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The incidence of prostate cancer is rising worldwide due to the ageing of the population and the increasing availability of prostate-specific antigen (PSA) screening. Prostate-specific antigen testing has led specifically to an increase in the proportion of patients diagnosed with early-stage (localized) prostate cancer. Radical radiotherapy is one of the curative treatment options for localized prostate cancer and it also has a role to play in locally advanced and even metastatic disease. This chapter reviews the relative merits of radiotherapy in comparison to the other management options for early prostate cancer and summarizes the staggering technological advances that have occurred in prostate radiotherapy over the last decade.

Surgery for prostate cancer has evolved, with the main purpose of curing one of the most common male malignancies at an early stage in its natural history, and preventing the morbidity otherwise associated with unchecked disease progression to more advanced, incurable stages. The operation by which this may be achieved, radical prostatectomy, advanced considerably during the 20th century through developments in anatomical knowledge and surgical experience. It is now a routine surgical procedure in urological oncology carried out through a range of surgical approaches, each with its own advantages and disadvantages.

Prostate cancer is now the most prevalent of all male malignancies and the second most common cause of male cancer deaths. Death rates have trebled over the last 30 years, and changes in mortality during this period are shown in Table 3.1 [].

Prostate cancer is now most frequently diagnosed malignancy and the second leading cause of cancer-related death []. Death rates have increased over the past 20 years and mortality may approach that of lung cancer within 15 years [].For patients with advanced disease, the response rate to hormonal therapy is about 80%, but this is not durable, and all patients will eventually develop hormone-refractory prostate cancer (HRPC) []. Chemotherapy has been shown to have palliative benefit in symptomatic HRPC, but has not yet been demonstrated to prolong survival. Median life expectancy for patients with HRPC is only 12 to 18 months, underscoring the urgent need for new therapeutic approaches [].

Bladder cancer is the fourth most common cancer in men and the eighth most common cancer in women worldwide, and the incidence continues to rise. In the United Kingdom, 13,600 new cases per annum contribute 5% to the national cancer burden []. Over 100,000 diagnostic, check, and interventional cystoscopies each year are performed in surveillance protocols in attempting to monitor for disease progression. In the United States, there were approximately 57,500 new cases and 12,500 deaths in 2003, resulting in an annual expenditure ($2.2 billion/year) almost twice that for prostate cancer []. These figures reflect the lifelong commitment to surveillance and intervention for recurrent and progressive disease. The difficulties involved in this complex process were emphasized in McFarlane et al.’s [] seminar in 1996, where considerable divergence of opinion was noted among clinicians presented with a variety of clinical scenarios. This chapter provides an overview of the current rationale behind the therapeutic options available for superficial bladder cancer treatment. In this way, it is hoped to empower clinicians with a broad sweep of the evidence on which therapy is based.

Transitional cell carcinoma (TCC) of the urinary bladder is the second most common genitourinary malignancy. Each year, over 73,000 new cases are reported in Europe and over 56,000 new cases in the United States. A substantial percentage of these patients develop metastases despite initial management for presumed localized disease, whereas others have metastases at the time of presentation. Once metastasis occurs, the median survival for patients with TCC is approximately 1 year. To improve this poor survival rate, intense efforts over the past two decades have focused on the development of active chemotherapeutic regimens for use in this disease, both in the perioperative setting and in the setting of advanced disease. Chemotherapy for advanced disease is discussed here first because of its impact on the management of early-stage disease.

Renal cell carcinoma is an important malignancy accounting for approximately 3% of all adult cancers []. The incidence of renal cell carcinoma has been steadily and significantly increasing over the past two decades, with worldwide mortality expected to exceed 100,000 []. A significant proportion of patients with localized disease can be cured by nephrectomy; however, at presentation approximately 50% of patients have locally advanced or metastatic disease []. The outlook for these patients remains poor, with a 5-year survival of less than 10% [].

The discovery of diverse details of the genetics, cell biology, and pathology of disease and the extensive infrastructure for synthesis and testing of targeted drugs or immune strategies are a basis to be hopeful that innovative, effective, widely applicable therapies can be realized for metastatic kidney cancer. High-dose interleukin-2 had been the sole medical therapy approved by the U.S. Food and Drug Administration (FDA) for the treatment of metastatic renal cancer, and interferon-a, also in widespread use, has had approval in Europe. More than 100 published single-arm/single-drug kidney cancer trials, many based on sound preclinical hypotheses, would seem to be a basis for pessimism. Partial response and disease stabilization at high frequency led to the approval of sorafenib and sunitinib. Whereas progress in conventional cytotoxics has largely bypassed renal cancer, and immune therapies have had dramatic success limited to a minority of patients, some therapies may turn out to be broadly tolerated and efficacious. This is an era for optimism for the application of new technology to kidney cancer therapy.

The last 30 years have seen extraordinary advances in the management of metastatic germ cell cancer of the testis. Prior to the advent of cisplatin-containing chemotherapy in the mid-1970s, chemotherapy was highly toxic, and gave poor results, with cure unusual in those with advanced disease. Following the introduction of cisplatin, and subsequently etoposide, progress has been rapid, not least in the development of ancillary drugs (e.g., 5- hydroxytryptamine [5-HT] antagonists and growth factors). Modern therapy is now usually curative, tolerable, and has few long-term side effects. Indeed, the current dearth of randomized trials for most subgroups of these patients is largely a testimony to the advances taking place during this period.

Testicular germ cell tumors are highly curable, even when metastatic at presentation. Although this is largely because of their sensitivity to platinum-based chemotherapy, well-timed surgical intervention is also crucial in achieving a high cure rate. The diagnosis is usually established by inguinal orchidectomy, and orchidectomy alone represents adequate treatment for many patients. Operative removal of metastatic disease, usually after chemotherapy, is also highly effective and may be curative. Thus the importance of surgical treatment for testicular cancer should not be underestimated.