Part 1 Urology's 'Dust Bowl': The prostate cancer journey, a mighty hard row in rural America

Happy 2024. First in a series: "The Rural Urology Crisis: A Mighty Hard Row"--plus Dr. Leapman's column

(The Dust Bowl.)

It's a mighty hard row that my poor hands have hoed
My poor feet have traveled a hot dusty road
Out of your Dust Bowl and Westward we rolled
And your deserts were hot and your mountains was cold”

“Pastures of Plenty“ (1941) by Woody Guthrie

By Howard Wolinsky

The Dust Bowl was an environmental catastrophe in the 1930s that devastated farms and those who worked them on the Great Plains. Two and a half million Americans were displaced, becoming migrants seeking jobs and new lives.

Today, the shortage of urologists, their outdated training, and the lack of resources for rural medicine have resulted in a mighty hard row to hoe for men with prostate cancer all along the spectrum of high- to low-risk who live in these underserved areas.

The Dust Bowl of urology has resulted in medical migrants who travel hundreds of miles to obtain care in big cities because local doctors are unwilling or unable to provide Active Surveillance (AS) with simple blood tests and biopsies.

Urologists who do practice in the outback and their patients often don’t have access locally in nearby small towns and middle-sized cities to uropathology specialists, though they can reach out to experts in major cities. Likewise, Magnetic Resonance Imaging (MRI), increasingly a vital tool for modern urologic practice, may not be available nearby, and there may not be expert abdominal radiologists with prostate expertise to read the results. There also can be long waits for MRIs at regional centers,

Is this reasonable for those who need sophisticated care for higher-risk cancers? Maybe. But it doesn’t make sense to me for those with low-risk disease seeking surveillance.

The shortage of urologists and other surgical specialists

According to the American Urological Association (AUA), 60 percent of all U.S. counties do not have a practicing urologist. This is especially the case in rural counties, and the shortage of course goes beyond urology.

About 20% of Americans live in rural areas, but according to the American College of Surgeons (ACS), only 10% of surgeons, like urologists, practice in rural areas.

Perfect storm

ACS described the perfect storm of today’s surgical Dust Bowl:

“Rural patients are generally older, have a higher prevalence of chronic diseases, are less well-insured and educated, and present with more advanced disease. Access to care is problematic because of socioeconomic, geographic, and health system barriers. Surgeons in rural areas are hindered by lack of technical and human resources and expertise, difficulties in keeping skills updated, and lack of specialty support.”

Bright Lights, Big City

AUA notes there have been significant declines in the number of urologists per capita. And the rural areas are hit hard.

When urologists enter practice, they typically are carrying $150,000 in debt. It’s a big overhead on their earnings.

Better pay in big cities, averaging over $500,000 per year, is an attraction, so are the bright lights and culture of the big city, where many trained.

As the post-World War I-era song put it: “How Ya Gonna Keep 'em Down on the Farm (After They've Seen Paree?)" The lyrics suggest that the Doughboys, the American Expeditionary Forces on the Western Front, wouldn’t want to return to family farms after experiencing the culture of Paris.

The same apparently holds for urologists.

Bottom line: Urologists in general are in short supply, but they especially are in rural areas. Urologists practicing in rural areas generally, per AUA, are not as well-trained as their urban counterparts.

The matter of Zip codes

In January, I begin my second semester in graduate school for a Master’s degree in Public Health from the University of Illinois Chicago School of Public Health. (Go Flames!)

One of the biggest lessons we’ve learned thus far: Our health and quality of care depend on our Zip code. Healthier people cluster in wealtheir Zip code areas.

Using Zip code data, a team of top researchers, led by Tullika Garg, MD, a prominent prostate cancer researcher from Penn State (Go Nittany Lions!), including a staffer from the AUA, reported on the hard row of rural urology in AUA’s Urology Practice in September 2022.

They found:

—Rural urologists were older than urban urologists so presumably more out of date on current practice. They were on average 61 years old and in practice 25 years compared to their urban brethren who on average were 55 years old and in practice for 21 years. Since 2016, mean age and years in practice increased for rural urologists but remained stable for urban urologists, “suggesting an influx of younger urologists to urban areas.”

—Compared with urban urologists, rural urologists had significantly less fellowship training and more frequently worked in solo practice, multispecialty groups, and private hospitals. So some rural docs’ knowledge and practice may be somewhat behind the times.

More about the shortage of urologists: It’s growing worse, especially in rural America. Studies suggest a shortage of almost 4,000 urologists by 2025. That’s a lot when you consider there were only 13,000 urologists practicing in the United States in 2019.

Garg et al. stated what may be the obvious: “The urological workforce shortage will particularly impact rural communities and their access to urological care.”

Seniors dependence on urologists

In this time of shortages, demand for urologists is ramping up. According to the Centers for Disease Control and Prevention (CDC), which considers prostate cancer a public health crisis, over half of urology visits were for patients 65 and above.

We’re getting greyer. The U.S. population was projected to grow by 11% between 2019 and 2034, with an anticipated 42% increase in the number of people aged 65 and older. If you pair the growth of the aging population with the fact that urologists typically treat older patients, higher demand is coming in the years ahead as 10,000 Americans turn 65 every day.

The Older Population in Rural America: 2012-2016 report shows that 18% of the rural population was 65 years and older compared to 14% in urban areas.

A hard rain is coming to prostate cancer patients and other urological patients living in rural America. And we don’t have umbrellas ready.

(Next: A medical migrant from rural Kansas tells his story.)

'Uros keep pushing surgery.' Columnist Dr. Leapman weighs in.

Note from the editor: Send your questions about AS and urology, radiology, pathology, sexual health, genomics, and lifestyle via email to mailto:pros8canswers@gmail.com (back-up: howard.wolinsky@gmail.com).

(Keep the questions short and sweet. They should be of general interest. Sign with your real name, or just initials, tell me where you live, how long you‘ve been on AS, how it’s going for you. Share a whimsical signature if you’re so inclined. Like ‘Butch from Idaho” or “Lost in Flossmoor.’)

Question:

I’ve had four different sets of biopsies in the year 2018. I kept switching doctors. At one clinic, all wanted to immediately remove or destroy my prostate. They at first said DRE indicated nodules, but the third doctor said that he could feel none. I am on my fourth urologist, an academic practice.

Each doctor wanted to take their own biopsy. I’ve had six biopsies so far. Way too many. Some with up to sixteen cores. Many cores had Gleason 6 in various quantities.

The latter biopsies showed less quantity, almost none, of Gleason 6. MRI’s show no lesions. PI-RAD is 3. Genomic test [Oncotype DX] is 33. PSA varies from 1.2 to 1.5, with last week’s at 1.4.

Every doctor has stated that they enjoy doing surgery, which to me is both good and pathetic at the same time.

I don’t trust any doctors anymore, and I tell them as much. I tell my latest urologist that I’m only having seven biopsies in my life, so he had better be certain of something before he does anything.

I insist on AS, but he keeps pushing for removal. I’ve told him I am only open to water vapor therapy, or nothing, and my mind is saying no to even that. He wants to do another MRI in six months, but as much as he wants to do surgery, because he has fun doing it, concerns me.

Bothered in Badgerland

Dr. Leapman:

I have to be careful reviewing the history without all of the details but my general thoughts would be to reiterate that the conventional candidates for Active Surveillance have low-grade disease (i.e. Gleason grade group 1 AKA Gleason 3+3=6), a low PSA (<10), relatively few cores with cancer, no findings on imaging concerning for more aggressive disease. If genomics is performed a lower genomic risk is encouraging. For patients meeting these criteria, the existing high-quality evidence supports Active Surveillance rather than treatment. It may be worth having a consultation elsewhere if someone feels that things aren’t adding up. As noted in the email chain we still have a problem of overtreatment of low-risk disease. The motivations are varied and complex. These include financial motivations to treat, and interest in performing treatments, but I think more than anything an “old school” mentality that we should treat cancer to avoid the very low but still possible risks of disease progression. Doctors often worry about acts of omission – a scenario where we recommend surveillance and metastasis is later identified. These are low probability events (approx. 1% or lower especially when well selected with MRI, genomics, targeted biopsy etc) and I think the key is to disclose these risks to patients and make sure they are empowered to make the decision. In almost all cases I think the risk-to-benefit calculation lands in the direction of Active Surveillance rather than immediate treatment.

Thanks for the thoughtful question

Michael S. Leapman, MD, MHS, is an associate professor of urology and clinical program leader of the Prostate & Urologic Cancers Program, Yale Cancer Center, New Haven. He has a special interest in low-risk prostate cancer, Active Surveillance, nerve-sparing robotic prostatectomy, focal therapy, high-risk disease, molecular imaging, and PSMA PET scans. Send Dr. Leapman questions on Active Surveillance at mailto:pros8canswers@gmail.com

Away we go: “Putting Glee in Gleason”: Our Joke of the Month

Charles Metzger, MD, a retired urologist who works with the Prostate Forum of Orange County, was one of the winners in The Active Surveillor’s Gleason humor contest, named for the two great ones: Dr. Donald Gleason, who developed the Gleason scores we all love much, and Jackie Gleason, “The Great One.”

Away we go with more comedy stylings from Dr. Metzger, the Medical King of Urologic Comedy:

—Did you know Viagra pills come with pop-up instructions?

—Unhappy with the results of circumcision, a man sues his doctor,. The judge took the man into his chambers to review the surgical outcome. Once he took a look, His Honor remanded the case to small claims court.

Ouch.

(Dr. Metzger with his ‘Glee in Gleason’ prize, a copy of the new edition of the “Invasion of the Prostate Snatchers” signed by co-author Mark Scholz, MD, co-founder of the Prostate Cancer Research Institute.)

Sign up for ZERO support group on AS in March

By Howard Wolinsky

For the past three years, I have run a special Active Surveillance support group for ZERO. Last year, our virtual support meeting drew 60 patients to talk about AS. By far, it was the biggest session of any at the annual ZERO Summit.

So sign up now and join us at 11 a.m. Eastern on Tuesday, March 12, 2024.

Register in advance for this meeting:
https://us02web.zoom.us/meeting/register/tZUsfuqgrjIoG9AWf7voMhzT_UjdqbQQbQPA

An endorsement from a reader

Happy New Year. You should feel good about the work you have done and continue to do for men’s health. It’s quite a legacy and bodes well for the future—Roger Norris, Minneapolis.