2024 EAU Meets National Societies Meeting looks at current and future developments

On 7 June, EAU Secretary General Prof. Arnulf Stenzl welcomed representatives of Europe’s national urological societies to Noordwijk, the Netherlands. The EAU hosted 61 delegates, from 34 countries, representing 38 different societies for a day-long fact-finding and brainstorming programme.

Tue, 25 Jun 2024 • Loek Keizer
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Group photo of EAU and National Society representatives in Noordwijk, the Netherlands on 7 June, 2024.

The Annual Noordwijk meeting has become “an established meeting throughout Europe,” said Prof. Stenzl (Tübingen, DE), offering a chance for an exchange of views, and an introduction of new priorities for the EAU. “We invited you to bring younger colleagues, so we could make some important introductions and so that they get a good idea of where the field will be going in the coming years.”

In fact, one of the four major topics to be discussed on the Dutch riviera was the future of urology, when it comes to the subject matter of the field specifically, its increasing diversity, and the young generation’s needs for education and training.

The three other major topics were an update from the EAU’s Policy Office, the EAU’s ongoing efforts regarding the use of real-world data and new initiatives from the Patient Office. Together, these four discussion points formed the basis of rotating break-out sessions with groups of different countries’ representatives.

As part of the introductory “Plenary Session” that morning, EAU Guidelines Chair Prof. Maria Ribal (Barcelona, ES) gave the assembled delegates an update on various ongoing and upcoming projects. The EAU Guidelines app was launched earlier this year to great success, featuring access to the Pocket Guidelines in an easy to navigate package. It also includes interactive algorithms, scores and calculators and 39 “cheat sheets” that summarise each topic in one page.

Prof. Ribal also announced the opening of recruitment for Study II of IMAGINE, a project which assesses Guidelines implementation. This second study will assess adherence to guidelines for antibiotic prophylaxis in cystoscopy. It follows on from the first study, which audited ADT use before prostate cancer surgery and ended up including 6598 cases from 187 hospitals in 31 European countries.

Following the introductory lectures, the groups of delegates were invited to round-table style discussion, and in turn joined by an EAU team with representatives from each project or topic.

The meeting’s location gave an inspiring setting for brainstorming in the briny air.

The Future of urology

When introducing the first topic earlier that morning, Prof. Stenzl gave a potted history lesson of the development of urology from a diagnostic to a surgical interventional discipline. There is of course a large overlap with uro-oncology, which has been gaining prominence in recent decades, sometimes at the expense of available OR time for urologists. This is a development that has been a long time coming but will be accelerated with the adoption of the latest systemic treatments. With less emphasis on surgical intervention, a question is how to keep urologists involved or even in the driver’s seat when dealing with patients.

Prof. Stenzl pointed out the EAU is already closely involved in uro-oncology: “The EAU’s current activities in uro-oncology include interventional and systemic guidelines, and projects like the UroEvidenceHub and Praise-U.”

In the break-out session, former Scientific Congress Office chair Prof. Peter Albers (Düsseldorf, DE) was interested to inventorise whether urologists could prescribe oncological drugs in their countries, and whether there were established cancer centres. The break-out group that included the Baltic countries, Ukraine, Georgia, Armenia and Cyprus showed a real cross-section of different approaches in Europe.

In most cases, prescription of oral medication (mainly ADT) fell within the realm of the urologist, with systemic therapies falling under medical oncologists or specially trained urologists. In some cases, quirks of health insurance rules meant that while urologists are allowed to prescribe most cancer treatments, it is only reimbursed through the involvement of medical oncologists. In one country, there even seemed to be a deliberate choice on behalf of the urologists to not involve themselves in systemic treatment at all. This led to some discussion about whether urologists could continue to have the luxury of this choice.

When it came to the multi-pronged topic of equity, diversity and inclusivity (EDI) in European urology and the EAU specifically, Young Urologists Office chair Dr. Juan Luis Vásquez (Copenhagen, DK) was interested to find out if the national delegates felt adequately represented within the EAU and its events. What sort of barriers were preventing participation in events or boards? Different levels of income across Europe continue to present a challenge, which the EAU is addressing with special membership and event rates for middle and lower income countries.

There has been a doubling of female faculty at the EAU’s Annual Congress over the past five years, hitting a record-high 20% for EAU24 in Paris. Dr. Vásquez pointed to EUREP, the EAU’s residency programme as a positive development: around one third of the participating residents is female, as is a quarter of the faculty. Dr. Vásquez presented some first conclusions about participation in the EAU’s Talent Incubator Programme. (Only a few days later, that programme would win “Best EDI Initiative” at the International & European Success Awards 2024, organised by the Association of Association Executives.)

Finally, the third part of the future of urology came in the form of training and educating residents and young urologists. The European School of Urology was represented by its Chair, Prof. Evangelos Liatsikos (Patras, GR). “Standardisation of education is the keyword for the coming years. We are working on structured learning pathways, an E-BLUS-like concept for everything in urology,” said Prof. Liatsikos, referring to the European training programme for basic laparoscopic urological skills, which offers a structured and objective trajectory.

“How can we understand the younger generation’s needs?” he continued. “We need to extend our hands and show them that they are welcome. National differences will continue to exist, but hopefully language will not be a barrier any more soon, thanks to AI-generated simultaneous translation in events, telemedicine, even remote supervision.”

Some considerations young urologists have, as identified by the ESU are prioritising of wellness and their work-life balance. Also key is the availability of high-quality, evidence-based education that is affordable and clinically relevant. The impact of the education should match the effort when resources like time and money are more relevant than ever. “As I see it, the younger generation will be operating on us one day, so train them well!” Prof. Liatsikos quipped.

In the break-out session, awareness of the ESU’s educational programmes and other ‘products’ was still a challenge for some, an area where national societies could help reach their country’s residents. Different avenues for reaching residents were considered, including outreach via ‘youth representatives’.

Other practical points raised were the clashing of EUREP with compulsory military service for third-year residents, and more focus on help on writing papers with a view to getting research published internationally.

Profs. Stenzl and Albers discuss the finer points of the relationship between urology and oncology.

Policy and screening initiatives

The EAU’s Policy Office was well-represented in Noordwijk, by several of its leaders. Chair Prof. Hein Van Poppel (Leuven, BE) introduced several speakers and project leads, stressing that beyond the clear medical benefits, it would now become a case of political will and local practicalities to set up early detection programmes for prostate cancer across Europe.

“We need to show that screening is feasible, and that it can work in different countries, in different circumstances,” Prof. Van Poppel said. “We already know that it decreases mortality.” Prof. Van Poppel re-introduced the PRAISE-U screening algorithm as it was currently being piloted in different countries across Europe and pointed to the publication of the Lancet Commission on prostate cancer as presented in Paris at EAU24: Europe can expect a “surge of prostate cancer cases” by 2040 as its population ages.

Dr. Lionne Venderbos (Rotterdam, NL) introduced PRAISE-U Work Package 2 and updated the national societies’ representatives on the preliminary results of the project, partly based on their own input as requested at last year’s Noordwijk meeting. This concerned, among others, the identification of several critical barriers to the implementation of PCa screening in Europe.

The most critical of these was a lack of political support (government, health ministries) in individual countries. Possible solutions to overcome this barrier are sustained awareness campaigns (also towards the general population), consensus meetings with key stakeholders, political lobbying and the development of European guidelines for screening.

Other barriers and potential solutions concerned the lack of human, physical or financial resources to operate screening programmes (potentially alleviated by developing standardised, compatible IT systems) as well as a potential lack of participation: inadequate public promotion of the screening programme, through primary care physicians or otherwise. Solutions proposed are targeted awareness campaigns, the involvement of patient organisations and GPs, as well as making access to screening as easy as possible, potentially even through home testing.

Key to the PRAISE-U project is the collating of information. Data produced so far, country fact sheets and related publications are all freely available in the recently launched PRAISE-U Knowledge Hub. The hub also serves as a starting point for any national society wishing to become involved or learn more about the project.

Prof. Philip Van Kerrebroeck (Antwerp, BE), Vice-chair of the Policy Office was also on hand to discuss updates on the Urge to Act campaign, also previously presented in the context of the National Societies Meeting in Noordwijk. Prof. Van Kerrebroeck: “Aside from the health challenges of urinary incontinence, we are learning more about the economic burden for our continent, currently estimated at €69 billion per year! With 55-60 million Europeans with continence problems, there is a significant impact on productivity and a clear decrease of independence.”

The Policy Office supports national societies with guidance and materials to get continence care on the national agenda. Discussion in the break-out session revealed that highlighting the economic burden in particular (but also the environmental impact) could be a way to broach the subject politically. In various countries, the topic is taboo or hardly spoken about. In countries where taboos are less of a problem, this has proven to be a process that can take decades. Campaigns and awareness have contributed to this long-term commitment to getting the topic on the political and health agenda.

Prof. Van Kerrebroeck leads discussion about the Urge to Act in one of the break-out sessions.

Unlocking the power of real-world evidence

A major recent initiative by the EAU is the establishment of its UroEvidenceHub, a new programme to store and analyse real-world urology data. The Hub has as stakeholders not only the EAU’s Research Foundation and Guidelines Office, but also its Patient and Policy Offices, emphasising the many sources and applications for its real-world data.

Explaining the potential and indeed need for real-world data in urology was Prof. Philip Cornford (Liverpool, GB). He explained how clinical trials are about safety and efficacy of drugs or treatment, but in a very carefully selected group of patients, and designed to get approval, registration or otherwise making a claim: “Clinical trials might make for great papers, but they are not necessarily good for the patient in front of you. The follow-up is only short for trials, but innovative use of data could be a real game-changer that makes a difference for our patients.”

Prof. Cornford outlined the different sources of real-world data that future decisions could be based on. Apart from obvious and important categories like clinical and medication data, and scientific literature, there is great potential in the use of claim data, molecular profiling, family history, mobile health (like wearable devices), environmental data, patient-reported data, and patients’ social media communities.

During the afternoon’s break-out sessions, Profs. Cornford and James N’Dow (Aberdeen, GB) wanted to hear from the national society representatives which centres in their countries were collecting data and how access was arranged.

While electronic patient records were common in nearly every country, legislation differed greatly in what doctors were allowed to access, subsequently. Individual clinics might send their patient data into a national database, but find it hard to get follow-up information on patients, only having access to basic summaries unless access is granted in the style of a clinical study.

Other countries, like Cyprus have tremendously joined-up healthcare, allowing doctors to follow up their patients across different centres. From country to country, strict GDPR, ethical and consent rules mean that typically the patients determine who has access to their data.

In Ukraine, which is facing tremendous hardships by the ongoing war, non-electronic systems are currently preferred for their reliability when access to electrical power is not always guaranteed. Its military currently has the most sophisticated and nation-wide health database in the country.

Prof. Cornford concluded with a sneak peek at how patients and urologists alike could, through real-world data-informed shared decision-making, decide on the best approach. By factoring in the patient’s priorities in terms of quality-of-life, survival and cost, and by using available data from comparable patients, both patient and urologist could arrive at a satisfactory treatment approach for various conditions. This use of data tied in to the Patient Office’s upcoming projects as well.

Shared decision-making

The EAU Patient Office introduced as a major theme the increasing importance of shared decision-making (SDM). The development of relevant support tools and the increased awareness among urologists are the first objectives. Ultimately, patient-reported outcome measures and experience measures (PROMs and PREMs) will offer new insights that could affect existing guidelines recommendations.

Prof. Eamonn Rogers (Galway, IE), Patient Office chair: “It is becoming apparent that patients want to become more involved in their care, with surveys showing that 75% want to share the decisions about their treatment. These decisions go beyond the medical too, for instance the impact of treatment on their work or relationships. There is also the matter of partners who can also be unhappy as a result of decisions made. These are all things that you don’t see in clinical trials but certainly affect our patients greatly.”

Prof. Rogers and Patient Office Vice-Chair Dr. Michael Van Balken (Arnhem, NL) explained how the current Patient Information website would evolve to include more decision-making aids, more interactivity and more animated explainers. This would help better reach and engage patients, and in the cases of older patients, through their sons and daughters.

During the break-out sessions, the Patient Office board was interested to hear from the group of representatives what their experiences were with patient information, and in particular if their departments were already using SDM tools. This led to some interesting insights in regional and national differences across Europe.

Generally, it was clear that younger patients tended to do their own research, more so than older generations. This is not at the expense of trust in doctors, but more in addition to. Another common theme was the lack of time to discuss and inform treatment with their patients, sometimes limited to 20-minute slots (or less) when an hour would be more appropriate. High-quality materials like websites or animations could help give patients a more complete picture, in addition to face-to-face consultation with the treating physician. Finally, there was broad support for patient information that also applied to the next of kin: what can parents, children and partners expect, and what should or should they not do to help their loved ones?

Interesting differences in approach appeared with discussion about certain hospitals having an “advisory council” to represent patients and advise in related matters. Ideally teams or hospitals should have a team member who is dedicated to offer patient information or support, not to replace the urologist’s recommendations but to reliably inform patients.

The Patient Office has invested in the services of an AI-powered translation company, which should make localisation of the EAU’s currently existing patient information much more affordable if national societies are interested in adopting them (after a final expert check). While an attractive proposition that would work for several smaller countries who do not produce national patient information, potential stumbling blocks are the legal status of minority languages in some countries, meaning that the documents may not be suitable until every minority language is supported by the software package (a work in progress).

A show of hands from all the assembled representatives.

Conclusions and further points

The day concluded with a topic-based summary of the most important points of discussion from the break-out sessions. Prof. Albers was surprised by the great diversity across Europe that was revealed when examining the relationship between urology and oncology. This sparked further discussion with Prof. Stenzl about the German and Austrian experiences of introducing oncology into urology training, the establishment of dedicated cancer centres and the role of surgery. “Drugs are going to become less toxic and more effective, and we need this knowledge,” Prof. Albers concluded.

In terms of education, greater awareness of the ESU’s activities could be created by the national societies, perhaps through dedicated education or training representatives. There was also enthusiasm among the national societies for more ESU support of regional events, and more short-term scholarship opportunities. Further audience discussion revealed the continuing desire for support when it comes to young urologists publishing their first international papers. While on the one hand, “academic principles” are deprioritised as part of the younger generation’s emphasis on work-life balance, other initiatives for academically hungry young urologists exist, like the UK’s BURST trainee-led research, journals for young urologists and of course the EAU’s own Young Urologists Office.

In terms of prostate cancer screening, the break-out discussions had covered a lot of ground, leading Prof. Van Poppel to re-emphasise the work ahead as more countries join the projects, as well the importance of the involvement of the national societies.

All in all, this year’s EAU Meets National Societies Meeting highlighted the symbiotic and collaborative nature between the European Association of Urology and Europe’s countries’ individual societies: their membership overlaps, countries are represented in the EAU’s activities and boards, and the EAU can act with a common voice on a European level, amplifying national concerns on behalf of all urologists.