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Sam Chang: Hi, my name is Sam Chang. I'm a urologist in Nashville, Tennessee, and I work at Vanderbilt University Medical Center. And we're actually joined, and I'm quite pleased, because this is the first time I've actually met Annie in person. Anne Lizardi-Calvaresi is a nurse practitioner who really leads the urologic oncology and urology nurse practitioner kind of group at Thomas Jefferson University. And I have read about work that Annie's done. I've seen some of the work that she's done. And she has actually helped run a course at the AUA, AUA 2023, focusing on systemic therapies that basically urologists and nurse practitioners are actually involved in. And I was fascinated by the course, because I think it's incredibly important. So first of all, thank you for being with us.

Anne Lizardi-Calvaresi: Thanks so much for having me. It's an honor to be here.

Sam Chang: And tell me how this course kind of developed in your minds, the faculty's mind. Tell me a little bit about that.

Anne Lizardi-Calvaresi: So I started working in the outpatient clinic, doing primarily GU oncology, 11 years ago, was getting more and more involved with the AUA, but there wasn't a lot of programming for the advanced practice provider, for the NPs or the PAs. And I went to my two collaborating physicians and I said, "You know what? I really want to offer something to APPs to get us more involved, to educate on the management of GU malignancies." And so we proposed the course. This was the seventh year that we've given this course.

Sam Chang: Wow.

Anne Lizardi-Calvaresi: I actually just gave it this morning.

Sam Chang: Oh, fantastic.

Anne Lizardi-Calvaresi: And so we keep changing it and updating it as all of the novel therapies are coming to fruition, and as there are more and more treatments available for these patients with prostate, bladder, and renal cancer.

Sam Chang: So as you see these systemic therapies becoming more available, many of them within the realm of the urologic oncologist, the urologist, tell me what the uptick has been in terms of interest, in terms of excitement, in terms of those who attend your course.

Anne Lizardi-Calvaresi: I think the really, really exciting thing about all of this is that we have these newer agents that are prolonging overall survival, and they're prolonging radiographic progression-free survival, and so because they're so new, we're always revealing new information, because we have to update it each year. And I don't think that APPs are given the opportunity to maintain their education or to maintain their CEUs, except for situations like this or on a virtual platform.

Sam Chang: I see.

Anne Lizardi-Calvaresi: And so I think this really offers a really upfront view of what we have available to treat these patients.

Sam Chang: And so from the standpoint at Thomas Jefferson, if I have either high risk or more advanced prostate cancer or bladder cancer or metastatic or early advanced kidney cancer, the surgeons may or may not operate. Tell me how the advanced practice provider then becomes integrated with the care of those kinds of patients. Are you the initial person? Do you help with that decision to start systemic therapy? Do you in fact then help in the follow-up? Tell me kind of the role then of an advanced practice provider, because I think this is going to become increasingly more common. So I'd love to hear what you guys do and if you guys have found that it's become more common.

Anne Lizardi-Calvaresi: Yeah, no, it certainly has become more common. We have this urologist shortage that's only going to continue to grow. A lot of times, I meet the patient at their initial visit, either right after diagnosis or even right before diagnosis.

Sam Chang: To establish a relationship, for sure. I see.

Anne Lizardi-Calvaresi: Exactly.

Sam Chang: I see. Okay.

Anne Lizardi-Calvaresi: And then I'm there throughout the duration of their treatment. And so when we're giving certain treatments, I'm there monitoring their labs, ordering their imaging studies, managing their AEs. So I'm usually there kind of every step of the way. When patients get a little more advanced, usually we'll send those patients over to medical oncology for management, but we're still there from urologic perspective.

Sam Chang: Right. And so as you do that, what I've noticed at our institution is actually the integration of the advanced practice provider from the urology center, but also having a great relationship on the medical oncology side with APPs, as well as the attendings and the MDs. But that ability early on to establish the importance of your role in that patient's care, I think, is really important, and can carry over to the other disciplines. Tell me how this all started, because more and more, just as you noticed and noted, rather, the shortage of urologists, every urologist is busy and what he or she may take on, it becomes more difficult to do everything. And so tell me how your role evolved over the past 11 years. How did you say, well, I'll start doing some more of the systemic therapies. I'll start. How did that go?

Anne Lizardi-Calvaresi: That's a great question. So when I first started, I worked as what we would call an extender. So I would work alongside-

Sam Chang: Yeah, we used that term. Yeah.

Anne Lizardi-Calvaresi: Yeah.

Sam Chang: Used. Past tense. Yeah.

Anne Lizardi-Calvaresi: Used. Right. So I went from seeing patients, maybe 20 to 30 in a clinic, alongside my collaborating physician, and kind of gently phased out to see partly my clinic, partly theirs, and there was some crossover. And now I'm seeing 20 to 30 patients a day on my own. Whereas before, it was probably closer to 15 a day. And certainly there have been days where I've had 35. Sadly, there have been a couple days where I saw 40. But these newer agents that urologists are prescribing, whereas before, we would send the more advanced patients over to medical oncology right away, especially the oral anti-androgens, we can easily prescribe those. And we can follow the patients, watching the PSA, and managing the AEs. And same thing with bladder cancer. So we have the BCG shortage, so we're giving a lot of intravesical chemotherapeutic agents, and those patients always fall under my care when they're coming in for their bladder instillations. Same thing there, making sure they're getting their treatment, making sure that I'm managing their side effects.

Sam Chang: They're lower tract symptoms, whatever they may be having. I see.

Anne Lizardi-Calvaresi: Exactly. And then making sure that they're coming back for their surveillance cystoscopy or for their post-op, I'm sorry, for their induction follow up cystoscopy and biopsy, depending upon their staging. So I think it's really, really important from an APP perspective to be super involved to make sure that patients are compliant and to make sure that they're getting the care that they need.

Sam Chang: Well, I can clearly tell you from experience the relationship between patients and our advanced practice advisors, that it's essential. The sense of trust is real and palpable. So to me, it's so difficult to keep up with the field as more and more these agents become available and different indications and those types of things. So first question about that is, so how do you keep up with all that? And then secondly, what can the AUA do? What can the SUO do? What can UroToday do? What can organizations do to help in this introduction of new information and then integration of that into people's practice? That's a tough question.

Anne Lizardi-Calvaresi: That is a tough question. That's a tough question.

Sam Chang: Yeah. So first of all, how do you keep up with it? What do you do?

Anne Lizardi-Calvaresi: So I read a lot. I try to listen to podcasts and the virtual sessions that are available on AUA University. And certainly by attending the AUA. I'm in the mid-Atlantic section. I'm at every AUA, or I'm sorry, every mid-Atlantic AUA meeting.

Sam Chang: Section meeting. Sure.

Anne Lizardi-Calvaresi: Right. So live and in-person meetings I find very beneficial, but not everyone can travel. So those virtual meetings are super, super helpful for a lot of APPs who have less time to be out of office.

Sam Chang: Right. So that's what I was wonder then. So how do these organizations then, and pharmaceutical companies want to know this, this is the question they ask all the time, is how do they help disseminate the message? So for you, I don't want to say you're representing every APP, but for you and for other APPs, what do you find really effective then to get to learn new information?

Anne Lizardi-Calvaresi: I think we need a multitude of platforms. I think we need written literature. I think we need virtual. I think we need podcasts that they can listen to when they have available time. And then I think we need to continue to have the in-person meetings. I direct the APP program. That's all day Saturday, all day Sunday, at this meeting.

Sam Chang: At the AUA. Yes.

Anne Lizardi-Calvaresi: Right. And so this is the fourth year that I'm co-director. And during the pandemic, we actually had 1,300 attendees, and I think that was because it was very much easier for them to get on at home. But I will tell you that we have 450 registered for this coming weekend.

Sam Chang: Unbelievable.

Anne Lizardi-Calvaresi: Which is great.

Sam Chang: Yeah. That's fantastic.

Anne Lizardi-Calvaresi: So we're seeing more and more and more APP involvement.

Sam Chang: Well, I really appreciate the AUA opening up time, space, commitment to this type of program. And what I think what I've noticed about that program, because it's a great program, I love the integration of APP leaders giving presentations of what he or she may do. I love the integration of a few MDs giving kind of the highlights of the newest research. Again, kind of conversations that I've had with others and will continue as this whole role, a combination of multidisciplinary care. Yeah, that includes RAD, RADonc, but it also includes, within the team, the indispensable nature of everything that you all do as a group. And this idea, I think we both kind of scoffed at the physician extender. No, this is a caregiver, this is a care provider, this is a member of the team. So I really applaud your efforts. All right.

Anne Lizardi-Calvaresi: Thank you.

Sam Chang: This is your dream list, kind of biggest wish. What is your biggest wish when it comes to, say, the AUA, SUO, or any group? How can they further support all of y'all's efforts?

Anne Lizardi-Calvaresi: Oh, gosh. That's a great question. I think promoting educational opportunities for all of us, and that includes our nursing staff too, honestly, because they are such a big support system for us. But providing funding for it, so that we are all able to get to those educational opportunities, even if they're just virtual, right? So obviously, it's a lot less out of pocket, but making sure that those educational opportunities are available to all of our ancillary staff and certainly to the NPs and PAs who work in urology.

Sam Chang: Yeah. No, I think that's a great point. And then being able to be flexible enough that they can do that on a Friday, not a Friday, but say a Tuesday night after work or all those types of things, I think really makes sense.

Anne Lizardi-Calvaresi: Right. After they've cooked dinner and they've put their kids to bed and they can just hop on and do a one-hour session or something like that.

Sam Chang: Annie, very nice to meet you in person now.

Anne Lizardi-Calvaresi: So great meeting you person.

Sam Chang: I really appreciate obviously all your efforts. And a shout-out to our nurse practitioners at Vanderbilt and our physician assistants at Vanderbilt. They're indispensable. So they would give me grief if I didn't say anything about them, but-

Anne Lizardi-Calvaresi: As they should.

Sam Chang: They should, because they're an indispensable part of the team. So thanks again for spending some time with us.

Anne Lizardi-Calvaresi: Thank you so much.