Ten Best Readings

Ten Best Readings On Genitourinary Cancer

Julio M. Pow-Sang, MD
H. Lee Moffitt Cancer Center & Research Institute

The ten best recent articles in the medical literature relating to genitourinary cancer are reviewed here.

Potosky AL, Miller BA, Albertsen PC, et al. The role of increasing detection in the rising incidence of prostate cancer. JAMA. 1995;273:548-552.

The authors analyze a population-based study of incidence rates and procedures used from 1986 to 1991 to detect and diagnose prostate cancer. They voice their concerns regarding the widespread use of screening intervention programs that may detect latent, asymptomatic cancers with the consequent implications in costs and quality of life for men aged 65 years and older.

von Eschenbach AC. The biologic dilemma of early carcinoma of the prostate. Cancer. 1996;78:326-329.

A conceptual framework is presented to evaluate prostate cancer behavior along three different pathways. The author describes an indolent cancer (Type 1), a slowly progressive cancer (Type 2), and a virulent and systemic cancer (Type 3). Research efforts should be directed toward identification of genetic, molecular, and biologic methods that could predict which cancers would not require treatment, which would benefit from local curative interventions, and which would require systemic therapies.

Garnick MB, Fair WR. Prostate cancer: emerging concepts. Part I. Ann Intern Med. 1996;125:118-125.

The authors discuss advances in prostatic-specific antigen interpretation including prostate-specific density, velocity, and age-specific reference ranges. They also describe the emerging concept of "free" and "bound" PSA ratios and the use of PSA in determining the pathologic extent of prostate cancer.

Middleton RG, Thompson IM, Austenfeld MS, et al. Prostate Cancer Clinical Guidelines Panel Summary report on the management of clinically localized prostate cancer: the American Urological Association. J Urol. 1995;154:2144-2148.

The panel reviewed all articles in the MEDLINE data base from 1966 to 1993 on treatments for stage T2b prostate cancer. Outcomes for radical prostatectomy, radiation therapy, and observation were inadequate for valid comparisons of treatments. The panel recommends that treatment alternatives be presented to patients as options.

Lundholm C, Norlen BJ, Ekman P, et al. A randomized prospective study comparing long-term intravesical instillations of mitomycin C and bacillus Calmette-Guerin in patients with superficial bladder carcinoma. J Urol. 1996;156;372-376.

This randomized Norwegian study compares mitomycin C with bacillus Calmette-Guerin (BCG) bladder instillation in patients with superficial bladder cancer at high risk for recurrence and progression. The investigators found an advantage for BCG over mitomycin C in recurrence but no difference in progression. An accompanying editorial (page 389) further reviews BCG.

Underwood MA, Reeves J, Smith G, et al. Overexpression of p53 protein and its significance for recurrent progressive bladder tumours. Br J Urol. 1996;77:659-666.

This study shows no additive predictive prognostic value for p53 over staging and grade. The authors discuss issues regarding overexpression of p53 and problems with interpreting immunohistochemistry samples.

Logothetis C, Swanson D, Amato R, et al. Optimal delivery of perioperative chemotherapy: preliminary results of a randomized, prospective, comparative trial of preoperative and postoperative chemotherapy for invasive bladder carcinoma. J Urol. 1996;155:1241-1245.

This randomized trial from M.D. Anderson Cancer Center compares preoperative vs postoperative chemotherapy for bladder cancer. No survival advantage was found between neoadjuvant vs adjuvant M-VAC, but preoperative chemotherapy may increase the resectability of localized bladder cancer and contribute to organ preservation.

Roth BJ, Dreicer R, Einhorn LH, et al. Significant activity of paclitaxel in advanced transitional-cell carcinoma of the urothelium: a phase II trial of the Eastern Cooperative Oncology Group. J Clin Oncol. 1994;12:2264-2270.

This phase II trial demonstrates that paclitaxel is effective in locally advanced or metastatic transitional-cell carcinoma of the urothelium with a complete response rate of 27%. This trial is the basis for the recently activated ECOG protocol E2895, "Phase II Study of Cisplatin Plus Paclitaxel in Advanced Carcinoma of the Urothelium," which may be the beginning of a new generation of combination chemotherapy agents for the treatment of advanced cancer of the urothelium.

Saxman SB, Nichols CR, Foster RS, et al. The management of patients with clinical stage I nonseminomatous testicular tumors and persistently elevated serologic markers. J Urol. 1996;155:587-589.

This retrospective study addresses patients with clinical stage I disease with persistently elevated serum human chorionic gonado-tropin (HCG) or alpha-fetoprotein (AFP) levels after orchiectomy and with negative imaging staging studies. The authors recommend systemic chemotherapy for patients with persistently elevated AFP levels and for those with markedly elevated serum HCG levels. For patients with a mild HCG elevation, they suggest testosterone and a repeat test, as some patients may have a false-positive elevation that can normalize after this intervention.

Steinbach F, Stockle M, Hohenfellner R. Clinical experience with nephron-sparing surgery in the presence of a normal contralateral kidney. Semin Urol Oncol. 1995;13:288-291.

Nephron-sparing surgery is a new concept in uro-oncologic surgery. The authors demonstrate the appropriateness of this ap-proach in selected patients with kidney cancer.

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