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Neal Shore: Hi, I'm Neal Shore, the Director of Carolina Urologic Research Center in South Carolina. It's a great pleasure for me to have a conversation today with my good friend, Gordon Brown. Gordon is a GU oncology fellowship trained at MD Anderson who's now been in practice for just about 15 years, and is in the leadership of his group in New Jersey known as New Jersey Urology. He heads the advanced therapeutics for his clinic and practice. He also is the Director of Robotics at Jefferson Health Systems in the greater New Jersey area.

Gordon, you've had an amazing early part of your career and you're really getting involved in so many things. You're also on the leadership of LUGPA FORWARD. What I think is remarkable about your career is what you've done in such a short period of time. I'd like you to address some of the things that you've seen and you've experienced in the last decade or so specifically in advanced prostate cancer, and how it's changed from the time when you were a fellow to the time now where you're leading your large groups practice initiatives. Even some of your thoughts about our colleagues who are getting into practice now, and even some of our colleagues who are maybe in practice 20 years who may be wanting to get more involved in advanced GU oncology.

Gordon Brown: Sure, Neal. Thanks for having me, it's always a pleasure to talk to you. As you stated, certainly when we were in ... Things have changed fairly dramatically over the last decade or so. Certainly, as it relates to the management of patients with advanced prostate cancer. When I was a fellow, our focus primarily was on operations. Primarily, medical therapy was something that the GU medical oncologists had the primary kind of stake in. We had somewhat limited exposure quite honestly to that realm. The mainstays of therapy at that time were Taxotere and additional chemotherapies. In fact, the AFFIRM trial and the 301 weren't even published yet.

Since that time, we've seen dramatic advances in the management of patients with advanced prostate cancer. We've seen six new FDA approved therapies, all of which has significantly improve overall survival, all of which are, for the most part, well-tolerated, and all of which we've adopted into our clinical practice on a routine basis.

To meet those challenges and to maintain the kind of gatekeeper status for patients with prostate cancer, we've had to develop advanced prostate cancer clinics. We've done that in a fairly systematic guideline-driven way utilizing champion physicians around an internal pathways developed based on NCCN AUA guidelines for both the initiation of therapeutics, ADT, including more advanced NHAs. Within that, we've been supported in that role primarily with mid-level support and with nurse practitioners and advanced practice nurses who help us kind of administrate to oversee that patient care on a daily basis.

The challenges, frankly, that we've seen as we've grown and as my career has gone along has been really in the administration of the program as a whole. Trying to get buy in from various stakeholders, understanding that there's a big unmet clinical need here and having pull through from the time of identification of patients up through initiation of therapy, and ultimately dealing with end of life issues.

Trying to make a system which is scalable, replicable, and pathway-driven was one of our biggest challenges. We had to identify various stakeholders internally, both from a nonclinical leadership perspective, but also from a physician champion perspective to achieve those goals.

I've changed quite a bit from where I've started. My initial clinical practice was focused primarily on radical cystectomy and IVC thrombectomies in big surgical procedures. I still do a lot of surgery, but now I'm overseeing a tremendous amount of care in the patients with advanced cancer, specifically advanced prostate cancer. Our goal, however, is to build that really scalable GU oncology center.

From a young LUGPA perspective, we view this as an opportunity to try to impart some of these trials and tribulations, some of the challenges we've had along the way to people who are considering careers in large groups. Understanding where our wins have been, where some of our losses have been, and to kind of benefit from some of our growth really over the last 10 to 15 years.

We've evolved quite honestly, nonetheless as a practice, but I think as a profession. I mean we're different, substantially different now than we were a decade ago, and I think part of that is in response to market forces, and part of that is in response to advances in technology which allow us to maintain our gatekeeper status for management of patients with advanced prostate cancer.

Neal Shore: That's really well said and I realize how much effort went into that. Tell me where the wins are for this movement towards aggregation, consolidation of practices and sub-specialization. Where are the wins in terms of for the individual physician, and for the practice and for the patient? Of course I'm going to ask you what are the challenges? Where can you get better?

Gordon Brown: Sure. I think from a win perspective, the win is focused solely on the patient. Now we have physicians who don't dabble in the care of these patients. We have physicians who are completely engaged in the patient's care from the time of diagnosis to the time of death in a very rapidly changing therapeutic landscape. We have the ability to ensure that patients aren't missing windows of therapeutic opportunity and aren't missing the ability to receive treatments which we know improve their survival.

From a group perspective, we now understand that we're able to more efficiently take care of these patients and we can kind of reduce overhead costs associated we know with that management of that patient care population. From a physician perspective, I think it's gratifying to understand that you're engaged in these care and that you can really deliver new options to patients, which frankly, seven or eight years ago we didn't have. I think it's a very exciting time to be taking care of patients with advanced prostate cancer, and one which really has revolutionized the care of this patient population.

Unfortunately, the challenges are such that as you grow, trying to translate a certain philosophy of care, one. Two, making sure that people in your practice are adhering to your pathways and getting wholesale buy in from all of the stakeholders, not only from an administrative perspective, but also from a clinician's perspective. That requires a significant amount of time from our side to deliver on that for our patients, but certainly it's worth the effort.

Additional challenge is really becoming in trying to make this a scalable program, make it one that is a transposable along multiple geographic locations. Now that we cover the entire state of New Jersey, we've had to do some virtual webinars for example. We've had to have virtual tumor boards. We've had to have case reviews done virtually simply to capture providers in distinct geographic locations who may be 80 or 100 miles away to make sure that there are patients getting the care that they need. That model has been successful, but it's been challenging kind of getting that up and running on a scalable fashion.

Neal Shore: I fully get that. Having grown up in New Jersey, it's a relatively small state but incredibly densely packed with lots of communities and a lot of difference, a lot of variety. I know in your group, you're very integrated. You have an extensive use of advanced practice providers, your large number of clinicians, physicians, you work and coordinate integratively with medical oncologists, radiation oncologists, nuclear medicine physicians as well. You're basically giving all of the systemic therapies in advanced prostate cancer. Is that something that you see other groups moving into that similar model over time?

Gordon Brown: I do, and I do specifically because I think this is bigger than just prostate cancer. As we talk about prostate cancer specifically, I think it's going to be hard to keep up with the rapid evolution of this disease state and the therapeutic options for that if you don't do it consistently, one. Two, I think that the free flow of patients back and forth whether it be from medical oncology to me, or whether it be from me to radiation oncology, that flow within the practice I think is an important aspect of that patient's care, and maximizes their ultimate outcome, and the patient satisfaction with their caregivers.

Lastly I guess, that it allows us to have an integrated approach to have truly a setting where it's multidisciplinary, it's a collaboration that's centered around the patient itself, and one that allows us to focus solely on the care and outcome of the individual patient as it relates to management of their advanced disease.

Neal Shore: Well, Gordon, thank you so much for taking the charge and demonstrating the leadership in LUGPA FORWARD as well as in a large, successful, continuously evolving group. At the end of the day, it's about advancing care patients optimization and advancing the field. Thanks very much.

Gordon Brown: Neal, my pleasure. Thanks again for having me.