Which Doctor When?…. Jan Manarite, 2015

WhichDrWhen2  Which Doctor When?…

When I walked this prostate cancer journey with my husband for over 13 years, we were often confused by the different titles that physicians had.  Some sounded similar.  Some doctors gave certain treatments – some didn’t.  And, of course, the instinct to change my husband’s lead physician, plus the right to do so was sometimes overwhelming.  We changed lead physicians 3 times during that 13 years, but landed with one who we could develop a good relationship with, and worked with him for over 9 years.  But it was always easier for me to suggest a change than it was for my husband.  It was his cancer at stake, his patient-doctor relationship.  Changing doctors was scary, but it always paid off when we thoughtfully followed our instincts.

These 3 short articles I’ve written come from those experiences, plus my 14 years as a prostate cancer advocate, writer and speakerYou can find these articles and more online at PAACT’s Blog  – www.PAACT.help/Blog


Changing Physicians?

Changing doctors was scary, but it always paid off when we thoughtfully followed our instincts.


(1) What’s the Difference Between an Urologist and a Medical Oncologist?   And Which One Should I be Seeing?
If you are a prostate cancer patient, the urologist is most likely the physician who did your biopsy, gave you your diagnosis, your Gleason Score and discussed your treatment options with you.  He may have discussed prostate surgery (prostatectomy), especially since he/she is a surgeon.  The urologist is the first doctor you see, deal with and probably develop a bond with since he delivered the message that you had cancer.


A medical oncologist is a cancer doctor who treats all types of cancer.  In some other cancers, he is the first doctor you see, not the surgeon.  In prostate cancer, he is often the third doctor you see, after the urologist and the radiation oncologist.  This can be confusing for patients.  They may not know which one to see or if they even have a choice.  I would argue that you always have a choice and ultimately it is always up to you, the patient.  Period.


I walked the prostate cancer journey with my husband for 13 years.  He was metastatic at diagnosis, so we saw a medical oncologist in the first week.  In fact, he was so advanced that he never had a prostate biopsy.  His diagnosis came from a metastatic tumor removed from his spine.  So his case is completely different than most men.  But I did learn to work through the system, trying to keep him and his cancer as the most important things.


Here are some differences between most urologists and medical oncologists that should help you decide who you would like to see for your prostate cancer care.

Differences Between an Urologist and a Medical Oncologist


Medical Oncologist

Trained in surgery? Yes No
Trained in internal medicine? No Yes
Trained in hematology? (issues of the blood) No Yes
Trained in pain management? Usually No Usually Yes
Can administer hormone therapy shots? Yes Yes
Can administer chemotherapy? No Yes
Can administer Xgeva or Prolia? Yes Yes
Can write prescriptions? Yes Yes
Can check CBC bloodwork same day/in house? Usually no Usually yes
Has dedicated, clinical Nurse Practitioner
or Physician Assistant?
 Usually no  Usually yes

For further reference –

  1. The Best Medical Team for Advanced Prostate Cancer Treatment.  April 2014,
    Everyday Health; http://www.everydayhealth.com/health-report/conditions/how-pick-advanced-prostate-cancer-medical-team.aspx
  2. Health Professionals Associated with Cancer Care.  August 2014,
    American Cancer Society; http://www.cancer.org/treatment/findingandpayingfor
  3. I am not an Urologist.  February 2014, Mark Scholz, MD; http://prostatesnatchers.blogspot.com/2014/02/i-am-not-urologist.html
  4. Finding the prostate cancer specialist who is right for YOU.  March 2011,
    The New Prostate Cancer Infolink; http://prostatecancerinfolink.net/tips-tools/pick-prostate-cancer-specialist


(2) What’s the difference between a Radiologist and a Radiation Oncologist?

A Radiologist is a physician you probably never meet, yet still impacts the understanding and treatment course of your cancer.  He reads and interprets your imaging or your radiology exams.  In prostate cancer, radiology exams include CT Scan, MRI, and X-ray (most commonly).  Ultrasound would also be considered radiology, but in the case of prostate cancer, most urologists do their own ultrasounds and don’t use radiologists.  There are other imaging techniques which are called “nuclear medicine” because they require an injection that is radioactive or a “radio-pharmaceutical.”  Nuclear medicine imaging in prostate cancer includes Bone Scans (both the T99 and the F18) and all PET Scans (C11 Choline, C11 Acetate and F18 or Sodium Fluoride).


Now, to complicate issues just a little more….there are Radiologists who DO see patients, therefore they treat prostate cancer, but they are the exception to the rule.  Sometimes they are referred to as interventional radiologists.  In our world of prostate cancer, some familiar names would include Dr. Duke Bahn in CA who is known for cryotherapy and focal cryo, Dr. Fred Lee in MI (retired) who did the same, and Dr. Gary Onik in FL who also does cryo and focal cryo.  There are also radiologists like Dr. Aytekin Oto in Chicago who are doing work in focal laser treatment for prostate cancer. (Note – focal treatments treat part of the prostate as opposed to all of the prostate.)


Now – on to the Radiation Oncologist.  This is the physician who administers your radiation treatments for cancer, so this is much different than a radiologist.  There are so many types of radiation treatments in prostate cancer, I will not attempt to name them all.  But at the very least, think of daily radiation treatments to the prostate and short term radiation to metastatic disease as common treatments given by radiation oncologists.  There is also radioactive seed implantation to the prostate (brachytherapy) which usually involves both the radiation oncologist and the surgeon (urologist).


One last type of radiation that a radiation oncologist may administer is an injectable radiation for bone metastases called Xofigo (radium 223).  This is for men who are metastatic and on hormone therapy.  As you may know, this is called mCRPC (metastatic castrate-resistant prostate cancer).  The other type of physician who might also administer Xofigo is a Nuclear Medicine Physician.


Simply understanding the differences between physicians can help you in your research and help you decide who to make an appointment with.  This is all part of patient empowerment – we hope this explanation is helpful to you.


(3) What’s the difference between a Radiologist and a Nuclear Medicine Physician?  In fact – What the heck is Nuclear Medicine? 
Again a radiologist is a physician you probably never meet, yet still impacts the understanding and treatment course of your cancer.  He reads and interprets your imaging or your radiology exams, such as CT, MRI and X-ray.


A Nuclear Medicine physician also reads and interprets imaging, but some types of imaging are not called radiology – they are called nuclear medicine or nuclear imaging.  In prostate cancer the most common nuclear imaging exams are Bone Scans, and all types of PET Scans.  These are considered nuclear medicine because the patient receives an injection that is radioactive, called a radio-pharmaceutical as part of the imaging.  (An MRI or CT Scan can sometimes require an injection, but it is not a radiopharmaceutical, so they are not nuclear medicine.)

Radiologists and Nuclear Medicine physicians read and interpret your imaging.

Another way to state the difference between imaging with radiology vs nuclear medicine, is that radiology is designed to see anatomy (shapes & sizes), while nuclear medicine is designed to see physiology (cells, molecules, chemical interactions, etc.).  If you’ve ever had a PET scan (nuclear imaging) for your prostate cancer, you may have had it “fused” with a CT scan (radiology).  That’s because the PET is better at visualizing cancer cells, but the CT scan is better at visualizing anatomy such as organs, bones, etc.  Since no medical imaging is 100% perfect, using 2 different techniques together often improves the accuracy of the exam.


Something else unusual about Nuclear Medicine, is that it includes both imaging and treatment – because a radiopharmaceutical can be used for either, and the radiopharmaceutical (injection) is what makes something “nuclear medicine.”  So, nuclear medicine physicians not only deal with imaging, but they also administer a few select treatments.  In prostate cancer, this is mainly one treatment right now, which is Xofigo (radium 223).  Xofigo was FDA approved in 2013 for men on hormone therapy, with rising PSA and bone metastases.  See full Xofigo information online at www.xofigo-us.com/patient. So if you are scheduled to start Xofigo, you may have a clinic visit scheduled to see a nuclear medicine physician, who you may have never met before in your cancer care.  The only other type of doctor who administers Xofigo is a Radiation Oncologist – See article (2) above.


In the world of prostate cancer there are many twists and turns along the journey.  The medical system is often complicated and sometimes overwhelming.  Understanding the medical system can help you navigate your journey.  Knowing a little about the different physicians will be helpful.  So, if you hear the word nuclear medicine, know that it includes both imaging and treatment in prostate cancer, and know that it’s slightly different than radiology when it comes to your imaging.  Use this information to formulate better questions for your nurses or medical oncologist.  Better questions always bring better answers.  Stay empowered.