ATLANTA—A turf war is brewing between urologists and interventional radiologists over the minimally invasive treatment of small malignant renal tumors.
Urologists, traditionally the specialists of open surgery, more often use percutaneous ablation techniques for small renal masses. But now interventional radiologists are getting into the act, performing catheter-based ablation procedures.
In response, the future may hold a new subspecialty of interventional radiology/oncology, speakers said here at the American Urological Association Annual Meeting.
A urologic surgeon and an interventional radiologist presented their sides of the story in a point-counterpoint plenary session titled “Interventional Oncology: Radiologist vs. Urologic Oncologist.”
“The potential for controversy applies to any procedure where there is some level of image-guided intervention,” said the moderator, Surena F. Matin, MD, Associate Professor of Urology and Medical Director of the Minimally Invasive and New Technology in Oncologic Surgery (MINTOS) program at the University of Texas MD Anderson Cancer Center.
“In urology, the primary areas involved are the kidney and, just recently, focal therapy for prostate cancer. The message is coming through—interventional radiologists are here to stay, and they want to be involved in treatment of small renal tumors.”
Depending on where one is, some level of engagement should occur between the two specialties, he said. A hybrid approach may be in the future, particularly with the urologist who is trained and has certification for image-guided interventions.
How that works out will depend on what technology and expertise is available at different centers—“but ultimately it will come down to what is best for the patient.”
Training in Image-Guided Procedures
Surgery should definitely be done by urologists, but ablations should be done by radiologists, said Ronald J. Zagoria, MD, Interim Director of the Division of Radiologic Sciences, Professor in the Department of Urology, and Professor and Interim Chair of the Department of Radiology at Wake Forest University School of Medicine.
“The best option is nephrectomy for younger healthy patients, but percutaneous ablation is probably right up there as second best, and that option should be discussed by the patient and a urologic oncologist,” he said. “But ablation should best be done by a radiologist, because radiologists are the experts in image-guided procedures, with the training and experience. Urologists have very little training in that.”
Dr. Zagoria, who said he performs more than 100 such procedures a year at Wake Forest, noted that radiologists are trained in radiation safety and image interpretation, and are the specialists who supervise the imaging equipment.
“Almost all this done is with CT guidance, and large departments have dedicated CT machines that are not that simple and often require additional maneuvers to protect surrounding organs and the ureter and prevent excessive renal damage as well as excessive radiation.”
And although there can be complications in an ablation procedure, they rarely involve the urologist, he said.
“These are mostly managed by the radiologist, and sometimes by a hospitalist, if the patient needs to be admitted for a transfusion or treatment of an infection, for example. Some can be managed with the help of a urologist, such as placement of a temporary stent, but surgery is rarely required to treat one of these complications.”
Long-term follow-up usually is provided by a urologist with a radiologist reviewing images, but it can be done by either specialist.
Speaking in an interview after the meeting, Dr. Zagoria said the ideal program should include treatment evaluation by a urologic oncologist who has good knowledge of ablation as an option. “Tumor boards would be fine, or the patient could be referred to a radiologist by a urologist to discuss the option of ablation.
“We [radiologists] do ablations in kidney, liver, lungs, and bone, and it is easy to apply that to the kidney, while it would take quite a bit of time to train a urologist just to do ablations.”
But in the long term, he said, if urologists have an interest, a training program could be developed in the radiology department that would lead to some sort of board certification with a cooperative effort between the urology board and the radiology board.
The Cardiology Experience
Peter Pinto, MD, Director of the Fellowship Program in the National Cancer Institute's Urologic Oncology Branch and Surgical Director of the NCI's newly formed Center for Interventional Oncology, said urologists are best trained to treat renal tumors.
“A kidney mass on imaging is not just a technical exercise—it may not be a clear cell [carcinoma] but may be papillary oncocytoma, a truly different disease process, and only urologists understand the oncogenic pathway for this disease process,” he said.
In terms of turf, Dr. Pinto pointed to what has happened in the treatment of heart disease.
“Cardiothoracic surgeons have lost patients as the field has evolved to minimally invasive techniques such as angioplasties and stents, and, as a result, cardiology now controls that patient load. And as angiography moved to cardiac CT, cardiologists moved with that, and they often interpret their own CT scans for the heart.”
He said he feared a similar situation with renal cancer as the field moves to image-guided ablation therapy.
“And tomorrow it will be prostate cancer, and I would argue that that happens to be our bread and butter. It's a similar story—we do open surgery, we've evolved to robotic surgery, and in the future we will move to either image-guided biopsies or needle ablation.
“Who will do those techniques: will it be us, or—like cardiothoracic surgeons—will we lose it to radiology?”
Dr. Pinto offered a more positive view of the future, a hybrid training program such as what the NCI offers at the Center for Interventional Oncology (www.cc.nih.gov/centerio).
“We train our urologists to be interventional radiologists,” he said. “When residents pick our fellowship for urologic oncology, we guide them through surgery, open and robotic laparoscopy; we guide them in medical oncology, and we work with an interventional radiologist, Dr. Bradford Wood, Director of the Center for Interventional Oncology and Chief of Interventional Radiology, to share in the care of these urologic oncology patients.”
In the meantime, while a cadre of new hybrid specialists builds, urologists and interventional radiologists will have to cooperate for the best patient care, Dr. Pinto said.
“In community-based hospitals where the interventional radiologist maybe does not have the same background in urologic cancer as the urologist, he or she needs to allow the urologist to be part of that procedure,” Dr. Pinto said in a telephone interview after the meeting.
And if the urologic oncologists have not gone through that specialized training and are not able to perform an image-guided treatment, he said, they need to partner with a radiologist to accomplish that goal of treating minimally invasively through image guidance.
“Turf wars or boundaries are really not in the best interest of patients,” Dr. Pinto said. “We have to cross-train and create hybrid physicians who have the ability to perform these interventional procedures while understanding the biology of these urologic cancers.”
No Line in the Sand
“Each speaker had solid points to make,” Dr. Matin said in an interview after the session. “Dr. Zagoria, the radiologist, feels very strongly about radiology performing these procedures, but I think that ‘drawing a line in the sand’ as a response to that may not be the best way forward.
“Ultimately we need to keep in mind the focus, which is how do we deliver optimum care to the patient.”
He said Dr. Pinto's perspective on potentially creating a hybrid training program may be a very valid and reasonable response to what some view as radiology now taking over what traditionally has been “urologic turf.”
The concept of a hybrid field “is unique and potentially paradigm changing,” Dr. Matin said. “Dr. Pinto is to be congratulated for that forward thinking, and it's something we should all consider in our own centers and practices.”
He said Dr. Pinto's and Dr. Zagoria's arguments had strengths, “and, depending on where you come from, you may want to side with one or the other. But the response that [either] ‘urology or radiology has to take over everything’ is clearly not a tenable long-term strategy.”
Dr. Matin said there isn't as much potential for a turf battle in academic centers because they are in a type of system where it is easier for physicians to collaborate. But even so, controversies can occur in academic centers, he said, if a center doesn't have a particular expertise but does have an established program and then brings in that expert.
For example, he said, a radiologist may already be doing urologic interventions where there wasn't urologic expertise, “but then when a urologist comes in, there's a problem. That's not an unusual situation.”
But the private practice level is where this has become much more of a point, Dr. Matin said.
“Billing and financial issues are the elephant in the room that sometimes aren't spoken of, and that's been more of a controversy.”
A slightly different version of this article appeared originally in Oncology Times, another newspaper published by Wolters Kluwer Health/Lippincott Williams & Wilkins.