Dr Jayram Discusses His Experience Establishing and Maintaining an Immunotherapy Program at Urology Associates of Nashville
Lauren Oesterheld, BSN, RN
Specialty Networks, a Cardinal Health company, Cleveland, Ohio
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Good afternoon, and thank you for joining us today at our latest Meet the Expert with our special guest, Dr Tom Jayram, bladder cancer section editor of Reviews in Urology. In addition to being a section editor, Dr Jayram is the director of advanced therapeutic centers at Urology Associates of Nashville. Here, Dr Jayram discusses his experience establishing and maintaining an immunotherapy program at Urology Associates of Nashville, including clinical and operational aspects of a multidisciplinary team led by a champion physician, adverse event management, and being at the forefront of a changing treatment landscape. I’m your host today, Lauren Oesterheld, the Adoption Team lead at Specialty Networks, a Cardinal Health company.
The following interview has been edited for clarity and length. The full video interview can be accessed by scanning the QR code provided.
Lauren Oesterheld, BSN, RN: Thanks for joining us today, Dr Jayram.
Tom Jayram, MD: Nice to be here. Thanks, Lauren.
Ms Oesterheld: We recently had a discussion of the importance of setting up a multidisciplinary team for the proper patient monitoring and adverse event (AE) management protocols in order for urology practice to confidently prescribe and administer immunotherapies. I know you have a very established immunotherapy program at your practice, and I wanted to use this medium to share with our readers your experience. To start, what was the impetus for starting your immunotherapy program at your practice?
Dr Jayram: Thanks, Lauren. Great to be here. It’s really great, the work that you guys are doing to try to bring a lot of this information out and very visible into community urology. A big area of my interest over the last few years has been understanding what’s coming in urinary tract cancers and trying to prepare the community or trying to assist in making sure the community is involved. We want to be active participants, not reactive participants, in a lot of what’s happening. So, the cancer landscape is clearly changing in all of the major cancers that we treat, and a big part of that is systemic therapy, which is evolving dynamically. The role for systemic therapy is now more, and it’s now more intricate than it used to be. We’re not just giving systemic therapy to people once they develop metastatic disease. We’re giving systemic therapy to patients earlier in the disease process, in combinations with localized treatments such as surgery and radiation, with the hope of decreasing their need for really aggressive systemic approaches like chemotherapy down the road. So, really, the impetus is this stuff is not going away. It’s coming earlier and earlier into the treatment paradigm for bladder and kidney especially. There’s a lot of interesting studies that are going on in prostate, as well. And so really preparing urologic practices for this next step in cancer care is to try to bring these treatments in house, understand how patients deal with them, and understand what the operational and the clinical considerations are for our patients and our practices.
Ms Oesterheld: Hearing you talk about the clinical and operational elements definitely leads into my next question. It seems to be a loaded question, I know, because there’s lots of parts to it, but could you summarize the steps you took to establish your immunotherapy program within your practice as it relates to those clinical and operational aspects?
Dr Jayram: I think we need to try to simplify this because any practice that’s interested in doing this, you’re not going to want a 25-step, complicated process, but basically you need a champion physician who’s interested in this stuff, who understands the importance of urologists being active participants in this whole process, and someone who has a busy and a big practice that can potentially navigate patients through an advanced program by themselves. So, you need a champion physician. You also need a team. You need midlevel providers, an oncology nurse, and an infusion nurse. But really that’s not a big ask, considering most big urology practices have a lot of these resources that have been utilizing this on the prostate cancer side for a long time. So it’s really just wearing a different hat and providing a similar service, but you definitely need a team.
What that team looks like is different in each practice with the different requirements and the different personnel that each practice has, but I can say that you definitely need a team to help manage the program. And then I would say the last thing, which is really important, is, you need clinical and cultural buy-in from the group. What that means is, you need your practice to understand that this is a complicated landscape that we’re dealing with. Not every doctor in the practice is going to be interested, have the time, or really have the capacity to do this on their own. And so there has to be a culture of referral, and there has to be a culture of “Let’s send this to the person who does this the best.” And if you have those things, you usually can hit the ground running and develop a program. You need patience, you need oversight, you need a team, and that’s really where it starts. And then you go from there.
Ms Oesterheld: I don’t think we can go into talking about immunotherapy without hitting the AE management. I think it’s such a key part and one of the areas that for many of the practices we talk to with the adoption team is a primary area of focus when they look at the potential of bringing this in house. And so we’d love if you would share a little bit about what your approach to AE management was and some additional steps that you took to prepare as you launched this in your program and continued to successfully have an immunotherapy program at your practice.
Dr Jayram: Adverse events are still the biggest line item in this whole endeavor. They’re still the biggest barrier for new practices to move toward doing this, and rightfully so; it’s a different set of AEs. However, if done correctly, I’m a firm believer that big urology practices with good oversight and some of the things we talked about in the last topic can do this at a high level. So number 1, you need appropriate patient identification. You have to understand who’s going to benefit the most and who are some of those patients that may have a higher likelihood of developing more toxicity than they would benefit. So number 1 is patient identification, understanding the clinical rationale, the indications in bladder, kidney cancer, but also understanding where that benefit really is most. And the example that I always give would be the young patient that has a high-risk renal cell carcinoma, T3 into the renal vein. That patient, if they’re young and healthy and have recovered well from surgery, has a really, really good benefit to risk ratio of having adjuvant immunotherapy.
Whereas the patient who may be in their 90s and has a little bit of carcinoma in situ in their bladder that’s BCG unresponsive and has a lot of medical comorbidities, that patient probably has less of an impact with that therapy. So you really have to understand that first and foremost because your AEs are going to stem from that. And then afterwards, again, you need to utilize your team. We’ve developed operating protocols on how to manage side effects. We still run a lot of clinical trials, but we learned a lot of this from clinical trial protocols. And then you have to keep your eyes and ears open all the time. Any new side effect in a patient who’s being treated is an immune-mediated AE until proven otherwise. And utilize your resources, whether it’s currently available clinical guidelines on immunooncology (IO) management for toxicity, which are very readily available. The National Comprehensive Cancer Network, the European Society has some, American Society of Clinical Oncology has, there are some very nice resources on how to manage these toxicity events. But then also it’s understanding the flow of patients, the flow of the phone calls and how to get patients treated, evaluated, and triaged the easiest. So all of those things come to life as you start treating patients, and these things happen. But I can tell you the cornerstone of all of this is good education, planting the seed in the patient’s and your staff’s heads that these can be serious side effects, and you need a process to manage them.
Ms Oesterheld: I know one of the things we have talked about in the past with helping build the adoption team is the importance of also developing a referral system of specialists, right? Because you’re not meant to manage these alone in a practice. So, can you talk a little bit about that network of specialists that you have had in place to help manage some of those AEs and what that partnership looks like?
Dr Jayram: You really do need specialists who are engaged in this. And at this point, IO therapy has been around long enough. All good specialists understand this process. They understand immunemediated AEs as it relates to their specialty, and they understand the process for potentially withholding the drug, postponing it, stopping it, giving steroids. So the routine stuff, the diarrhea, the rash, the endocrine abnormalities that are fairly routine, I would say at this point, I can manage those on my own. My team can manage those on their own with steroids or withholding the treatment or supportive medications with more complicated AEs or more serious AEs. You really have to have an outlet to a specialist, whether it be a dermatologist for a refractory rash or an endocrinologist for severe thyroid dysfunction or endocrine dysfunction. These are things that are really important, and those specialists obviously can help you very, very much in terms of guiding the next steps, making sure that patients are receiving appropriate follow-up or the correct follow-up.
And also allowing patients that the urologist may say, “This patient can’t keep going. This doesn’t look really good.” I’ve had patients who have seen the specialists, they’ve done a few things and said, “Yeah, we will co-manage this patient. You can keep going, and we can do OK.” Really important to engage specialists, to have people that can fit a patient in fairly soon. Developing those relationships is really important. And I don’t want to undercut the importance of the medical oncologist. The medical oncologist really is the gatekeeper for a lot of these systemic therapies. They have really vast experience with managing complex immune-mediated AEs. And so I also would say having a good relationship with that provider so that you can pick up the phone and say, “Hey, what do you think we need to do here?” is an important concept.
Ms Oesterheld: I appreciate that. In talking with a few practices we’ve helped launch, some of them thought this would be the most daunting part, but they actually found, when they got on the phone and started making phone calls, other specialties. To your case in point, immunotherapy has been around for a while. They’re like, “Yeah, no problem.” So it can seem like a lot upfront, but it’s really important to have those in place. So, as it relates to that topic, any advice you would give other independent urology practices about AE management with immunotherapies?
Dr Jayram: I think I usually start by saying, “You don’t have to be doing this, and this is something that obviously requires a minimum amount of infrastructure expertise and a minimum number of personnel. And a good relationship with a good medical oncologist and a good referral pattern is really important.” But the urologist doesn’t have to be doing this. And I would take that 1 step further. They probably shouldn’t be doing this if they don’t have some of the things that we’ve mentioned in our earlier discussion. But for the urologists that have the infrastructure and the support, I would start—obviously intelligently, you would pick healthier patients with manageable disease, really sit and focus on the education, and then kind of understand how that looks in real time. What are the patterns of the phone calls? What are the things that you feel maybe you can do better?
The monitoring, the x-rays, the labs. So I would probably say, start slowly and with the correct patient. And then, as the program gets bigger, really start to firm up those protocols. How often are you talking to these patients after their infusions? How often are you checking labs? What does your steroid protocol, your steroid taper look like? These are all things I think that happen over time. But with experience, I think we would all agree that urologists manage complex systemic agents in other disease states, androgen deprivation, things like abiraterone, things like poly(ADP-ribose) polymerase inhibitors and prostate cancer. This is something that if you do it enough and you have a good team and people who are focused on managing these things, you can do this. And the bottom line is, like we talked about, utilize your resources, utilize help when you need to, and don’t be afraid to refer out.
Ms Oesterheld: Absolutely. Any pitfalls or lessons learned in your vast experience over the years with infusing immunotherapy?
Dr Jayram: In terms of the actual infusion, it’s like what we talked about: Develop a program, understand your limitations as a site, understand who you have helping you, what you may need. I always say monitoring patients is just as important as managing patients. So being able to have a reliable process to patients is really important. So that surveillance piece, that touchpoint piece where your midlevel is calling the patient, asking them how they’re doing, is really a crucial part.
Ms Oesterheld: And while some urology practices may have that established immunotherapy program to date, we’ve really seen that trend pick up over the past couple of years. Do you anticipate that this will continue to evolve in the future with all the pipeline of drugs and development in this space?
Dr Jayram: I think it has to. Like we said, we now are looking at a scenario where we may be giving immunotherapy to patients who are BCG naive. We may be giving immunotherapy in combination to patients before their radical cystectomy. Urologists, I think, are going to be interested in being involved in that process. And I don’t think medical oncologists are going to have the capability or the capacity to take every single BCG-naive patient and give them concomitant immunotherapy with their BCG. I think from a logistical standpoint, it makes it harder on the whole system if urologists are just not involved at all. So absolutely, there’s going to be more indications to come. There’s likely going to continue to be trials that read out. And I think the important thing, too, is understanding that just because it’s approved doesn’t mean it’s for everybody.
There are going to be patients that have this benefit, I would call it this therapeutic window, where the benefit carries a lot more than the potential risk. And so those are the patients who should be targeted with immunotherapy because, let’s face it, it’s a systemic agent. It does have side effects. Some of these side effects can be permanent and irreversible. So you really have to understand who will benefit the most and not just use a 1-size-fits-all approach. So I do think that we’re going to start seeing a lot more interest in immunotherapy as these indications come earlier, and that first one may very well be in the BCG-naive space.
Ms Oesterheld: Great! Thanks. And then, to wrap up, what would your number 1 piece of advice be for any program that is looking to potentially establish an IO program within their practice?
Dr Jayram: I would probably reiterate, just know what your capabilities are, know what your limitations are. I wouldn’t say that you have to start over and build this big program with hiring a bunch of people. I think if you’ve done a good job with prostate cancer, if you’re involved in clinical trial research, if you have a lot of expertise in bladder and kidney cancer, this isn’t a big lift. This is something that can be done. And I think the biggest piece of advice is if you’re not in a situation where you feel comfortable doing this, it’s still important to understand the education. It’s still important to understand the management of the side effects because you’re going to be seeing these patients. But clearly, referring to a practice or a medical oncologist that does this a lot is in the patient’s best interest. But again, because of how prevalent these treatments are becoming, especially in earlier-stage urologic oncology, I would say that every urologist should have a good foundation when it comes to these treatments.
Ms Oesterheld: Thank you so much, Dr Jayram, for sharing your experience in the private urology setting with immunotherapy and beginning and obviously continuing a very, very successful program. Just to reiterate, I’m Lauren with the Adoption Team, which is a free service to our members at Specialty Networks. I work very closely along with other key opinion leaders, like Dr Jayram, who have helped us understand what it takes to build a successful immunotherapy infusion program. As we know, that’s going to expand out from just infusions to other methods, but it really can help visualize or interpret how this could look with the clinical and operational and financial aspects in your practice. And so if you’re interested or you’re in process, we would love to connect with you. And again, highlighting what you said, Dr Jayram, you may decide that this is not something that you’re ready to take on at your practice, which we fully support, but we also really help with the patient identification. And that leads to our goal of getting every patient to the right treatment at the right time. So again, I appreciate all of your input for our readership. If you would like to listen to this full interview along with other interviews like it, please visit www.reviewsinurology.com. Or, you can download the Reviews in Urology app now available in Apple Store and Google Play. Thank you so much, and have a great day.
Published: June 23, 2025.
Conflict of Interest Disclosures: L. Oesterheld has nothing to disclose. T. Jayram holds a consulting or advisory role with AstraZeneca, Ferring, Janssen, Merck, Photocure, and Telix and has received research funding from AstraZeneca, CG Oncology, Janssen, Merck, and Protara.
Funding/Support: Publication of this interview was made possible through the generous support of Pfizer, Inc.
Author Contributions: Both authors contributed equally to the content of this interview.
Data Availability Statement: No data were created or referenced in this interview.
Citation: Oesterheld L. Meet the expert: Tom Jayram, MD. Rev Urol. 2025;24(2):e113-e118.
Corresponding author: Lauren Oesterheld, BSN, RN, Adoption Team Lead, Specialty Networks, LLC, 600 Superior Ave, Suite 1500, Cleveland, OH 44114 (lauren.oesterheld@cardinalhealth.com)