BERKELEY, CA (UroToday.com) -
Prostate cancer ADT/bone-health clinics – not a common service
With no early models for Lancaster Urology Associates to observe, Leanne Schimke, CRNP, CUNP has been a driving force for the day-to-day micromanagement of prostate cancer patients' care, with bone health preservation in mind. The urology partners have embraced the concept of integrating bone health education, androgen deprivation therapy (ADT), and now immunotherapy infusion treatments. Leanne credits urologist and prostate cancer specialist Paul Sieber for fueling the interest in bone health education and participation in related ADT and immunotherapy clinical trials.
It all started in 2007, and merged into a full-service ADT/bone-health clinic by 2010, with full support from the Lancaster Urology partners. In her capacity as a certified registered nurse practitioner with dual certification as a family nurse practitioner and a urology nurse practitioner, Leanne is the point person with patients. For example, Lancaster Urology has an injection day for most individuals on androgen deprivation therapy and on that day she sees the patients and “connects the dots” in terms of educating the men on expected side effects and how to deal with them, scheduling DXA scans to evaluate bone density, and directing treatment. She monitors PSA progression and schedules follow-up bone scans and other tests to monitor disease progressions. Leanne sees patients at least once yearly (and more often, as indicated) to evaluate how they are doing. Prior to each injection day, Leanne reviews all the scheduled patients’ charts to make sure everything is up to date and to update herself on the status of their prostate cancer. Lancaster Urology has a strong research program and Leanne also evaluates if men are candidates for any of the studies.
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“We (at Lancaster Urology) take ownership for monitoring and treating the side effects from any therapy,” said Schimke. “Asking, 'what knowledge does the patient need to be empowered and how can we keep the primary family practice physician better informed so the side effects are manageable?' The patient population differs; we recognize there are no exact profiles for a given treatment, so the flexibility comes in recognizing how a rising PSA may or may not indicate disease progression. It’s one piece of data that the team follows closely.” One case comes to mind, “A gentleman gets a second injection on ADT and has nagging questions but isn’t sure how to address them. I initiate the conversation by talking about bone health, bone pain (if it’s noticeable), hot flashes, erectile dysfunction, muscle fatigue, and muscle loss resulting in increased abdominal girth. This patient was so relieved to realize that these changes were normal and there were ways was to manage them.”
As a urology group practice, there are economies that compel Lancaster Urology’s ADT/bone clinic to be more effective. The designated “ADT injection day” for these patients is one morning each week. The same nurses do the injections, and the men like knowing who they are going to see each time. It’s like a security blanket, there is comfort in familiarity. The nurse maintains a consistency of touch points, reinforcing the educational messages. “We have a mutual goal of keeping these patients healthy -- with a special focus on bone health preservation.” If the man has a question or problem, the nurse lets Leanne know so she can see him and address his concerns immediately. Medical insurance plans provide coverage of these services, which supports the patient’s overall quality of life and his piece of mind.
Moving forward, as she reflects on where the ADT clinic is heading, at Lancaster Urology, it is continually evolving. “I am the emissary of information between the patient and the physician between office visits. That includes ordering radiology tests to evaluate for bone metastases when the PSA rises from 12 to 48, for example. Likewise, I order the bone scans and provide a check-and-balance for the continuum of care, bringing issues to the attention of the physician sooner than later. If the PSA is rising, I discuss the case with the urologist and we may decide to start on a new medication or offer the man the opportunity to enroll in a research trial.”
Lancaster Urology has an active role in ongoing clinical trials. “It helps that I follow the case histories of our patients and alert our physicians if a patient might be a good candidate for inclusion in various research studies. For example, the PSA is rising; this patient might be a good candidate for Sipuleucel-T, abiraterone acetate or enzalutamide. Dr. Paul Sieber is well informed about these newer treatments and clinical trials. He has been a principal investigator in many of the clinical trials. It’s a credit to our entire group practice for our progressive focus on research, treatment, education, and quality of life.”
Schimke is definitely optimistic about the level of prostate cancer treatments for advanced disease. At the SUNA 2012 meeting in November, she delivered a session about bone health treatment. A thousand miles away, Dr. Sieber was presenting on a similar topic at the 2012 annual LUGPA (Large Urology Group Practice Association) meeting. “We’re very fortunate to have Dr. Sieber’s expertise in prostate cancer treatments. As a group we have been able to get up to speed quickly on these newer treatments for men with metastatic castrate-resistant prostate cancer.”
With any new therapy, Leanne sees and hears about the side effects quickly from her patients. “Whether the patient is being administered Provenge, Zytiga® or XTANDI® or a combination of other treatments, our nurses and myself are there to help them manage the natural course of side effects. Each patient handles them a bit differently, and for some, nausea or vomiting are major concerns. We address those and have very specific protocols that describe the anticipated side effects of the new drugs, the administration of anti-nausea medication, or the schedule to test electrolytes and blood pressure every two weeks; it’s in this way that we can maintain a consistent and vigilant level of care.“
As for benchmarks, Schimke says Lancaster Urology has two offices -- in Ephrata and Lebanon, PA and the ADT/bone clinic has always been centrally located at the Lancaster office. “We’re assessing how to provide remote ADT services. I know of other Larger Urology Group Practice Association (LUGPA) members with 20-plus satellite offices and they have asked how they can incorporate this concept into a larger community. Right now providing the ADT/bone health services from a central location has worked very well. Some of my SUNA colleagues have come to observe and experience the clinic. That’s gratifying, because we’ve got a real-life case study going on here with good results.” The “good results” are based on education follow-through and ultimate bone protection. Schimke is the first to admit that the concept is evolving. ”For example, we do not have national urologic oncology imaging guidelines for prostate disease progression, nor recommendations for evaluating the doubling time on PSA with respect to bone pain or the omission of bone pain. So, we continue to document and collect this type of data for the ongoing clinical discussion. To that point, at our clinic, if the patient has a PSA range of 10 to 20, that patient is encouraged to get a bone scan.”
For Leanne Schimke, this program has been very rewarding. “When a patient comes to the clinic and asks to speak to her (they may be nearly in tears, maybe depressed from the toll of the disease) I know why I do this job. We’re here to support them and deal with the physical and mental symptoms of this disease. I’m their familiar face and that gets the conversation going. We talk about their meds, quality of life, their diet and the role of calcium and Vitamin D. As importantly, we pay attention to the increased risk for cardiovascular disease associated with prostate disease and treatments."
"It’s a good day when the patient falls but doesn’t break anything, or the male patient experiences hot flashes and can’t tolerate the discomfort, but we talk through it and get the proper medication ordered. He comes back at this next visit smiling with relief -- that’s a good feeling.”
About Lancaster Urology Associates*
Lancaster Urology, ("LU") has a long history; since 1946 these urologists have incorporated several philosophies in their work ethic: “Only hire a doctor to work in our practice if it is a physician that you would go to or would send a family member for treatment. Select hard working doctors with a first-class, superior work ethic, and communicate with the patients in detail and give them all the options for treatment.” Lancaster Urology is headed by Victor Altadonna, MD, President of the Executive Committee and includes 12 urologists in this group practice.
About Leanne Schimke, CRNP, CUNP
A certified registered nurse practitioner, Leanne Schimke is dual certified as a family nurse practitioner and a urology nurse practitioner. With a strong interest in urologic health, she sees, in collaboration with urologists within her practice, emergent care patients with a variety of urological problems, with a focus towards providing optimal attention and care to patients.
Leanne has 30 years of experience in the health care field. She initially obtained her registered nursing degree from Butterworth Hospital School of Nursing in Grand Rapids, Michigan and went on to earn her bachelors of science in nursing from the University of Detroit Mercy and subsequently, in 1998, her master of science in nursing, with certification as a family nurse practitioner, from Millersville University. In 2005, she obtained certification as a urological nurse practitioner.
*2106 Harrisburg Pike Suite - 200, Lancaster, PA 17601