Uro-Oncological Controversies in Euro-Oncology

Meeting Review

8. RIU0491_07-31.qxd 8/4/10 4:22 PM Page e125 MEETING REVIEW Uro-Oncological Controversies in Euro-Oncology Highlights From the European Association of Urology Section of Oncological Urology, January 15-17, 2010, Vienna, Austria [Rev Urol. 2010;12(2/3):e125-e128 doi: 10.3909/riu0491] © 2010 MedReviews®, LLC Key words: Cancer mortality rates • Robotics • Prostate cancer screening • Bladder cancer • Renal cancer n January 15, 2010, the 7th Meeting of the European Association of Urology (EAU) Section of Oncological Urology (ESOU) opened in Vienna, Austria, for a 3-day event that discussed and debated a diverse range of topics in uro-oncology. The meeting led off with a review of remarkable study findings that confirmed that significantly more men than women die of cancer. Different treatment methods O Reviewed by Elisabeth Eckersberger, MD, Herbert Lepor, MD, New York University School of Medicine, New York, NY; Helen Sadri, MD, Alexander Farr, MD, Markus Margreiter, MD, Mike Harik, MD, University of Vienna Medical School, Vienna, Austria; Bob Djavan, MD, PhD, New York University School of Medicine, New York, NY. were discussed, as were the EAU guidelines, and a dialogue was had, not only on theory versus current practice, but also on future directions in drugs and technological advances. The congress opening was followed by welcome speeches by Bob Djavan care systems worldwide, Vienna exhibits a balance between adequate medical coverage to all and spending and research funding. Wehsely further underlined the need for adequate cancer prevention programs and patient education plans. Remarkable data on men’s health were presented by Siegfried Meryn, MD, from the University of Vienna, who stated that, although it was found that the death rate from cancer is greater for men than for women, the underlying reason for this trend is less clear. It is thought that lifestyle, approaches to health screening, and a delay in seeking medical help play important roles in this, but the underlying reasons are complex and not fully clear yet. and Vincent Ravery, who sit on the Executive Board of ESOU. Sonja Wehsely, Secretary of Health of the city of Vienna, outlined the achievement in health care and health management in the city in the past years. With one of the most advanced health Recent Findings in Men’s Health Remarkable data on men’s health were presented by Siegfried Meryn, MD, from the University of Vienna, who stated that, although it was found that the death rate from cancer is greater VOL. 12 NO. 2/3 2010 REVIEWS IN UROLOGY e125 8. RIU0491_07-31.qxd 8/4/10 4:22 PM Page e126 Uro-Oncological Controversies in Euro-Oncology continued for men than for women, the underlying reason for this trend is less clear. It is thought that lifestyle, approaches to health screening, and a delay in seeking medical help play important roles in this, but the underlying reasons are complex and not fully clear yet. The study showed that, even among those common cancers that affect both sexes, men faced significantly greater risks both in occurrence as well as mortality. Mortality, in particular, is thought to be affected by a significant delay in seeking medical attention even once symptoms are present. Agestandardized rates showed similarly clear results: in 2006, rates were 406.7 in men and 354.6 in women per 100,000; and in the United States, rates were 587.6 for African American men and 517.2 for white men per 100,000, and 394.9 for African American women and 411.5 for white women per 100,000. Data from the United Kingdom showed an even greater contrast, with death rates of 211.3 males and 153.1 females per 100,000, in addition to reports that stated that the overall number of years of potential life lost due to cancer is substantially greater for men than for women. Meryn reported that although the reason for the higher cancer mortality in men is not well defined, the lower screening uptake, for instance, for bowel cancer in men suggests that although men are at greater risk, they are less likely to be tested. Biologic factors also seem to play a role, as well as different lifestyle choices made by men (eg, diet, smoking, and excessive alcohol consumption); all seem to contribute to dying prematurely. Discussions on Prostate Cancer Different aspects of prostate cancer were presented by a number of participants including recent controversies and challenges, talks on topics ranging from both recent successes in screening, radio- and drug therapies, e126 VOL. 12 NO. 2/3 2010 and surgical techniques, as well as struggles with guidelines, population perception, and patient wishes. Perhaps the most controversial discussion concerned the rise of robotics in prostatectomy procedures. Both Herbert Lepor, MD, from the Department of Urology at Langone Medical Center at New York University, New York, and Jens Rassweiler, MD, from the Department of Urology at the University of Heidelberg, Germany, confirmed that in current practice there is a displacement of open radical retropubic prostatectomy (ORRP) by robotic radical prostatectomy (RRP), part of which can be attributed to the strong marketing effect of robotic surgery. Lepor took a firm stance that ORRP is not dead, citing study results that showed the increased costs and false expectations concerning RRP, leaving patients more likely to be regretful and dissatisfied than those undergoing ORRP. An emphasis was also placed on surgeon experience, focusing on the fact that comparisons between results of each procedure could only be fairly assessed if the surgeons were equally proficient in their respective techniques. Rassweiler argued in favor of laparoscopic surgery, stating that laparoscopy will survive, and that technological advances and improvements of the method will without a doubt improve outcomes. Certain procedures, such as ablative surgery or pyeloplasty, are likely to be especially relevant in the further development of laparoscopic surgery. Additional key arguments focused on screening for prostate cancer and imaging and treatment options. As coauthor of the prestigious European Randomized Study of Screening for Prostate Cancer (ERSPC), Fritz Schröder, MD, from Erasmus University and Medical Center, The Netherlands, reported on ERSPC and the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. Schröder stated that the ERSPC trial REVIEWS IN UROLOGY showed a significant 20% reduction in the relative risk (RR) of prostate cancer death in the group of men aged 55 to 69 years. In men actually screened, the RR reduction was 31%.1 In addition, the trend in mortality curves seems to suggest that larger effects correlate with longer follow-up, and that throughout this, health care providers are likely to struggle with the high rate of overdiagnosis and number needed to treat. Aspects of treatment modalities were reviewed by Mark Emberton, MD, from the University College of London, United Kingdom, and Thomas Wiegel, MD, from the University Hospital Ulm, Germany. Emberton spoke on focal therapy for men with localized prostate cancer, reporting that the use of the Sonablate® 500 (Focus Surgery, Inc., Indianapolis, IN) device has resulted in a return to baseline in key aspects of genitourinary function, and may offer an alternative option to those patients who place high utility on preserving genitourinary function. A further topic was dose escalation—which is necessary for low- and intermediate-risk tumors treated in combination with hormonal treatments—although the most appropriate dose remains uncertain, Wiegel reported. Key Messages on Bladder Cancer Treatment options for bladder cancer were discussed during the next section, among them the role of chemotherapy and new surgical techniques. A review of neoadjuvant chemotherapy was presented by Marko Babjuk, MD, from the Charles University and General Teaching Hospital in Prague, Czech Republic, who described it as an important aspect of treatment prior to cystectomy, rather than after surgery. Patients tend to tolerate more cycles better before cystectomy, resulting in the downstaging of tumors, which allows for more successful surgeries, 8. RIU0491_07-31.qxd 8/4/10 4:22 PM Page e127 Uro-Oncological Controversies in Euro-Oncology as well as the ability to treat micrometastases present at the time of diagnosis. Photodynamic diagnosis is emerging as a way of preventing failures to see preexisting small papillary tumors and aiding resection in lowrisk non–muscle-invasive bladder cancer, resulting in a 26% reduction of 9M recurrence rates. Axel Heidenreich, MD, from the Department of Urology at the University Hospital Aachen, in Germany, indicated that extended curative in approximately 50% of renal units with cancer, but papillary and solid tumor recurrences of the upper tract cannot be prevented. Aspects on Renal Cancer Experts from all over the world gathered together to discuss renal cancer during the ESOU meeting in Vienna. Lecture topics included minimally invasive techniques, targeted therapies, and the management of complica- Photodynamic diagnosis is emerging as a way of preventing failures to see preexisting small papillary tumors and aid resection in low-risk non–muscle-invasive bladder cancer, resulting in a 26% reduction of 9M recurrence rates. pelvic lymphadenectomy has been shown to improve progression-free survival if  16-cm lymph nodes are removed. Different aspects of upper urinary tract (UUT) cancer were discussed from various viewpoints and treatment options. As a relatively rare disease, UUT cancer has not been studied as closely or extensively as bladder cancer. There are 2 main treatment techniques currently recommended and used: treatment with mitomycin C and bacillus Calmette-Guérin (BCG), either through a percutaneous nephrostomy tube or retrograde reflux from the bladder with an indwelling double-J stent in association with the Trendelenburg position. Dr. A. Patel outlined the current endourologic management of clinically localized UUT urothelial tumors, citing long-term endoscopic surveillance of both upper and lower tracts as obligatory after successful endoscopic UUT transitional cell carcinoma treatment. Chemotherapy for UUT cancer was discussed at length by Christian Pfister, MD, PhD, from the Department of Urology at Rouen University Hospital, in France, who reported that in situ BCG therapy is tions from both medical and surgical therapies. Robotic surgery, laparoscopic treatment, and minimally invasive ablative techniques were among the most heated discussions held on this topic. Gabriel Haas, MD, from the Department of Urology, SUNY Upstate Medical University, Syracuse, definitively argued that robotic renal surgery is the technique of the future and is here to stay, selected tumors ranging from 4 to 7 cm in size. Sequential treatment algorithms in renal cell carcinoma (RCC) were discussed by Manuela Schmidinger, MD, from the Clinical Division of Oncology at the Medical University of Vienna, Austria, who reported that targeted agents have drastically changed the outcome of patients with metastatic RCC (mRCC), reporting survival of  40 months. Treatment choice must be based on individual patients, with standard care including sunitinib or bevacizumabIFN for first-line favorable/intermediate risk adapted to individual cases. Metastasectomy in RCC, including outcomes, complications, and prognostic markers, was presented by Ziya Kirkali, MD, from the Department of Urology, Dokuz Eylul University School of Medicine, Ankara, Turkey. However, doubt was shed on metastasectomy as a curative approach, although effective palliation has been clearly determined. Prospective randomized trials are clearly needed to investigate whether metastasectomy improves overall survival—current evidence, however, Laparoscopic nephrectomy is up-and-coming as a minimally invasive technique, but due to technical difficulties and learning curves, open partial nephrectomies still remain the standard of care in tumors < 4 cm, and in selected tumors ranging from 4 to 7 cm in size. and is already a preferred treatment of small renal masses (SRMs). Detection rates of SRMs have increased in past decades, and Franck Bladou, MD, from the Department of Urology at the Hospital Sainte Marguerite, Marseille, France, discussed the possibility of using nephron-sparing surgery. Laparoscopic nephrectomy is up-andcoming as a minimally invasive technique, but due to technical difficulties and learning curves, open partial nephrectomies still remain the standard of care in tumors  4 cm, and in points to the more liberal use of this surgery even in the setting of mRCC. Awards and Recognitions The EAU Section of Oncological Urology distributed 2 important awards during the Vienna Meeting: one for honorary achievement and the other for best paper. The best paper award was won by a group of researchers from Spain, headed by lead author Jose Maria Gaya-Sopena, MD, from the Department of Urology in Barcelona. Their VOL. 12 NO. 2/3 2010 REVIEWS IN UROLOGY e127 8. RIU0491_07-31.qxd 8/4/10 4:22 PM Page e128 Uro-Oncological Controversies in Euro-Oncology continued paper titled, “Patterns of Progression in Patients With Non-Muscle Invasive Bladder Cancer Who Underwent Radical Cystectomy After Intravesical BCG Failure,”2 received a unanimous vote as best paper by the ESOU jurors— who reviewed a total of 39 submitted papers—for its insights into clinical practice. Fritz Schröder, MD, and Richard Hautmann, MD, received the first honorary awards presented by the ESOU. Schröder is a venerable scien- e128 VOL. 12 NO. 2/3 2010 tist and physician, and in addition to numerous previous awards, has been promoted to knighthood in the rank of Commander in the Order of the Dutch Lion. Hautmann is professor and chairman of the Department of Urology at the University of Ulm in Germany and is an expert on urooncological diseases. He was cited for his pioneering and ground-breaking contributions to the field of urooncology. Like Schröder, Hautmann has received numerous other awards, REVIEWS IN UROLOGY including the German Cancer Award and the German Society of Urology’s Nitze Medal. References 1. 2. Roobol MJ, Schröder FH, Crawford ED, et al. A framework for the identification of men at increased risk for prostate cancer. J Urol. 2009;182:2112-2120. Gaya-Sopena JM, Huguet J, Palou J, et al. Patterns of progression in patients with non-muscle invasive bladder cancer who underwent radical cystectomy after intravesical BCG failure. Paper presented at: 24th Annual European Association of Urology Congress; March 17-21, 2009; Stockholm, Sweden.