Urologists and medical oncologists have witnessed a rapid growth in systemic therapeutic options for treating genitourinary malignancies that increasingly integrates radiation therapy to primary cancers, nodal beds, and even metastatic sites. The culmination of these advances has been the creation of multidisciplinary teams that expertly provide comprehensive care to patients with urologic cancers. This book provides the framework to create such a multidisciplinary clinical team focused on the treatment of urologic malignancies with representation from urologists, medical oncologists, and additional specialists who work together to provide optimal team-based care. The book integrates advanced systemic therapeutics including immune-based and targeted therapies. Readers gain a better understanding of the benefit of multidisciplinary co-management through specific examples such as hormone sensitive metastatic prostate cancer, neoadjuvant chemotherapy for muscle invasive bladder cancer, and immunotherapy approaches to advanced bladder and kidney cancer. The book also discusses the integration of genomic tumor characterization and personalized medicine into surgical planning, tumor biopsies, and chemo-immunotherapy selection, emphasizing the expansion of new therapeutics for urologic malignancies and the changing definitions of disease progression.
Urologic Oncology: Multidisciplinary Care for Patients is a comprehensive resource for urologists, medical oncologists, radiation oncologists, genetic counselors, fellows in urologic oncology and medical oncology, residents in urology and radiation oncology, advanced practice providers, practice managers, and pharmaceutical representatives.
Author(s): Kelly L. Stratton, Alicia K. Morgans
Publisher: Springer
Year: 2022
Language: English
Pages: 501
City: Cham
Contents
Contributors
Chapter 1: Creating a Multidisciplinary Clinic
Introduction
Historical Perspective
The Multidisciplinary Clinic at Sidney Kimmel Cancer Center Thomas Jefferson University
Impact of Multidisciplinary Care
Establishing a Multidisciplinary Clinic
Conclusion
References
Chapter 2: Supportive and Palliative Care for Genitourinary Malignancies
Prostate Cancer: Identity
Vasomotor Symptoms
Sexual Health and Intimacy
Kidney Cancer: Variability
Unique Treatment Toxicity and Adherence
Adherence and Persistence with Oral Agents
Decisional Conflict Regarding Cytoreductive Nephrectomy
Prognostic Uncertainty
Bladder Cancer: Vulnerability
Dilemmas in Choice of Urinary Diversion
Ostomy Care and Management
Neobladder Care and Management
Frailty
Overlapping Supportive Care
Comprehensive Pain Management
Antiresorptive Therapy for Palliation of Bone Pain
Mood Disorders
Nausea and Vomiting
Chronic Lower Urinary Tract Symptoms
Hematuria
Palliative Care
References
Chapter 3: Operationalizing Genetic Testing in the Care of Patients with Prostate Cancer
Introduction
Germline Genetic Testing
Prostate Cancer Genetics
Genetic Testing Models
Identifying Patients Appropriate for Genetic Counseling and Testing
Pre-test Education and Informed Consent
Test Selection
Results Delivery
Somatic Testing
Cascade Testing
Identifying and Overcoming Barriers
Cementing the Genetic and GU Clinical Team Partnership
Patient Disparities
Key Takeaway
References
Chapter 4: High-Risk Localized Prostate Cancer
Defining High-Risk Prostate Cancer
Treatment
Observation
Radiation and ADT
Duration of ADT
Combination Radiotherapy
Surgery for High-Risk Prostate Cancer
Salvage Therapies for High-Risk Disease
Treatment of Adverse Pathological Findings Versus Treatment for Failure
Treatment of Node-Positive Disease
Surgery After Failure of Radiation Therapy
Future Directions
Radiation and Novel Hormone Therapies
Conclusion
References
Chapter 5: Treatment of Metastatic Hormone-Sensitive Prostate Cancer
Introduction
Agents Demonstrating Overall Survival Improvement in mHSPC
Docetaxel
Abiraterone Acetate
Novel Anti-Androgens
Apalutamide
Enzalutamide
Agents with No Proven Benefit in mHSPC
Bisphosphonates
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Comparative Efficacy and Sequencing of Agents in mHSPC
Localized Therapies: Surgery, Radiation to the Primary Tumor, and Metastasis-Directed Therapies in Oligometastatic HSPC
Emerging Therapies
Conclusions
Summary of Key Points
References
Chapter 6: Expanding Options for M0 Castration-Resistant Prostate Cancer (CRPC)
Introduction
Metastasis-Free Survival (MFS) and Advanced Prostate Cancer Research
Therapeutic Options in M0 CRPC
Enzalutamide
Apalutamide
Darolutamide
Agents Under Investigation
M0 CRPC and Meta-data
Adverse Events and Side Effects in M0 CRPC Treatment
Managing M0 CRPC in Clinical Practice
References
Chapter 7: Immunotherapy for Metastatic Prostate Cancer
Introduction
Approved Immunotherapies for Prostate Cancer
Sipuleucel-T
Immunotherapy Based on Biomarkers in Prostate Cancer
Evaluations of Immunotherapy in Unselected Patients
Ipilimumab
Pembrolizumab
Investigating Combinations of Immunotherapy in Prostate Cancer
Ipilimumab and Nivolumab
Enzalutamide and PD-1/PD-L1 Inhibitors
Cabozantinib and Atezolizumab
Olaparib and Durvalumab
Future Directions
Conclusion
References
Chapter 8: Advances in Prostate Cancer Imaging
Introduction
PET Imaging Techniques for Prostate Cancer
F-18 Sodium Fluoride PET/CT or PET/MRI Bone Scan (F-18 NaF PET Bone Scan)
F-18 Fluorodeoxyglucose (FDG) PET
C-11 Choline or F-18-Choline PET
F-18 Fluciclovine
Ga-68 or F-18 Prostate-Specific Membrane Antigen (PSMA)
F-18 Fluorodehydrotestosterone PET (F-18 FDHT PET)
Localized Disease/Initial Staging
Magnetic Resonance Imaging (MRI)
PET Imaging Probes
Biochemical Recurrent (BCR) Prostate Cancer
C-11 Choline or F-18 Choline PET
F-18 Fluciclovine
Ga-68 or F-18 Prostate-Specific Membrane Antigen (PSMA)
Metastatic Prostate Cancer
Treatment Response
Biologic Characterization
Theranostics
References
Chapter 9: Bone Health Management
Introduction
Physiology of Bone Remodeling
Evaluation of Bone Mineral Density
Pathophysiology of Bone Metastasis in Prostate Cancer
Treatment-Related Bone Loss
Consequences of Glucocorticoids
Consequences of Androgen Deprivation Therapy
Consequences on Bone Metabolism
Management of Bone Health and Bone Metastases (Tables 9.3 and 9.4; Fig. 9.1)
Bone-Targeted Agents: Bisphosphonates and Denosumab (Table 9.5)
Prevention and Treatment of Osteoporosis and Fragility Fractures
Prevention of Skeletal-Related Events
Safety of Bone-Targeted Agents
Other Therapies and Combinations
Radium-223 Dichloride
Conclusion
References
Chapter 10: Radiotherapy for Advanced Prostate Cancer
Introduction
Palliative Radiotherapy for Advanced Prostate Cancer
External Beam Radiotherapy
Radionuclides
Radiotherapy with Oncologic Intent for Advanced Prostate Cancer
Treatment of the Primary
Treatment of Metastatic Lesions
Radionuclide Therapy
Future Indications of Radiotherapy for Advanced Prostate Cancer
Conclusion
References
Chapter 11: Optimizing Perioperative Treatment for Kidney Cancer
Introduction
Complications After Surgery for Localized/Advanced Renal Cell Carcinoma
Decision-Making: When to Operate
Preoperative Risk Stratification
Assessment of Comorbidity Burden
Functional Status
Frailty
Nutrition
Body Composition
Immune Profile/Inflammation
Prognostic Models to Convey Risk in Metastatic Disease
Laboratory Evaluations
Comprehensive Geriatric Assessment
Medical/Other Consultation
Perioperative Optimization
Counseling/Expectation Setting
Preoperative Nutritional Optimization
Preoperative Exercise Recommendations
Smoking Cessation
Systemic Therapy Hold Parameters
Pre-surgical Planning
Intraoperative Considerations
Postoperative Optimization
Immediate Postoperative Period
Follow-Up and Cancer Survivorship
Summary
References
Chapter 12: Surgical Treatment for Metastatic Kidney Cancer
Introduction
Cytoreductive Nephrectomy: Historical Perspectives
Cytoreductive Nephrectomy in the Era of Targeted Therapy
Risk Stratification of Patients Planned to Undergo Cytoreductive Nephrectomy
The Timing of Cytoreductive Nephrectomy
Cytoreductive Nephrectomy in the Era of Checkpoint Inhibitors
The Role of CN According to Current Guidelines
Metastasectomy for Renal Cell Carcinoma
Predicting Outcomes After Metastasectomy
Systemic Therapy After Metastasectomy
The Role of Metastasectomy According to Current Guidelines
Conclusions
References
Chapter 13: Targeted Therapy for Renal Cell Carcinoma
Introduction
Pathophysiology
Metastatic Renal Cell Carcinoma
Frontline Therapy: Combination Therapy
Frontline Therapy: Single-Agent Therapy
Second-Line Agents: Post-IO Therapy
Second-Line Agents: Post-TKI Therapy.
Future Trials
Localized Renal Cell Carcinoma
Adjuvant Therapy
Neoadjuvant Therapy
Future Trials
Novel Agents
Summary
References
Chapter 14: Hereditary Cancer and Genetics in Renal Cell Carcinoma
Introduction
Germline Genetic Testing in Kidney Cancer Patients
Surgical Management of Patients with Localized Hereditary Renal Tumors
Implications of Germline Genetics in Management of Metastatic RCC
Hereditary Renal Cell Carcinoma Syndromes
Von Hippel-Lindau Syndrome (OMIM 193300)
Hereditary Leiomyomatosis and RCC Syndrome (OMIM 150800)
Birt-Hogg-Dube Syndrome (OMIM 135150)
Hereditary Papillary RCC (OMIM 164860)
BAP1 Tumor Predisposition Syndrome (OMIM 614327)
Hereditary Paraganglioma-Pheochromocytoma Syndromes (OMIM 185470)
Other Hereditary Syndromes with Increased Risk of Renal Cancer
Conclusions
References
Chapter 15: Immunotherapy
Immunotherapy in Patients with Metastatic RCC
Immunotherapy in the Adjuvant Setting in Patients with Local/Locally Advanced RCC
Ongoing Clinical Trials in Metastatic RCC
Biomarkers for Immunotherapy in Metastatic Renal Cell Carcinoma
Conclusions and Multimodality Care in Renal Cell Carcinoma in the Immunotherapy Era
References
Chapter 16: Evolving Treatment in Non-muscle-Invasive Bladder Cancer
Introduction
Tumor Biology, Genetics, and Risk Stratification
Tumor Biology and Genetics
Risk Stratification
Endoscopic/Cystoscopic Treatment and Management
Transurethral Resection of Bladder Tumor (TURBT)
Surveillance
Intravesical BCG
Bacillus Calmette-Guerin (BCG)
Mechanism of Action
Induction and Maintenance Regimens
Risks/Adverse Reactions
BCG Failure
Intravesical Chemotherapy
Chemotherapy Post-TURBT
Adjuvant Intravesical Chemotherapy
Low-Risk NMIBC
Intermediate-Risk NMIBC
Mitomycin C (MMC)
Mechanism of Action
Optimizing Response to MMC
Maintenance MMC
Epirubicin
Mechanism of Action and Side Effects
Epirubicin Versus Other Agents
High-Risk NMIBC and BCG Failure
Gemcitabine
Mechanism of Action, Comparison to Other Agents, and Side Effects
Docetaxel
Mechanism of Action and Usage
Combination Therapy
Non-BCG Immunotherapy
Programmed Cell Death Protein (PD1) and PD1 Ligand (PDL1) Inhibitors
Pembrolizumab
Risk/Adverse Effects
Atezolizumab
Risks/Adverse Effects
Emerging Therapies
Nadofaragene Firadenovec (rAD-IFN/Syn-3)
ALT-801 and ALT-803
Vicinium (VB4–845)
VPM1002BC
Enhanced Chemotherapy
Chemohyperthermia (CHT)
Electromotive Drug Administration (EMDA)
Photodynamic Therapy
Role for Radical Cystectomy
References
Chapter 17: Neoadjuvant and Adjuvant Therapy for Muscle-Invasive Bladder Cancer
Introduction
Neoadjuvant Chemotherapy (NACT)
Neoadjuvant Cisplatin-Based Chemotherapy Does Not Impact Feasibility of Curative Surgery
Selection of Patients Appropriate for Cisplatin-Based Chemotherapy
Non-MVAC Options for NACT
Gemcitabine Plus Cisplatin
Non-Cisplatin-Based NACT
Pathologic Response to NACT Is a Predictor of Patient Survival
Adjuvant Chemotherapy
Adjuvant Chemotherapy After NACT
Biomarkers of Response to Cisplatin-Based Chemotherapy
Risks of Clinical Understaging in MIBC
Immune Checkpoint Blockade as Neoadjuvant Therapy
Neoadjuvant Anti-programmed Death-1(PD-1)/Programmed Death Ligand-1 (PD-L1) Monotherapy
Combined Blockade of Cytotoxic T-Lymphocyte Antigen 4 (CTLA-4) and PD-1/PD-L1 in the Neoadjuvant Setting
Neoadjuvant Combinations of Immune Checkpoint Blockade with Targeted Agents
Addition of Neoadjuvant Immune Checkpoint Blockade to Chemotherapy
Phase 3 Trials of Neoadjuvant Immune Checkpoint Blockade
Immune Checkpoint Blockade in the Adjuvant Setting
Non-immunotherapy Investigational Treatments in the Perioperative Space
Conclusions
References
Chapter 18: Bladder-Sparing Approaches to Treatment of Muscle-Invasive Bladder Cancer
Background
Historical Approaches to MIBC
Radical Cystectomy
Postoperative Radiotherapy
Surgical Morbidity
Introduction to Bladder Preservation
Selection Criteria
Selective Bladder Preservation vs. Radical Cystectomy
Bladder Preservation Treatment Paradigms
Surgical Monotherapy
Transurethral Resection of Bladder Tumor
Partial Cystectomy
Radiotherapy Monotherapy
External Beam Radiotherapy
Brachytherapy
Combined Modality Treatment
Partial Cystectomy/TURBT and Chemotherapy
Trimodality Therapy
Treatment Overview
Outcomes and Literature Review
Evolving Considerations
Neoadjuvant Chemotherapy
Variations in Fractionation
Hypoxia Modification
Molecular Stratification
Immunotherapy
Response Evaluation
Post-Treatment Follow-Up
Management of Recurrent Disease
Locoregional Recurrence
Distant Recurrence
Node-Positive Disease
Quality of Life Considerations
Radiation Techniques
Simulation
Target Volume
Dose
Dose Constraints (Conventional Fractionation) [75, 123]
Fields
RTOG Approach
Summary of Treatment Recommendations
Conclusion
References
Chapter 19: Treatment of Metastatic Bladder Cancer
Introduction
First-Line Treatment for Metastatic Bladder Cancer
Treatment for Cisplatin-Eligible Patients
Treatment for Cisplatin-Ineligible Patients
Carboplatin-Based Chemotherapy
Immune Checkpoint Blockade
Maintenance Immune Checkpoint Blockade
Treatment in the Second-Line and Beyond Setting
Immune Checkpoint Blockade
Chemotherapy
FGFR Inhibitors
Enfortumab Vedotin
Future Perspective of Treatment
Combination Treatment with Immunotherapy
Molecular-Targeted Therapy and ADC
Treatment for Metastatic Non-urothelial Bladder Cancer
References
Chapter 20: Treatment of Upper Tract Urothelial Carcinoma
Background
Epidemiology
Risk Factors
Genetic Factors
Lynch Syndrome
Diagnosis
Enhanced Imaging Modalities
Staging
Prognosis
Pre-operative Factors
Surgical/Post-operative Factors
Molecular Markers
Management
Endoscopic Management
A Special Note on Ureteroscopy
Percutaneous Surgery
Segmental Ureteral Resection
Intracavitary Instillation
Adjuvant Therapy
Primary Ablative Therapy
MitoGel
Radical Surgery
Low-Grade Disease
High-Grade Disease
Pre-operative Considerations
Surgical Technique
Outcome Comparison for RNU Technique
Bladder Cuff Resection
Endoscopic
Open Technique
Laparoscopic Technique
Robotic Technique
Outcome Comparison
Post-operative Care
Lymph Node Dissection
Curative and Diagnostic Role
Template
Complications
Intravesical Therapy After Radical Nephroureterectomy
Systemic Chemotherapy
Neoadjuvant
Adjuvant
Surveillance
Metastatic UTUC
Primary Nephroureterectomy
Metastasectomy
Systemic Therapy
First-Line Therapy
Platinum-Based Chemotherapy
Checkpoint Inhibitors
Second-Line Therapy
Salvage or Third-Line Therapy
References
Index
