Seminars in urologic oncology最新文献

This case report follows the course of a highly aggressive bladder cancer that presented with carcinoma in situ and illustrates the rapid rate of progression from superficial to invasive disease that may be observed in some individuals. This case also highlights concerns about alternative management options and the dilemmas that arise when cystectomy is delayed by failed conservative strategies attempting to preserve the native bladder. This discussion focuses on the combination of radical transurethral resection (TUR) and systemic chemotherapy as a therapeutic alternative to cystectomy. The concept, technique, indications, and contraindications of radical TUR, and the rationale for combination systemic chemotherapy are discussed with reference to this case. We consider the value of radical TUR and systemic chemotherapy as an alternative to cystectomy and the reasons why this patient would not have been a suitable candidate for this bladder-sparing approach.

The transformation of normal urothelium into histologically different neoplastic states has been well characterized, and current clinical management of both superficial and invasive bladder cancer has benefited from recent scientific discoveries. The ability to define novel treatment strategies including surgical, chemotherapeutic, and gene therapies relies on our understanding of the basic mechanisms underlying human bladder carcinogenesis. Many in vitro culture systems and in vivo animal models have been developed over recent years, which have been used to define key molecular events that are associated with the development of bladder cancer. The biological pathways through which normal urothelium may progress to superficial or invasive disease will be discussed in the framework of recent advances in the field.

Bladder-preserving modalities for patients with invasive bladder cancer have become increasingly popular in recent years. Surgical-only approaches, such as transurethral resection (TUR) or partial cystectomy, are unique among a variety of bladder-preserving modalities, most of which involve combination with radiation and chemotherapy. TUR and partial cystectomy remain incompletely evaluated due to relatively small series in the literature and the lack of standardized selection criteria. The outcome as measured by long-term bladder preservation and overall survival is not dissimilar to concurrent radical cystectomy series, possibly because of positive selection of patients.

Recurrent bladder cancer is due to tumor cell implantation, incomplete resection, and multicentric neoplastic changes throughout the bladder. The possibilities of 5-Aminolevulinic acid-induced fluorescence endoscopy (AFE), a highly sensitive method in detecting bladder cancer and laser energy as treatment to lower the recurrence rate in bladder cancer, are evaluated. After intravesical administration of AFE Protoporphyrin IX, a tumor-selective manner is excited by a xenon-arc lamp (wavelength 400 to 410 nm) to emit red fluorescence. Suspicious lesions can be detected by their red fluorescence and are electroresected or treated with laser energy. Complete resection or destruction of all tumors in the bladder is crucial to prevent recurrent and invasive growth of transitional cell carcinoma. AFE detects malignant lesions in the bladder with a sensitivity of 98% and Cis in 100%, respectively. Laser treatment of superficial bladder cancer lowers the local recurrence rate and reduces the risk of viable tumor cell implantation.

Low-grade carcinomas (pTaG1) comprise 50% of all stage pTa-pT1 carcinomas and have an almost benign course of disease. Follow-up policies may be changed so that patients with a single tumor at diagnosis and a negative cystoscopy at 3 months should be examined 9 months later. Check cystoscopies may be performed with flexible instruments and a considerable number of the recurrences could be managed with fulguration under urethral anesthesia only. Because low-grade carcinomas are so common, the seriousness of the other tumors in stages pTa-pT1 is not fully appreciated. Patients with high-grade carcinoma (pTaG2-G3, pT1G2-G3) have at least a 70% risk for recurrence and a 20% risk for stage progression. The course of disease is more unpredictable than for patients with low-grade carcinoma, and there are at present no firm data that support a change in follow-up routines. Routine follow-up urographies are not necessary.

Prostate Cancer Shared Decision, a CD-ROM program produced with the guidance of leading prostate cancer specialists, educates prostate cancer patients and suggests possible treatments. As the first portable, interactive prostate cancer decision-making tool, Prostate Cancer Shared Decision offers expert, plain-language explanations of prostate anatomy, cancer diagnosis, and treatment options. Through answers to lifestyle and attitude questions entered into a series of user-friendly questionnaire screens, Prostate Cancer Shared Decision helps patients understand their disease and feel comfortable with their treatment decision. This type of educational tool is representative of the new technology that is becoming available to patients with prostate cancer.

The optimum management for an individual patient with prostate cancer is not well defined. Patients with localized disease may be offered options ranging from observation, hormonal therapy, cryotherapy, radiation therapy, or surgery. Each option may have unique aspects to consider when counseling a patient often leading to multiple physician visits over an extended period of time. Since 1996, the Kimmel Cancer Center of Thomas Jefferson University has offered newly diagnosed urologic cancer patients the opportunity to be evaluated in a multidisciplinary clinic. Here, multiple physician consultative visits, including pathologic and radiologic evaluation and protocol evaluation, are provided during the session. Herein we report on our experience with this multidisciplinary approach for patients with prostate cancer.

This article describes my personal experience in dealing with the issue of decision-making for prostate cancer, and how I used available information on the disease to go about making my decision to have combined hormone therapy, external beam radiation, and brachytherapy. Many resources are available to patients today thanks to advances in technology. The guidance and information provided by my physicians was an essential element in my treatment decision, but I stress that the final decision was mine.

The increasing public awareness of prostate cancer coincides with a growing desire for patients to be better informed about their disease and treatment options. As technology advances, access to information about prostate cancer also expands. Publications, videos, interactive CD-ROMs, support groups, and the Internet are redefining how patients and their physicians interact to make decisions. As an example of the impact of technology on the practice of medicine, it is estimated that there are more than 70,000 health care-related Web sites. Although on the surface access to this information appears to be a benefit, it can often lead to more confusion and anxiety because much of the information can be conflicting. This is more likely to occur in a disease such as prostate cancer where there is no consensus of opinion concerning the management of localized disease. This article reviews the expanding array of technologies and resources, including the Internet, available to patients with newly diagnosed prostate cancer. With this vast amount of information readily available to the patient, the role of the physician in the interpretation of the data as it relates to the individual patient remains an essential part of health care in the information age.

Patients are expected to assume increased responsibility for self-management in health care. However, little attention has been directed to the problem of preparing individuals to play a more active role in the physician-patient relationship. Preparatory education about prostate cancer early detection and treatment is needed to enable patients to recognize the importance of their role in medical decision-making, voice personal values and preferences related to health care choices, and make informed choices under conditions of uncertainty about possible outcomes. Effective decision aids are needed to facilitate shared decision-making in the context of the physician-patient relationship along the continuum of prostate cancer care. Decision aids for patients have taken the form of informational booklets, scripted telephone counseling, decision boards, educational videotapes, interactive videodiscs, computer programs, and Internet Web sites. The impact of preparatory education and the use of decision aids should be evaluated in terms of change in knowledge and understanding, shifts in decision preferences, health care utilization, and satisfaction with care. The need for this type of patient interaction will grow as technology increases patient access to health care information.