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Playing Well With Others

David L. Graham, MD

29 Nov 2012 5:31 PM

In the November 1 issue of The ASCO Post, Dr. Derek Raghavan discusses the current knowledge regarding neo-adjuvant therapy for transitional cell carcinomas of the bladder and laments that more patients are not referred by urologists for this intervention. As a community oncologist specializing in GU malignancies, I can wholeheartedly empathize with his sentiment. In fact, I would also expand the questions raised to include those men who are found to have poor prognostic features at the time of prostatectomy (such as positive margins, capsular invasion, etc.) and are not sent for an opinion regarding immediate radiation. Excellent data from multi-institution cooperative group trials have demonstrated the benefit of this intervention yet, in community practices, these referrals are far from common. I can comment on GU malignancies but similar issues arise in almost every tumor type.

So what is the basis for this issue? Is it a difference in mindset between academic vs. community practices? It would be interesting for someone with both academic and community experience, such as Dr. Raghavan, to comment whether this is more of a problem in one type of practice as opposed to the other. Maybe the more disparate environment of single specialty groups, or even individual practitioners, present in most community environments makes transitioning this knowledge into routine practice more difficult. When a single overriding institutional authority is not supporting or enforcing these sorts of interdisciplinary approaches, even the best efforts at outreach and education can be less than optimally successful.

Dr. Charles Moertel was one of the earliest and strongest advocates for community oncologists’ ability to perform clinical research and contribute to the advancement of the knowledge base and therapies for our patients. I continue to believe in that idea and, in fact, I would go further to say that without the support and efforts of community oncologists, the speed of advancement would slow to a crawl. What I am struggling with now is how we put the knowledge to use. In other words, community oncologists can clearly help define best practices but may have greater difficulty adopting them.

The first step, as always, is to gather the baseline data. I would suggest a survey of urologists, with stratification of academic vs. multispecialty group vs. single specialty group/individual practitioners. Two simple scenarios could be addressed: When a patient has high-grade invasive transitional cell carcinoma of the bladder, how often are they referred for neo-adjuvant chemotherapy and how often are patients with poor prognostic features found at prostatectomy referred for post-op radiation? Optimally, this would be done jointly between ASCO and the American Urological Association.

I hope that no difference is seen in practice patterns between the groups. In that case, it’s just a matter of working harder to get these ideas incorporated into everybody’s practices. If differences are seen between the groups, however, the questions raised may be much more difficult to answer.
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David L. Graham, MD