Genitourinary Cancers

In a lively session at the 32nd Annual Meeting of the American Society of Clinical Oncology (ASCO), Jerome P. Ritchie, MD, Brigham and Women's Hospital, Boston, and Steven H. Woolf, MD, MPH, Medical College of Virginia,

After increasing sharply from 1989 through 1992, US prostate cancer incidence rates dropped by 16% for white men and nearly stabilized for African-American men (2% increase) in the latest period available for analysis, 1992 to 1993. These findings, based on the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) cancer registry information and US Census population estimates, are reported in the November 20th issue of the Journal of the National Cancer Institute.

ROCKVILLE, Md--The FDA has approved a new indication for Novan-trone (mitoxantrone), making it the first chemotherapy agent approved for the treatment of advanced hormone-refractory prostate cancer. Novantrone in combination with corticosteroids has been shown to reduce bone pain and stabilize or reduce reliance on analgesics in these patients without adversely affecting quality of life.

LOS ANGELES--"Prostate cancer is a disease of options," Douglas Keyser, MD, said at the American Society for Therapeutic Radiology and Oncology (ASTRO) meeting. And individual treatment decisions are difficult to make because of the lack of randomized studies and head-to-head comparisons between radiation therapy and surgery.

Superficial bladder cancer can be a frustrating disease for both the patient and physician. It has been referred to as a "nuisance disease" because of its propensity for recurrence, necessitating frequent cystoscopies and trips to the operating room for resection of recurrent disease. In addition, however, there looms for the patient and physician the 10% to 15% probability of disease progression, often requiring cystectomy to achieve local control and placing the patient at much greater risk for disease mortality. The challenge is to predict which patients will benefit from adjuvant therapy in order to avoid disease progression and, secondarily, disease recurrence.

Dr. Grossman's article provides a well-organized review of the literature on the treatment of superficial bladder cancer. At the time of diagnosis, approximately 80% of patients with bladder cancer have superficial tumors (limited to the urothelial lining of the bladder or the underlying lamina propria). In such patients, the risk of distant disease is low, and the natural history of bladder cancer is based on two separate, but related processes: tumor recurrence and progression to a higher stage of disease.

NEW YORK--Baseball-Hall-of-Famer Bob Watson remembered feeling "on top of the world" in October, 1993, after being named the first African-American general manager of a major league ball club (the Houston Astros), but the very next year, at the age of 47, he was feeling "angry and afraid" after learning he had prostate cancer.

NEW YORK--Michael Korda, best-selling author and editor-in-chief and vice president of Simon and Schuster, had never heard of PSA until a routine test showed that his was elevated; he had never thought about prostate cancer as something that could happen to him. After all, he was asymptomatic, a "fanatic exerciser," had given up smoking 20 years ago, and ate carefully.

GAITHERSBURG, Md--Members of the FDA's Oncology Drug Advisory Committee (ODAC) agreed that Immu-nex Corp.'s Novantrone (mitoxan-trone)--in combination with corticosteroids--offers a clinical benefit to patients with hormone-resistant prostate cancer.

NEW YORK--Pharmaceutical companies are currently investigating 25 new treatments for prostate cancer, including a potential vaccine, Alan Holmer, president of the Pharmaceutical Research and Manufacturers of America, said at a media briefing conducted by the American Cancer Society and the New York City-based Cancer Research Institute.

GAITHERSBURG, Md--Faced with significant differences between FDA staff and company-associated scientists in the analysis of data from two clinical studies, the FDA's Oncology Drugs Advisory Committee (ODAC) declined to vote either way on whether to recommend approval of Pharmacia & Upjohn's Remisar (bropirimine tablets) for the treatment of patients with BCG-refractory or BCG-intolerant urinary bladder carcinoma in situ (CIS).

NEW YORK--Marion Morra, associate director of the Yale Cancer Center, has collaborated with her sister Eve Potts, a medical writer for more than 30 years, to produce The Prostate Cancer Answer Book: An Unbiased Treatment Guide, published in September by Avon Books to coincide with Prostate Cancer Awareness Month.

Physicians screening African-American men for prostate cancer should use different cut-off points for a popular blood test because they will accurately detect 95% of cases in this high-risk group, according to a study published in the August 1 issue of The New England Journal of Medicine. The revised normal values for the prostate-specific antigen (PSA) test are based on a new diagnostic strategy and age-specific ranges for African-Americans, who have the world's highest prostate cancer rate.

BETHESDA, Md--Physicians have long hypothesized that natural variation in sex hormones may influence prostate cancer risk, said Meir Stampfer, MD, of the Harvard School of Public Health. Efforts to prove this, however, have yielded unclear results. Now, by examining the interrelationship of different sex hormones, Dr. Stampfer and his colleagues have achieved what he calls the first clear demonstration that circulating levels of sex hormones can predict a man's risk of developing prostate cancer.

Thomas Jefferson University in Philadelphia has received a patent for a molecular-based blood test that provides a novel approach to diagnosing prostate cancer. Jefferson has given exclusive licensing rights to the test to UroCor, Inc., for the United States and Canada, and to the Italian-based biotechnology firm Raggio-Italgene, for Europe and Japan.

The paper by Drs. Moul and Heidenreich provides a very nice review of prognostic factors for metastasis in patients with clinical stage I nonseminoma. Risk-adapted management--ie, the management of patients at low risk for metastasis by surveillance and patients at high risk for metastasis by retroperitoneal lymph node dissection (RPLND)--is very reasonable, and we are now at a point where a paradigm can be developed to accurately classify clinical stage I patients as either low or high risk and manage them accordingly.

The treatment of advanced prostate cancer continues to be an enigma. Every few years, it seems, a new variation in treatment is espoused and offered to the public. To date, two trends seem to have emerged: For men under 70 years of age, there seems to be a consensus that definitive treatment should be pursued for low-grade, low-stage, localized tumors. Prostatectomy or radiation therapy may cure or at least increase survival; for men over age 70, less vigorous treatment is often the preferred choice [1,2]. Nevertheless, outside of these two points of agreement, many other controversial questions remain and will persist for some time.

Over the last 10 years, we have learned more about not only the natural history of untreated locally advanced prostate cancer but also the ways in which we can effectively modify radiation therapy to treat this disease. There are now sufficient data to suggest that patients with prostate cancer that is considered locally advanced (stages T2b to T4) have a propensity for the development of lymph node metastasis and occult distant spread. In these patients, there also is a recognized difficulty in controlling the disease locally with radiation, due to the bulk of tumor present and the surrounding dose-limiting, late-reacting normal tissues.

Prognostic Factors in Low-Stage Nonseminomatous Testicular Cancer

The staging and treatment of prostate cancer are complex, particularly in patients with clinical disease that has advanced locally beyond the confines of the gland. Management choices are made more difficult by a paucity of

BETHESDA, Md--Physicians who screen for prostate cancer using prostate-specific antigen (PSA) need to use a different set of normal age-adjusted values for their African-American patients, say Judd W. Moul, MD, LTC, MC, USA, and colleagues from the Walter Reed Army Medical Center, Mayo Clinic, and Uniformed Services University of the Health Sciences funded by the Department of Defense (DOD) Center for Prostate Disease Research.

Whether patients with clinical stage I nonseminomatous testicular germ-cell cancer (NSGCT) should be treated with orchiectomy and retroperitoneal lymph node dissection (RPLND) or orchiectomy and surveillance remains

PHILADELPHIA--Although the addition of chemotherapy to supportive care with a corticosteroid provides no survival advantage for patients with hormone-refractory prostate cancer, the combination appears to achieve better pain control, compared with corticosteroid therapy alone.

ORLANDO--Treatment of recurrent prostate cancer, whether by prostatectomy or chemotherapy, has not yielded very effective or long lasting results. Many patients now ask about cryotherapy, in the hopes of better effectiveness and/or improved quality of life (less incontinence and less chance of impotence). However, urologists have been reluctant to use salvage cryosurgery for prostate cancer patients after radiation or hormonal therapy, because the outcome and quality of life data were simply not there, Louis L. Pisters, MD, said at the American Urological Association meeting earlier this year.

Pretreatment prostate-specific antigen (PSA) level is the single most important prognostic factor for patients undergoing radiotherapy for clinically localized prostate cancer. When combined with Gleason score and T-stage, pretreatment PSA enhances our ability to accurately predict pathologic stage. Patients with pretreatment PSA levels more than 10 ng/mL are at high risk for biochemical failure when treated with conventional radiation alone. A PSA nadir of more than 1 ng/mL and a post-treatment PSA more than 1.5 ng/mL are associated with a high risk of biochemical failure. Postoperative radiotherapy delivered while the tumor burden is low (eg, PSA less than 1 ng/mL) predicts a favorable outcome. Many of these conclusions about the usefulness of pretreatment PSA are based on the assumption that PSA can be used as a surrogate end point for disease-free and overall survival from prostate cancer. However, this assumption still remains to be validated by phase III trials. [ONCOLOGY 10(8):1143-1153, 1996]

Radical radiation therapy and radical prostatectomy are the two most commonly employed therapeutic alternatives for clinically localized (T1-T2,NX,M0) prostate cancer. A vigorous debate is ongoing about the relative efficacy of each modality. This debate centers around the percentage of patients who cannot be cured by one method or the other, suggesting that some patients may be better served by one treatment, or by some form of combined-modality therapy employing radiation after surgery or neoadjuvant androgen suppression before radiation.

ASCO--In an EORTC study, the combination of radiotherapy and adjuvant hormonal therapy with an LHRH analog has been shown to significantly increase survival in patients with locally advanced prostate cancer, compared with radiotherapy alone.

ASCO--Many men diagnosed with prostate cancer will not die of their disease if left untreated, but clinicians have no way of telling which early cancers require more aggressive treatment and which are likely to be indolent. A new genetic test, developed by researchers at Dana-Farber Cancer Institute, may shed some light on this important dilemma.

FORT LAUDERDALE, Fla--The duration of anticipated survival after a prostate cancer diagnosis, and therefore the period of time at risk in the disease, is unique to prostate cancer in the influence it exerts on selection of therapy.

Researchers at two major medical centers have found that radiation therapy is just as successful as surgery in treating younger men with early-stage prostate cancer. Currently, men 60 years old or under with prostate cancer are far more likely to be treated with surgery than with radiation therapy.