Multidisciplinary Care in Prostate Cancer

In the prostate cancer space, treatment decisions often involve specialists with varying medical backgrounds. In this Urology Medical Perspectives series titled The Role of Perirectal Spacers in the Treatment of Prostate Cancer, Ryan A. Hankins, MD, a urologist, and Sean P. Collins, MD, PhD, a radiation oncologist, both from MedStar Georgetown University Hospital, offer clinical insights on multidisciplinary care, with a focus on cross-specialty communications in the treatment of prostate cancer.

Ryan A. Hankins, MD: I’m an assistant professor of urology at Georgetown University Hospital in Washington, DC. I treat many different patients with prostate cancer from initial diagnosis, which is primarily done with PSA [prostate-specific antigen] screening and rectal exams. I also see patients who are referred to me from outside urologists for treatment discussions on available options for the treatment of prostate cancer. With the wide variety of patients whom I see, we offer fiducial markers and hydrogel spacing for patients who are planning to undergo radiation therapy for their prostate cancer.

Urology Times®: What is the dynamic of your communications with other specialists on your patients’ care teams?

Ryan A. Hankins, MD: We provide patients with a multidisciplinary approach to their prostate cancer care. We involve urologists, radiation oncologists, and medical oncologists, depending on what a patient needs during their journey through prostate cancer treatment. When patients have decided to undergo radiation therapy, the decision on the form of radiation therapy is made by a radiation oncologist. However, to receive radiation therapy, we typically provide the patients with fiducial markers, which are placed in the office through a transperineal procedure. There’s a transrectal ultrasound, transperineal placement of fiducial markers, and then the hydrogel spacing is performed. The other forms of treatment, such as androgen deprivation therapy, are typically handled by the medical oncologists in our practice.

Sean P. Collins, MD, PhD: I am blessed to work at MedStar Georgetown University Hospital as a radiation oncologist. I work with some of the best surgeons in the world. I’m lucky because we’re all really busy, and we just want what’s in the best interest of the patient. I know that if a patient chooses surgery at Georgetown, an excellent surgeon will do the procedure, they’ll have a low rate of urinary incontinence, and their sexual function will eventually return. About 20% to 30% of patients may need radiation afterward, and I know that because they’ve recovered from surgery so well, the radiation will go smoothly.

If a patient makes a treatment decision based on personal preference after they’ve been educated by both the surgeon and the radiation oncologist, we have amazing radiation technologies that can treat prostate cancer with high cure rates and low rates of toxicity. I’m so lucky that I work with Dr Hankins every day. Dr Hankins, for how many years have you been doing hydrogel spacers?

Ryan A. Hankins, MD: Five years.

Sean P. Collins, MD, PhD: I remember when I first taught Dr Hankins how to place spacers. I didn’t realize that he was going to be so amazingly good at it that eventually he would replace me. But in the beginning, it was a little bit tougher. As a urologist, he didn’t know exactly what a radiation oncologist was looking for in a spacer. In the early cases, we used to discuss every single case and offer feedback such as, “I think you did a really good job on this, but maybe we need a little more gel at the apex.” Then after about 10 cases, he was perfect.

Once in a while, patients do have adverse effects after the spacer placement or even have adverse effects after the radiation. The thing I love about Dr Hankins is he doesn’t blame me for the adverse effect. He asks, “Sean, how can I help you fix this problem? Or how can I help you make the situation better?” It’s been a joy. One of the best aspects of my career has been working with the urologists at Georgetown.

I’ve read the paper by Rebecca K. Delaney, PhD, [University of Utah Health] and I’m thankful that I work in an environment where the surgeons and the radiation oncologists are not competing for patients. We have amazing surgeons, and they think that their treatment is amazing, which it is. I also have to admit that I love administering radiation. I love taking care of patients who have received radiation. I agree with the manuscript by Dr Delaney that there are some biases that surgeons think surgery is great, and radiation oncologists think radiation is great. But we see the patients, we discuss both options, and the patient makes the choice.

I’m also happy to see that, as the Dr Delaney paper showed, both radiation oncologists and urologists recommend active surveillance at a high rate. I know for a fact that the urologists and radiation oncologists at Georgetown are fully committed to doing active surveillance in the right patients. I think we equally believe in it. I’m happy that the data from other institutions also show that.

Ryan A. Hankins, MD: I completely agree. It’s nice to not be in competition and feel that we work more in a collaborative effort.

Sean P. Collins, MD, PhD: I tell patients all the time that I am lucky that I get to work with Dr Ryan Hankins, who, in my opinion, is the best spacer placer in the world. I know when he places the spacer that there are not going to be any complications from the spacer placement, and that he’s going to make my life much easier. When there’s a well-placed spacer between the prostate and the rectum, the chance of significant rectal toxicity is greatly decreased. I am blessed to work with such amazing urology colleagues every day.

Ryan A. Hankins, MD: I think communication between both of us and the teams are why patients do so well and why they are able to navigate the system. That can be a challenge for patients.

Urology Times: You mentioned your institution’s procedures, but are there any additional strategies or considerations?

Sean P. Collins, MD, PhD: That’s a great point. Our institution has a tumor board every other Monday. And it’s not just that we have the tumor board; our tumor board is very well attended. I think the urologists, radiation oncologists, medical oncologists, radiologists, and pathologists enjoy going to our tumor board. We are colleagues that get along. We discuss challenging cases. I feel that I understand the opinions of my colleagues very well, and I think they listen to me when I talk with them. When I see a patient, whether I’ve seen them in the same room with Dr Hankins or whether he’s seen them first or I’ve seen them second, I think we have a very clear consensus on the standard of care in our institution. I almost never get surprised by what someone recommends. We all have subtle differences, and I think we believe that people are allowed to have differences in opinion, but on the main factors of patient care, we agree on most aspects.

Ryan A. Hankins, MD: I completely agree. We also come to an agreement between patient recommendations for treatment modality, whether it be surgery or radiation, but patients find that things go more smoothly when they’re not hearing conflicting recommendations. If there’s ever a concern whether someone should do one thing or another, it’s an excellent opportunity for us to all discuss and come to a consensus and then go to the patient afterward. Patients feel more comfortable after we’ve had a discussion about their care.

Sean P. Collins, MD, PhD: I’m lucky that I have really good urologists. I’ve been doing this for about 17 years, but they still teach me something at every tumor board. I’m not a urologist. I don’t understand the inner workings of why one type of BPH [benign prostatic hyperplasia] procedure is different from another BPH procedure. I think they work very hard to make me a better radiation oncologist. And I hope that when we’re discussing unique aspects of radiation, I help to make them a better urologist by better understanding the different radiation techniques. There are new doctors all the time. When any doctor comes into our group, I usually learn something new from them that I didn’t know before. We’ve been blessed by having a really good team of medical oncologists, radiation oncologists, urologists, radiologists, and pathologists over the last 17 years.

Urology Times: Can you think of any additional strategies or considerations that could improve communications between the 2 of you?

Sean P. Collins, MD, PhD: We don’t have specific consensus guidelines that we absolutely follow. But I think there’s a general understanding of what we generally do for specific patients in certain situations. Ryan, do you think there’s anything that I can do that would help you more in terms of communicating?

Ryan A. Hankins, MD: We work in a similar hospital setting but in different offices, and communication is electronic. We’re very fortunate. Because we work so closely together, I consider Dr Collins a friend of mine. We get along well. If there’s ever a question or concern, we can call each other. When it comes to communication, I think it’s very important for physicians to know their other subspecialists. Dr Collins says he works with great urologists. I am fortunate enough to work with one of the most prominent radiation oncologists with regard to prostate cancer in the world. I feel fortunate to work in this setting and to be able to pick up the phone and call Dr Collins if there’s ever an issue or question. It’s easy to say communication is key, but when you’re trying to help patients navigate prostate cancer and the intricacies of its treatment, we’re very lucky to be working in the situation where we are.

Sean P. Collins, MD, PhD: Do you think standard operating procedures could help us?

Ryan A. Hankins, MD: I personally like the idea of guidelines. I think guidelines are helpful when making treatment decisions, which goes along the lines of standard operating procedures. However, there are so many nuances and intricacies of the treatment of prostate cancer that no one treatment or plan fits all patients. That’s the fun of treating prostate cancer. You can really help patients, but you want to find the right treatment for each individual patient.

Sean P. Collins, MD, PhD: I would say all of us are keenly aware of the NCCN [National Comprehensive Cancer Network] guidelines and the AUA [American Urological Association]/ASTRO [American Society for Radiation Oncology] guidelines, and we try to maintain the spirit of those guidelines. But when you’re treating an individual patient, sometimes variations need to happen. We have a good mixture of experience at our tumor boards. I think we do a really good job of working within a framework of the guidelines while knowing when it’s appropriate to move away from the guidelines.