NCCN urothelial cancer practice guidelines. National Comprehensive Cancer Network

Urothelial tumors represent a spectrum of diseases with a range of prognoses. Once a diagnosis is established at any point on the urothelial tract, the patient remains at risk for developing a new lesion at a different or the same location, at a similar or more advanced stage. Continued monitoring for recurrence is an essential part of management, as most recurrences are superficial and can be managed by endoscopic means. Within each category of disease, more refined methods to determine prognosis and guide management, based on molecular staging, are under development. These methods are aimed at optimizing the individual patient's likelihood of cure and chance for organ preservation. For patients with more extensive disease, newer treatments typically involve combined-modality approaches using recently developed surgical procedures, or three-dimensional treatment planning for more precise delivery of radiation therapy. While these are not appropriate in all cases, they do offer the promise of an improved quality of life and prolonged survival. Finally, within the category of metastatic disease, a number of new agents have been identified that appear to be superior to those currently considered to be standard therapies. It is thought, therefore, that the treatment of urothelial tumors will evolve rapidly over the next few years, with improved outcomes for patients with all stages of disease.

Bilateral orchidectomy and flutamide versus orchidectomy alone in newly diagnosed patients with metastatic carcinoma of the prostate--an Australian multicentre trial

OBJECTIVES

To investigate the hypothesis that maximal androgen blockade improves the outcome of patients with metastatic prostate cancer.

PATIENTS AND METHODS

A total of 222 previously untreated patients with metastatic prostatic cancer were entered into a randomized, double-blind, placebo-controlled trial of bilateral orchidectomy with or without androgen blockade (112 receiving flutamide and 110 a placebo) which commenced in 1985 in four Australian centres. The characteristics of the patients, e.g. age, performance status, the presence of bone pain, duration of disease and the use of prior radiation, were well balanced between the groups. Patients commenced the protocol therapy with flutamide or placebo within the 7 days preceding surgery and continued this medication for a minimum of 2 years, unless there was unequivocal evidence of tumour progression.

RESULTS

Apart from a difference in grade 3 or 4 gastrointestinal toxicities between the flutamide and placebo arms (13% and 3%, respectively), serious or life-threatening toxicities were uncommon and equally balanced. The assessment of response in six patients (three in each arm) was inevaluable. The objective response rates were 45% and 56% in the flutamide and placebo arms, respectively. There was no difference in survival between the treatments.

CONCLUSIONS

This study was not sufficiently powerful to detect small differences in outcome (although the trend in survival favoured the placebo arm) but nevertheless failed to show any benefit for maximal androgen blockade over orchidectomy in this group of patients.