Face-to-Face with a Top Urologist and Wilmot Partner

Jul. 3, 2018

Dr. Jean JosephJean Joseph, M.D., M.B.A., is hard to miss on the campus of the University of Rochester Medical Center. At 6 feet, 5 inches tall, the renowned surgeon is often seen striding down corridors in scrubs between cases, busy offering a phone consultation or responding to email. With high-quality technique and skill, Joseph has removed thousands of cancers and taught a generation of surgeons — but he also tries to practice the art of medicine. He calls his patients the night before surgery to answer questions and suggest they get a good night’s sleep. The joke is that they often say, “No, YOU get a good night’s sleep!”

Recently Joseph has taken on bigger challenges. On Jan. 1, the innovator and pioneer in robotic surgery became the Winfield W. Scott Professor and Chair of the Department of Urology at URMC.

Four of the top 10 cancers — prostate, bladder, kidney, and testicular — are treated by urologists and the demand for services has caused tremendous growth in the department. URMC Urology has always had a relationship with the Wilmot Cancer Institute but Joseph promises to forge an even closer bond.

We sat down to talk about cancer, his vision, and priorities. Following is an edited version of our conversation.

Congratulations! Tell us about your new role.

As chair of the department, I oversee every aspect of our mission. That is, to be a destination for patient-centered urological care, to be a place of choice for those pursuing higher learning, and to be an outstanding place to conduct research. I want it to be an outstanding place to work for all involved.

Twenty-something years ago, we had five faculty members and now we have 20 faculty and we’re growing. It’s important that we have the clinical expertise to care for patients from the greater Rochester area and beyond. The Med Center has increased its radius, and our department has played a role in that. Our patients come from Pennsylvania, Canada, and the north corridor of New York state. Oncology is one of the strong pulls that bring our patients here, and you have to be competitive to succeed clinically. But ultimately the quality of our product goes back to how you educate and to our research.

As you look into the future, what is your dream in terms of controlling urological cancers?

Dr. Joseph and Patricia James chat in the hallwayThe dream would be, really, to be able to scan someone or take a swab of their saliva, do a genomic analysis, and be able to find a targeted way to alter the disease before it actually develops — employing genomics toward disease prevention.

We’re seeing some of that in terms of using genomics to drive treatment decisions. Our approach is not one-size-fits-all. We all have a unique makeup, and personalized medicine is where the field is going, whether it’s in prostate, bladder, or kidney cancer.

We’ve seen the most progress in prostate cancer. For a long time, the PSA (prostate-specific antigen test) has served as the biomarker. But it’s very general. Now it’s important to get to the next level, to use the multitude of data points we have regarding biopsies and family and personal history, to determine whether to treat the disease aggressively or to watch and wait. The future will include more of these biological markers and identifiers that help us to understand the best course for each particular individual.

The breast cancer genes (BRCA1 and BRCA2) are good illustrations. Everyone has heard about it — especially when Angelina Jolie talked about her situation — and those discoveries led to useful interventions. But we don’t have that for prostate cancer, or for bladder or kidney cancer. So, the dream is to have the same biomarkers that other cancers have, and to be able to identify and help people who are at greatest risk before cancer develops or at a time when they can live full lives without much medical intervention. Until there’s a cure for cancer, the goal is to improve diagnosis, improve treatment — and even better — to prevent it.

Some of that work is being done here at our cancer center. For example, Dr. Carla Beckham is looking at blood and urine samples from patients with bladder cancer and finding biomarkers associated with tumor development and metastasis.

Another very promising area is in surgery. We’ve been a pioneer in coming up with ways to use actual patient images to simulate surgery before the event happens. Dr. Ahmed Ghazi in our department has led this effort, which allows for more precise actions the day of surgery. Our simulation lab is unique in the country and it’s also tremendously valuable for our trainees.

When it comes to patient care, you have a reputation for building strong relationships with the people you treat. Why is that important?

We all have unique stories, and I tend to remember my patients not by their names or the state of their diseases, but by their life experiences. I’ve had patients from all walks of life, and yet our conversations click. I think it’s important to treat the person, not the disease.

If someone is coming up to Rochester from another part of the state, keep in mind that their doctor had to counsel them to come here. They could’ve chosen Memorial Sloan Kettering or any number of other places. And so, the caring-for process starts the moment you meet them. When I have a patient who’s staying in a hotel the night before surgery, I realize that can be agony. So I call them. It’s reassuring, and I think they feel as if they’re truly under your care, and that increases their confidence. They also come in the next morning with a positive mindset, in the right mood and with lower levels of stress, and that mindset may impact the healing process.

I get postcards and gifts of thanks. A month ago I got a beautiful flask filled with bourbon from a patient that I took care of 10 years ago. Ten years! I called him, and he said he just wanted to express his appreciation. I had another patient who sent me a cherry wood shoe horn that he made himself. It was a work of art. He told me, “You’re a tall drink of water and you need this.”

When patients show you the impact you’ve made on their lives, that you’ve been able to offer a glimmer of hope in hard times...it’s very humbling. It’s an honor. As physicians and scientists, we don’t always think about the impact we have. It’s an awesome responsibility.

You’re a prostate cancer specialist but when you look across all areas of urological oncology, what are the best opportunities to invest in?

Dr. Joseph and Patricia James chat in the hallwayWe have a lot of expertise in prostate, bladder, and kidney cancer. And while we’re delivering on the clinical side, I think we need to focus on delivering more with respect to research. Our scientists are working very hard. But prostate cancer in particular is a public health issue. Our approach for such a common disease has been to diagnose it early with the best technologies, and treat it appropriately. 

This institution was the first in the region to have MRI technology to differentiate between aggressive and non-aggressive prostate cancers. And that work must continue. The burden is on us to find ways to decipher who needs immediate treatment, which tumors are not medically urgent, and how to tailor the diagnostic approaches. This is extremely important because most prostate cancers grow slowly, but obviously you don’t want to miss the cases that are likely to grow and spread quickly. As I said earlier, ultimately it’s about personalized medicine — to be able to stratify a personal approach to care, to use the biomarkers that have been identified to help with prognosis.

Bladder cancer is another area to invest in. It’s also common, particularly in the elderly. We have a couple of researchers, Dr. Beckham and Yi Fen Lee, who have done a lot of work in identifying biomarkers to help with diagnosis and also as therapeutic targets. It’s very exciting. And there’s much groundbreaking work to be pursued.

I’ve talked about diagnosis and treatment but the third piece is prevention. It’s another arm that needs to be elevated.

How do you prevent prostate cancer?

Well, that’s a good question and we don’t have a clear answer. That’s why research has to move in that direction. This is what patients ask us all the time: “How can my kids avoid this cancer? My brother?” There are a number of studies that have looked at vitamins as a possible prevention but as quickly as they were shown to be effective they were disproved. So we don’t have an effective means of preventing it.

At the moment, our conversations with patients tend to focus on lowering the consumption of animal fats (meat, milk, butter, cheese), which are associated with a lower incidence of cancer in general. By lessening the consumption of animal fats, a person can also address a number of other health issues. That’s the best evidence we have.

What’s your department’s relationship with Wilmot and how might it change?

Dr. Joseph practicing surgeryWe have a great relationship. We’re an integral part of the Wilmot Cancer Institute and that will continue. In fact, I’ve appointed Guan Wu, M.D., Ph.D., a cancer specialist in Urology, to serve as Director of Urological Oncology. We are working on defining the position, but he will serve both the needs of the cancer center as well as our department. I’d also like to diversify our research a bit, but the focus will remain on oncology. We’ve invested for decades in cancer research and our recruits will target our growth in oncology.

Another goal is to partner with Dr. Jonathan Friedberg, Wilmot’s director, to move toward the University’s objective to obtain National Cancer Institute designation and become a comprehensive cancer center. This is the highest ranking awarded by the NCI, with special recognition of research expertise in laboratory, clinical, and population-based science. We all need to be marching in that same direction. We all have the same agenda: To understand the metrics of a comprehensive cancer center and to pursue them aggressively.

In the past few years, Wilmot has expanded in many directions. We now have 86 inpatient beds, making us the size of a small hospital, and we also provide outpatient care at 11 locations in the Rochester region. Can you talk about how your department fits into the University’s and Wilmot’s regional growth?

Urology is not just based at Strong Memorial Hospital anymore. We are a networked department. Our goal is to have partnerships with all of our affiliates. We’re currently recruiting faculty to be based at F.F. Thompson Hospital in Canandaigua, for example. We already have doctors there, but the demand for urologists is high in Ontario County and the east side of Rochester. We’re active in Geneva as well, and on the west side, in Batavia. Our tentacles very much parallel those of Wilmot’s. We’re also recruiting for the Dansville, Wellsville, and Hornell corridor. The idea is to have patients cared for at the place of their choosing.

We’re developing relationships with urologists in the region and our approach is to formalize that and be a resource for them. We may not have a faculty member in Ithaca, for example, but we want the physicians and men in Ithaca to think of us first if they have a problem.

Switching gears to a more personal question, you attended medical school at the University of Rochester and did your residency here, but then went off to Europe for additional training before coming back to Rochester. Why did you choose to settle here?

I have been privileged to travel to London and France for training, and I think Rochester is unique. The interface, the education of the next generation, and the research that’s being done here — it’s unparalleled. This medical center has always put these things together and found a way to synergize them. At other fine institutions across the country, you often have hospitals that are very independent from the medical school. And things work okay, but Rochester is unique in its ability to integrate all aspects of medicine in one place. The Rochester region is a great place to practice, and the patient-centered model we have — I can’t imagine finding a better place to pursue my career.

One final question — what keeps you up a night?

How much time do you have? (laughs) As I transition into this new job, a lot of things do. A leader is supposed to provide a vision. But you can’t just decree the vision, you need to get others to take it on and make it their own. So I think about how to make us an even better team that completes itself, that’s fully integrated. It’s an evolving process and it doesn’t happen on arrival. I am convinced that in all of us, there’s an appeal to reach the high road. As humans we ultimately want to deliver.