The evolution of the LUGPA Advanced Prostate Cancer clinic over the past 5 years has necessitated increasing levels of commitment, organization, and sophistication. The US Food and Drug Administration approval of immunotherapy, novel hormones, and, most recently, radium Ra 223 dichloride has increased the urologist’s ability to extend patient life in the metastatic castration-resistant prostate cancer (mCRPC) setting. Disease-state knowledge and familiarity with therapeutic options—mode of action, efficacy data, adverse events—are central to successful disease management. Aside from this clinical expertise, leadership and operational acumen are needed for optimal patient care and local market success. Infusion suites, dispensing pharmacy, and hot laboratory capabilities are the trio of service lines that empower a LUGPA group to offer all mCRPC life-extending therapies. As LUGPA groups integrate these therapeutic service lines, aligned staffing, roles, and responsibilities enhance treatment delivery and patient experience.

Members of Georgia Urology (Atlanta, GA) share their experience integrating and operationalizing these three services lines, most recently with their hot laboratory and radium-223 capabilities.

Conversation With Cynthia Masters, Chief Operating Officer

Dr. Kassabian: Thank you for joining me today. I want to give an outline of our advanced prostate cancer clinic here at Georgia Urology. As you know, we have been doing this for approximately 6 years, since immunotherapy was approved in the United States. Take us through the journey of how we have evolved and how we came to be where we are today in this clinic.

Ms. Masters: The program began in 2010. We take an integrated approach to advanced prostate cancer patient care with the medical director, all physicians, and leadership in each clinic. We closely manage how patients are integrated through our pharmacy technician, our clinical medical assistants, and our nursing staff, which includes the role of care coordinator. Initially, we sat down and decided what we wanted to accomplish. We agreed how that would happen, and how the midlevel provider would be a key element of our approach to patient care. This allowed a broader bandwidth of support to patients, which actually gives them a greater understanding of our ability to help them. We are a part of their lives and help them through key things happening to them here at Georgia Urology.

Dr. Kassabian: That is important, especially because we have a large practice, covering such a large geographical area, and multiple offices. The care coordinator plays an important role in meshing this, as do the physicians. As you know, this has evolved over the years. With regard to where we are heading (not that this would work in every practice), we have decided to implement advanced prostate cancer clinics around each geographic location run by a midlevel provider. All of our patients who receive androgen deprivation therapy are a part of this clinic and are seen by champion physicians. Could you elaborate on how this process was established?

Ms. Masters: These are things that our patients have requested. Putting a midlevel provider, or champion physician, in place instead of providing one-on-one attention, and bringing patients in so they can see that they are not alone in this journey, gives them a community approach to what is happening with regard to their care. All information is communicated and transparent to the patient; logistics are never part of the equation. The evolution lies in being able to transparently see where all of these patients are in the treatment process. We need to know how to support them through necessary testing and calls that need to be made—even our call center needs to know how to reach a patient and his or her provider. The champions in their office locations will make sure that they support the system; we apply the same methodology no matter where the patient is located. If patients move or something changes in their lives, we can bring them into a more convenient location where they can expect to have the same experience. They don’t see a different Georgia Urology.

Dr. Kassabian: So you’re focused on branding Georgia Urology with the advanced prostate cancer clinics?

Ms. Masters: Absolutely. It is a service line, really.

Dr. Kassabian: What measures do we have in our practice to make sure that patients don’t fall through the cracks, so they come to their appointments? For instance, if their prostate-specific-antigen level starts to rise in the castrate-resistant prostate cancer setting, how can we catch them early enough to give them quality care?

Ms. Masters: We look at all of the patients that are currently in our pipeline, and champion them through our care coordinator to get the information back to their service-line physicians. This ensures that they have the same information that we have. We have stopgaps; we are working on a template of data that we will pull from our electronic medical records (EMR) that will help answer many questions. Often, that’s what makes patients fall through the cracks—we don’t have proactive triggers; we are working on that with individuals who know how to work with our current EMR system. They are creating a better process so that we don’t have to mine data from the EMR, so that we are not overwhelmed with data. We have specific things that we document properly for everybody. IT personnel know that every time they go to a specific doctor who takes care of a specific patient, they will know where to find the necessary data; if they are not able to do so, somebody else will be able to find it.

Dr. Kassabian: We have adopted a lot of new therapies, and they had to be approved. The latest service-line treatment that we offer is radionuclides. Was it different to implement radionuclides compared with what we already offered in the advanced prostate cancer clinics?

Ms. Masters: It’s not really different. There is a pattern, a course, and a time frame. There are handling concerns. I would say we have to be more meticulous compared with the delivery of typical care. Everyone understands what their role is; before we even meet with the first patient, we have a multidisciplinary team of people who will be involved in that patient’s care and will walk through the processes, policies, procedures, and education. We have gone back and reeducated everyone, because once we get started, we find gaps. This is the normal process of improvement, in which we reevaluate and reestablish where we need to make changes, from the front desk all the way through to the discharge of the patient. If patients have questions they can give us a call—they are given direct phone numbers because we don’t want them to have to go through numerous staff to get an answer.

Dr. Kassabian: As you know, because of the radiation involved with radionuclides, rules are very different. Georgia allows a physician who is licensed to handle radioactive therapies, as well as to administer them. We have Dr. David Owens, who is our radiologist and is licensed in Georgia to infuse radioactive isotopes. Dr. Owens sees our patients typically once a month. We gather all of our patients on a specific day at a specific location to be infused. Of course the hot laboratory had to be developed. Can you go through that process? Was it difficult to install?

Ms. Masters: It was, from a reference standpoint. Obviously, there were some regulations, such as licensing. Any time we have to meet state or Federal standards, it is clear that we have to have great detail, notebooks of information on where to find things, what to do in unexpected circumstances, and how to handle situations in which things go wrong, so we did that. The state has come to see our facility and has asked us for some of our information and the paperwork we put together; they thought it was excellent and wanted to share it with other institutions because they thought the process that we created was 100% spot-on. They gave us that feedback. They asked for some of our information to help other centers structure their policies and procedures. We were able to show them our entire process, step by step—what the patient does, as well as the staff, in addition to the technology we use. It took a lot of time, but it was worth it. It was a learning process that resulted in better education that further enhanced coordination and patient care. It created a greater level of appreciation for what we do. All of those outcomes are positive and Dr. Owens was extremely pleasant to work with.

Conversation With Jason Shelnutt, Chief Executive Officer

Dr. Kassabian: Jason, thank you for taking the time to speak with me today. I want you to give an overview of our advanced prostate cancer service line, especially because we have multiple offices with a lot of physicians across a wide geographical area here in Atlanta. Talk about how we started this process and where we are today.

Mr. Shelnutt: We started the program several years ago in response to patient needs and the approval of a number of medications and treatment modalities that address this aspect of advanced prostate cancer treatment. Prior to that, we referred patients to external radiation oncology or chemotherapy providers. We were involved in the research with sipuleucel-T, and we began to do that in-house soon after FDA approval; we then hired staff with the expertise to administer sipuleucel-T, and, as there were other treatments developed. We have approximately 50 patients actively under care, receiving sipuleucel-T, oncolytics, or radium Ra 223 dichloride.

Dr. Kassabian: How different or difficult was the process of setting up a hot laboratory?

Mr. Shelnutt: It is a little more difficult simply because of the regulatory requirements. Handling of radiation is something that is regulated by the state. We went through the process of obtaining a state license to handle the radioactive substances. We had handled radioactive substances in the past, via seed implantation, so the process was not new. The license did take several months to obtain.

Dr. Kassabian: How do you allocate resources based on revenue? Can you tell me how to do that?

Mr. Shelnutt: Obviously, in the case of prostate cancer, we are always more concerned with having a complete service; however, you can’t have a service if you don’t have the revenue to provide the necessary level of support for those services. Working with these patients is complex. Support is required throughout the continuum of care. Time required is much higher than for any of our other patients. You can provide this care profitably but on must exercise great caution to insure approvals for payment and purchase the treatment at the lowest cost possible.

Conversation With Chris Speaker, RT, CRLS, Chief Lithotripsy Tech

Dr. Kassabian: Chris is our radiology technician at Georgia Urology. Chris, thank you for taking the time to speak with me today. Chris has been instrumental in implementing radium Ra 223 dichloride in our practice. Could you describe the process a little bit for us?

Mr. Speaker: The program has been quite interesting. Creating the layout has been a learning experience for us and for me personally as well. Radiotherapy prostate cancer treatment can last 6 months to a year. It has been laid out so well that it has given me the chance to pride good care.

Dr Kassabian: We have a hot laboratory, obviously. Can you describe the logistics of that?

Mr. Speaker: Bayer has been a key instrument in getting our office prepared. Using the “Xofigo Site Readiness Tool Kit” has allowed Georgia Urology to make the correct decisions.

Dr. Kassabian: We have Dr. David Owens, who is our radiologist, but he is also licensed to infuse. He is an important part of this team, making sure that the isotopes ordered are dispensed at the right time, for the right patient and at the correct strength according to the patient’s weight in kilograms.

Mr. Speaker: Correct.

Dr. Kassabian: Has this been a difficult process to implement in our practice?

Mr. Speaker: The initial set-up was not difficult. The experience and knowledge of working side-by-side with the physicist and radiologist has been a great experience and the practice and its patients only benefit.

The transcripts of these discussions have been edited for style and clarity.