Zach Klaasen

November 2014 ushered in the third year of the international urology journal club (@iurojc) and also marked the 2500th follower of @iurojc.

This month’s article was published in European Urology (@Uroweb) on October 10, 2014, Sequential Combination of Mitomycin C Plus Bacillus Calmette-Guerin (BCG) Is More Effective but More Toxic Than BCG Alone in Patients with Non-Muscle-Invasive Bladder Cancer in Intermediate- and High-risk Patients: Final Outcome of CUETO 93009, a Randomized Prospective Trial.

The discussion was once again well attended by many of the Urology twitter gurus and leaders in the field of intravesical chemotherapy for non-muscle-invasive bladder cancer (NMIBC) (@davisbj, @JimCatto, @DrHWoo, @jimmontie, @uretericbud, @shomik_s, @UroDocAsh, etc).

Given the recent worldwide shortage of BCG, this article proved timely for discussion @iurojc. The authors from Spain conducted a prospective, randomized trial including 407 patients with intermediate- to high-risk NMIBC – 211 patients were allocated to receive mitomycin-C (MMC) and BCG, and 196 patients to receive BCG-alone. At 5 years, the disease free interval significantly improved with sequential MMC and BCG compared to BCG alone (HR 0.57, 95%CI 0.39-0.83, p=0.003), and reduced the relapse rate from 33.9% to 20.6%. However, sequential treatment lead to increased toxicity even after lowering the MMC dose to 10mg (p<0.001). The authors concluded that due to higher toxicity, sequential MMC and BCG therapy should only be given to patients with high likelihood of tumor recurrence (ie. recurrent T1 tumors).

The discussion started with the point being made that BCG strain may influence outcomes, with reference made to the @Uroweb article discussing the outcomes of NMIBC and BCG strain.

Subsequently, we were reminded that patients with recurrent T1 tumors are at high risk for disease progression and mortality, and that appropriately fit patients should be offered aggressive treatment (radical cystectomy).

@uretericbud also made the point that we aggressively treat T1 prostate and T1 kidney cancer, which have low cancer specific mortality, however cystectomy is the last resort for T1 bladder cancer (mortality >30%).

The reality of the worldwide BCG shortage was also highlighted during the discussion, ultimately affecting other ongoing MMC and BCG trials.

This month’s discussion concluded with a conversation regarding treatment options during the BCG shortage. The conclusion among the discussants was for MMC during the induction phase of treatment.

Overall, the consensus was that although the results of MMC and BCG in sequence are encouraging, appropriately fit patients may still benefit from radical cystectomy for recurrent T1 disease. With the worldwide shortage of BCG, perhaps this decision will be easier to make. Happy #movember everyone.

The winner of the Best Tweet prize is Vincent Misrai who will receive a complimentary registration to the USANZ Annual Scientific Meeting to be held in Adelaide, Australia in March 2015.

Thank you to the Urological Society of Australia and New Zealand (USANZ) for providing this generous prize. Thanks also to European Urology for enabling this paper to be open access for the November #urojc.

Zach Klaassen is a Resident in the Department of Surgery, Section of Urology Georgia Regents University – Medical College of Georgia Augusta, USA. @zklaassen_md

“Happy Twitterversary! You’ve just turned 1”

Really? As I stared bleary eyed, post-call at the email in my inbox I couldn’t believe what an ingenious idea such an email was (how many of us remember the day we started using Twitter?) and that another year as a resident (albeit on Twitter) was behind me.

No question I was a “slow adapter” to social media, in particular Twitter – it was too reactionary, I was too busy, it would take up too much time. I can’t remember how or why I was persuaded, but curiosity led to me to create a Twitter account in the middle of the night while waiting to put up a ureteral stent. Immediately my perception and the time frame in which I obtained information completely changed. I started adding accounts for sports and news outlets and…..urologists and urology journals. Who knew?!

Over the past year, I’ve become more comfortable and engaged with Twitter. As a resident, there are a number of opportunities and a few challenges associated with navigating and managing a successful and educational Twitter experience.

Opportunities:

1) World-wide collaborations with leaders in the field who may otherwise be “less accessible” – as a resident, this may be THE most important aspect of Twitter. For those of us pursuing fellowship, building research connections, etc., being able to have access to and follow program directors and leaders in urology is invaluable.

2) Centralization for notifications of publications that are recently in press – as an aspiring urologic oncologist and academician, this is very helpful. BJU International (@BJUIjournal), the Journal of Urology (@JUrology), European Urology (@EUplatinum), Urology Match (@UrologyMatch) and UroToday.com (@urotoday) are personally a few of the most active and informative accounts I follow.

3) Connected at meetings – the ability to be “everywhere”! Getting updates from multiple concurrent sessions has changed the way I attend meetings. AUA 2014 this past year in Orlando was my first meeting on Twitter – to be able to keep up to date on concurrent sessions while contributing to the session I was attending, enhanced and broadened my learning experience.

Drs. Tim Averch, Benjamin Davies, Stacy Loeb, Brian Stork , Henry Woo, Matt Cooperberg, Declan Murphy (Not pictured, Dr. Christopher Bayne). American Urological Association Social Media Committee – See more at: https://www.drbrianstork.com/blog/medical-student-perspective-aua14/

4) Quick hit knowledge “tidbits” – what immediately comes to mind is the evolution of the International Urology Journal Club. This has been very useful and has changed the social media landscape for international, real-time, educational discussions.

Like everything with being a resident, Twitter takes time. However, whether we are walking to a meeting, waiting in the OR, riding the elevator, there are opportunities throughout the day to stay involved and engaged. While I may occasionally miss out on discussions, such as the 48 hours of Urology Journal Club (which may just happen to correspond with a call week), one can always use hashtags (ie. #urojc) to go back and catch up on the banter and knowledge shared.

Personally, I have yet to encounter my attendings expressing concern about what I’m Tweeting or how I’m engaging in social media. To my knowledge, residents are not receiving any formal training or best practice training in social media during residency. As Twitter continues to evolve and the field of Urology continues to lead the medical foray into Twitter, a resident “social media ethics seminar” may be something the AUA considers during the national meeting. Perhaps this may be held in conjunction with the Twitter training sessions at the AUA Resource Center and may take into consideration the recent Engaging Responsibly with Social Media: the BJUI Guidelines and the EAU Recommendations. As importantly, medical students interested in Urology should be aware of their online profiles displayed on social networking websites, considering that program directors are increasingly utilizing this avenue to further evaluate residency applicants.

Until then, we may all consider sticking to the advice of ESPN Radio personality Colin Cowherd “Social media: Don’t do it after a cocktail or in your underwear.”

Zach Klaassen is a Resident in the Department of Surgery, Section of Urology Georgia Regents University – Medical College of Georgia Augusta, USA. @zklaassen_md

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