Clinical Perspectives

Moving Forward in Genitourinary Oncology

November 14, 2012


Julio Pow-Sang, MD

There are many challenges in the management of genitourinary malignancies. First and foremost is the diversity of cancers within a single specialty. These include common cancers such as prostate, bladder and kidney, as well as the rarer testis and penile cancers. Second is the need to coordinate care between specialists so our patients benefit from the best treatment possible offered by surgeons, radiation oncologists and medical oncologists who must work together to improve delivery of care. Third is the significant knowledge gaps in our understanding of the multiple pathways at the molecular level that lead to cancer progression. A better understanding of these pathways and how they interact will offer the opportunity to develop more accurate therapies, aiming to improve cancer outcomes while optimizing quality of life for our patients.

At Moffitt Cancer Center we are addressing these challenges through a systematic approach, both in the delivery of care and our research initiatives. Additionally, we aim to fulfill our educational mission to train the new generation of specialists and researchers in genitor-urinary malignancies.  

In the area of care, we are fortunate to have a team of specialists under one roof. This team includes surgeons, radiation oncologists and medical oncologists – each with a particular focus of expertise in each of these malignancies. This “specialist within the specialty” approach allows for more in-depth care of patients with particular genitourinary cancers. Our specialists work together as a team when evaluating patients and meet weekly to review cases with our dedicated uropathologists and diagnostic radiologists. This assures that we provide the most personalized, integrated and cutting-edge care possible.

Each specialist brings unique expertise to our patients. From the surgical end, all our surgeons are robotically trained and offer this approach to all urological cancers when minimally invasive surgery is indicated. They also have extensive experience in urologic reconstruction and deal with complex genitourinary surgical cases. Our surgeons are leaders in expanding the indication of robotic technology to manage bladder cancer (robotic cystectomy) and testis cancer with residual tumors in the retroperitoneum (robotic retroperitoneal lymph node dissection). In the area of radiation oncology, our specialists are leaders in the use of intensity modulated radiation therapy and Moffitt-specific techniques to minimize rectal toxicity. They perform dose escalation with external beam radiation alone or in combination with high-dose radiation. Our medical oncologists are investigating new targeted agents for prostate and kidney cancer as well as working with our radiation oncologists and surgeons in improving bladder-preservation strategies in appropriately selected patients.

In the area of research, our basic and population science researchers work hand in hand with our clinicians to advance the knowledge of genitourinary cancers and to develop novel treatments.

Our basic researchers range their investigations from chemoprevention of cancers to the search for new treatments for cancers at all stages.

In men at risk of prostate cancer, one trial is looking at the effect of green tea on premalignant changes that may prevent the development of these lesions into actual cancer. Another study is looking at the effect of soy-like agents that may favorably affect prostate cancer in men undergoing robotic prostatectomy.

There are some men with very early cancer who are not candidates for active surveillance but who have unifocal cancer. We are investigating whether “focal therapy” has a place as a management option for these men.

In advanced prostate cancer, our researchers are investigating how the “metastatic microenvironment” works, as well as the specific pathways that may be impacted by targeted therapies. They are also looking at novel vaccines for other advanced cancers.

Some patients who underwent unsuccessful intravesical treatment have early, localized and high risk for progression bladder cancer. The only current option in these cases is surgical removal of the bladder. Our investigators are evaluating the impact of adding an anti-angiogenic agent to conventional intravesical therapy as an alternative to cystectomy.

Kidney cancer poses particular challenges. For early and small cancers, active surveillance is an option. Our clinicians are investigating clinical and molecular characteristics that will help better select these patients for observation. For advanced cancers, our clinicians are evaluating newer immunotherapy and targeted approaches to improve outcomes.

In education, we are training the newer generation of specialists and researchers through our clinical fellowship and postdoctoral programs.

Finally, our population and outcome researchers are evaluating the impact of cancer in populations with the disease. One study is testing better ways to educate patients and their families about cancer and to provide them with the tools to make informed decisions in order to include them as part of the care team. Another trial is investigating the impact that treatment has on quality of life.

These are exciting times in the fight against cancer. We now have technology that allows us to “see” cancer like never before. These advances, along with the expertise of our clinicians and researchers, promise to deliver better treatments for our patients with genitourinary malignancies.

Adapted from Florida MD, November 2012