Genitourinary Cancers

Testing further for a form of prostate-specific antigen (PSA) can help urologists find, stage, and classify prostate cancer in men whose PSA tests are ambiguous, according to a multicenter study that included The Johns Hopkins Hospital. The additional test, which is routinely available for all men taking the PSA test, can also help patients and their doctors determine the best course of treatment. The test measures free PSA, the form of PSA not bound to proteins in the blood. According to the study, the higher the percentage of free PSA compared to the bound form, the smaller the tumor is likely to be, the less chance there is that it has spread from the prostate, and the less likely it is that the disease is the most aggressive form.

SAN ANTONIO -The Southwest Oncology Group (SWOG) has announced the start of the first major phase III trial to compare the chemotherapy combination of docetaxel (Taxotere) and estramustine phosphate (Emcyt) with the commonly used combination of mitoxantrone (Novantrone) and prednisone for the treatment of advanced, hormone-refractory prostate cancer.

The Southwest Oncology Group (SWOG) announced the beginning of the first major phase III clinical trial comparing the combination of docetaxel (Taxotere) and estramustine (Emcyt) to the commonly used combination of mitoxantrone (Novantrone) and prednisone in the treatment of advanced, hormone-refractory prostate cancer. Patient enrollment is currently underway, with approximately 660 men being recruited. This trial is being conducted by SWOG and is funded by the National Cancer Institute (NCI) in collaboration with the Cancer and Leukemia Group B (CALGB) and North Central Cancer Treatment Group (NCCTG).

BALTIMORE-Physicians should consider using intravesical chemotherapy or immunotherapy as adjuvant therapy following surgery for non-muscle-invasive bladder cancer, according to new treatment guidelines released by the American Urological Association (AUA). “The fact that the peer-reviewed published data show that the use of intravesical agents after surgery lowers the probability of recurrence but not progression is the most important finding that we made,” panel chair Joseph A. Smith, Jr., MD, of the Vanderbilt University Medical Center, said in a news release.

The management of patients with clinical stage I nonseminomatous germ-cell tumors is still highly controversial. In a recent survey, urologists and oncologists were asked to state their choice of treatment for patients with clinical stage I nonseminomas who were at high risk for recurrence after orchiectomy. Not surprisingly, urologists chose retroperitoneal lymph node dissection over chemotherapy, while oncologists indicated a preference for adjuvant chemotherapy.[1]

Improvements in the clinical staging of testicular cancer may permit the identification of clinical stage I patients at low risk of harboring metastatic disease, who could be spared treatment and observed only. Both retrospective, single-institution studies and studies of unselected, consecutive patients have confirmed that vascular invasion, lymphatic invasion, and percentage of embryonal carcinoma are predictive of metastasis in patients with low-stage nonseminoma. Whether patients with these risk factors have a worse outcome if managed with surveillance, rather than with aggressive therapy, is unclear. Low MIB-1 staining (which identifies the Ki-67 antigen) in conjunction with a low percentage of embryonal carcinoma in the testicular specimen appears to be predictive of a low probability of metastasis. Computed tomography (CT) is a useful staging tool. A new prognostic classification system for seminomas and nonseminomas was recently developed by an international consensus conference. Laparoscopic retroperitoneal lymphadenectomy appears to be a feasible staging tool with acceptable short-term morbidity. Whether laparoscopic lymph node dissection is equivalent to the open procedure when used as a therapeutic modality is not yet known. At present, laparoscopy should be used only in selected patients in a study setting. Primary chemotherapy is not recommended currently because it has not yet been proven to be superior in patients with high-risk clinical stage I nonseminoma and can cause significant long-term sequelae.[ONCOLOGY 13(12):1689-1694, 1999]

Drs. Foster and Nichols, both recognized experts on testicular cancer, are to be congratulated for their concise overview of continuing controversies and challenges in the care of young men with this disease.

Experienced authors Richard Foster and Craig Nichols providea thoughtful, state-of-the-art discussion of current controversies in the management of testicular cancer. Present cure rates illustrate that significant diagnostic, chemotherapeutic, and surgical advances made over the past century have transformed testicular cancer from a once uniformly fatal disease into a tremendous oncologic success story.

BETHESDA, Md-Some kidney cancer patients in an ongoing phase II trial of an experimental antiangiogenesis monoclonal antibody have shown improvement. The randomized, three-arm study by National Cancer Institute researchers compares two different doses of the drug against a placebo.

CHICAGO-Despite recent excitement about therapy involving ifosfamide (Ifex) and other new chemotherapy drug combinations, MVAC-methotrexate, vinblastine, Adriamycin (doxorubicin), and cisplatin-remains the standard of care for advanced bladder cancer, Derek Raghavan, MD, said at the Chicago Prostate Cancer Shootout III Plus Bladder Conference, sponsored by the Chicago Urological Society, Chicago Radiological Society, and Chicago Medical Society

The article by Olson and Pienta is a thorough review of the important issues facing men with metastatic prostate cancer and their caregivers. Many recent reports have documented physicians’ lack of awareness about cancer pain, which underscores the significance of proper evaluation and management. As the authors note, any evaluation of current and future therapies must focus not only on the efficacy of pain control but also on how a particular treatment affects a patient’s overall quality of life.

This two-part article by Krieg and Hoffman, published last month and concluded in this issue, explores the current management of penile cancer (part 1) and urethral cancer in both men and women (part 2). My remarks will focus on female and male urethral cancer.

In this two-part article, Krieg and Hoffman review the management of patients with cancer of the penis and those with cancer of the urethra, respectively. Both of these cancers are uncommon, and, when they present as small, early, circumscribed lesions, both can be cured (with organ preservation) by radiation therapy. Also following organ preservation by radiation therapy, these patients must continue to be followed closely because 25% to 35% will develop a local recurrence and can be cured by prompt salvage surgery.

Often overshadowed by more common genitourinary cancers, such as prostate, testicular, and kidney cancers, penile and urethral cancers nonetheless represent difficult treatment challenges for the clinician. The management of these cancers is slowly evolving. In the past, surgery, often extensive, was the treatment of choice. Recently, however, radiation and chemotherapy have begun to play larger roles as initial therapies, with surgery being reserved for salvage. With these modalities in their treatment armamentarium, oncologists may now be able to spare patients some of the physical and psychological sequelae that often follow surgical intervention without compromising local control and survival. Part 1 of this two-part article, published in last month’s issue, dealt with cancer of the penis. This second part focuses on cancer of the urethra in both females and males. [ONCOLOGY 13(11):1511-1520, 1999]

Prostate cancer is the most commonly diagnosed cancer among American men. The majority of patients with advanced disease have metastatic bone lesions, which are frequently very painful. These lesions tend to respond well to treatment with both nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, although careful dose titration and individualized treatment plans may be needed to achieve maximal analgesia. Opioid side effects are often transient or well controlled with additional medication. Patients with intolerable side effects may experience fewer adverse reactions with a different opioid. Palliative radiation provides pain relief in up to 80% of prostate cancer patients with single or at most a few sites of localized bone pain. Bisphosphonates, powerful inhibitors of osteoclast-mediated bone resorption, are promising new agents for the treatment of painful bone lesions in prostate cancer patients. Radioisotopes, which deliver high-dose radiation to bone lesions without significantly affecting normal bone, are highly effective in providing some degree of pain relief in up to 80% of patients with diffuse, painful bone metastases. Also, chemotherapy shows promise in alleviating pain and possibly extending survival in patients with advanced prostate cancer.[ONCOLOGY 13(11):1537-1549, 1999]

WASHINGTON-The US Postal Service has issued a 33 cent postage stamp designed to encourage the early detection and treatment of prostate cancer. The stamp features a drawing of the male gender symbol against a red background. The words “Prostate Cancer Awareness-Annual Checkups and Tests” appear on the stamp, which was designed by Michael Cronan of San Francisco.

Large Study Confirms Radiation therapy not only destroys prostate cancer in patients with early disease but keeps it from returning, a very large study of patients from six medical centers has found.

BUFFALO, NY-Prostate cancer screening protocols and treatment for localized prostate cancer are less standardized than for other cancers such as breast cancer, and treatment choices remain difficult for many men and their physicians, Jerome P. Richie, MD, said at the Surgical Oncology Symposium, hosted by Roswell Park Cancer Institute.

Many patients with kidney cancer who had been exposed to high levels of trichloroethylene have a unique pattern of genetic mutations within their cancerous cells. These findings were reported by Hiltrud Brauch, PhD, of the University of Hamburg,

CHICAGO-Systemic chemotherapy would seem to be a reasonable option to reduce the number of deaths from metastatic transitional cell bladder carcinoma. To date, however, systemic neoadjuvant chemotherapy has failed to show an effect on survival, and the jury is still out on the issue of chemotherapy following definitive therapy, said Derek Raghavan, MD, chief of medical oncology, University of Southern California Norris Cancer Center.

Patients with poor-prognosis testicular cancer have a better chance of surviving if they are treated at an institution that cares for five or more such patients during an approximate 4-year period than if treated at an institution that sees fewer than five

Often overshadowed by more common genitourinary cancers, such as prostate, testicular, and kidney cancers, penile and urethral cancers nonetheless represent difficult treatment challenges for the clinician. The management

WASHINGTON-“The possibility of spontaneous regression suggests that immunotherapy is a valid route to pursue in kidney cancer research,” said Ronald M. Bukowski, MD, director of the experimental therapeutics program at the Cleveland Clinic Cancer Center.

BETHESDA, Md-The National Institutes of Health has unveiled a 5-year plan that, if fully funded, will nearly quadruple its total budget for prostate cancer research, from the $113.6 million spent in fiscal year 1998 to $420.1 million in FY 2003. NIH anticipates spending $180.3 million on researching the disease this fiscal year, the first year of the 5-year program, an increase of 58.7% over FY 1998.

WASHINGTON-“Enough evidence has accumulated to suggest that interleukin-12 [IL-12] deserves continued study in kidney cancer and other malignancies, even though it has had a difficult track record so far,” Janice P. Dutcher, MD, said at the 1999 Kidney Cancer Association Annual Convention. Dr. Dutcher is associate director for clinical affairs, Our Lady of Mercy Cancer Center/New York Medical College.