clinic Cancer Center. This alignment makes it possible for eligible patients to enroll in cutting-edge clinical cancer research studies, receive the most advanced treatments, and learn about their illness to actively participate in decisions about their treatment.

The Department of Oncology includes more than 50 oncologists and allied health professionals specializing in Medical Oncology. Members of the department work closely with colleagues in the Department of Radiation Oncology to provide each patient with accurate diagnosis and treatment using one or more types of cancer-killing therapies, and individualized care. They also collaborate with physicians and allied health professionals in related medical specialties — for example, Radiology, the Pain Clinic, Psychiatry and Psychology, Infectious Diseases and essentially all surgical subspecialties — to ensure that cancer patients and their families have access to total care for their physical, psychological, emotional and spiritual needs. Mayo Clinic's Cancer Education Center complements these efforts by providing patients and families with a large library and resource service devoted exclusively to cancer information.

Since its founding nearly 100 years ago, Mayo Clinic has offered cancer treatment. More than 100,000 adults have been diagnosed and treated in the Department of Oncology. For some, coming to Mayo Clinic was a last resort. More commonly, patients choose Mayo Clinic early in their diagnosis to access more treatment options to fight their cancer, and experience better outcomes and higher rates of healing and survival.

Other than the director of admissions, the only doctor I have seen at Univ of Florida & Shands is the medical oncologist. I am sure he has access to a slew of radiation oncologists and urologists/surgeons, but have not had the need to see any of them yet.

Not sure why Mayo operates differently but since I am already advanced PCa G9 with mets, maybe it's the same.

LupronJim