Urological Cancers

Urologic Oncology

Urologic oncology is the subspecialty of urology that focuses on cancers of the male and female urinary tract and the male reproductive organs. Urological cancers are common, potentially life-threatening, and comprise a significant part of urology practice. In the United States, prostate cancer accounts for more than 25% of all new cancer cases in men, bladder cancer for 7%, and cancer of the kidney and renal pelvis (the internal part of the kidney that collects urine) for 5%. Testicular cancer is relatively rare but is also treated by urologists. Urologists also treat women with kidney and bladder cancer, although the prevalence of these cancers is much less so than in males.

Our urology group–New Jersey Urology–embraces a multi-disciplinary health care team approach to urological cancers. In addition to urologists, radiation oncologists and medical oncologists are essential members of the urological cancer treatment team. A radiation oncologist is a specialist in treating cancer with radiation therapy, whereas a medical oncologist is a specialist in treating cancer with chemotherapy, advanced hormonal therapy, and immunotherapy. This trio–urologist, radiation oncologist, and medical oncologist–is a powerful management team with each member having a different expertise and contributing vitally to the decision-making and management process.

In 2021, three urological cancers rank on the list of the top ten most common cancers in men. Prostate cancer is number 1 (about 250,000 cases), urinary bladder cancer is number 4 (about 65,000 cases), and kidney and renal pelvic cancer is number 6 (about 49,000 cases). In females, kidney and renal pelvis cancer is number 9 on the list of the top ten most common cancers in women. Other rarer cancers treated by urologists include penile, urethral, and adrenal cancer.

Prostate Cancer

Risk factors are aging, race (African and Caribbean ancestry at highest risk), family history/genetics, and lifestyle. The only modifiable risk factors are use of tobacco and excessive body weight, both of which may increase the risk of aggressive and potentially fatal disease.

Because prostate cancer is a leading cause of cancer death and causes no symptoms in its earliest stages, screening recommendation for men who have a life expectancy of at least ten years includes an annual digital rectal exam of the prostate and a prostate specific antigen (PSA) blood test. Most prostate cancers are discovered by prostate biopsy prompted by an elevated or accelerated PSA or an abnormal prostate exam. Management options for early stage prostate cancer are active surveillance, robotic prostatectomy, and radiation. Focal therapies including cryosurgery and high intensity focal ultrasound are alternative options. Late stage prostate cancer options include hormonal therapy, chemotherapy and immunotherapy.

Bladder Cancer

The incidence of bladder cancer is four times higher in men than in women and two times higher in Caucasian men than African-American men. Tobacco is the biggest risk factor for bladder cancer, accounting for half of all cases. Occupational exposure to chemicals is another risk factor: dyes, rubber, leather, aluminum, paint, and arsenic in drinking water. In the vast majority of cases, bladder cancer presents with blood in the urine, and less commonly with irritative lower urinary tract symptoms including urgency, frequency, and painful urination. Early stage disease is treated by removal of the cancer via the cystoscope, often followed by intra-vesical therapy (immunotherapy with BCG or chemotherapy instilled directly into the bladder). More advanced cancers may require bladder removal and urinary diversion. Late stage bladder cancer is treated with chemotherapy. Bladder cancers have a high predilection for recurrence and therefore careful follow-up is necessary.

Renal Cell and Renal Pelvic Cancers

Renal cell cancers originate in the outer part of the kidney that produces urine, whereas renal pelvic cancers originate in the inner part of the kidney that collects the urine. 95% of kidney tumors are renal cell cancers. Risk factors include excess body weight, tobacco, and chronic renal failure. The vast majority of renal cell cancers are asymptomatic and picked up incidentally on imaging studies (ultrasound, computerized tomography, magnetic resonance imaging) done for other reasons, although rarely these cancer may present with symptoms, including blood in the urine, pain or a mass. On the other hand, most renal pelvic cancers present with blood in the urine. The treatment options for a renal cell cancer include active surveillance, removal of the involved part of the kidney, removal of the entire kidney, or focal ablation by freezing or with heat. For advanced disease, immunotherapy and targeted therapies are the main treatment options.

5% of kidney tumors are renal pelvic cancers, which behave similarly to bladder cancer. Tobacco and occupational exposure to chemicals are the greatest risk factors for bladder cancer. Treatment options for renal pelvic cancers include endoscopic techniques, instillation of immunological or chemotherapeutic medications into the renal pelvis, and surgical removal of the kidney and ureter. For advanced disease, chemotherapy is the main treatment option.

Testes Cancer

Although cancer of the testicle is rare, it is the most common solid cancer in young men age 15-40, with the greatest incidence in the late 20s, striking men at the peak of life. It is more prevalent in Caucasian men than African-American or Asian men and it occurs more commonly in men with undescended testes and Klinefelter’s syndrome. Testes cancer is a highly curable cancer, especially when picked up in its earliest stages, and also potentially curable even at advanced stages. It typically causes a lump, irregularity, asymmetry, enlargement, heaviness or a dull ache of the testicle. It most often does not cause pain. Testes cancer can also present with a sudden fluid collection around the testes, breast enlargement and/or tenderness, back pain and rarely shortness of breath, coughing up of blood or a lump in the neck.

Physical exam is followed by a scrotal ultrasound. Tumor markers—alpha-feto protein (AFP), human chorionic gonadotropin (B-HCG) and lactate dehydrogenase (LDH) are routinely obtained. An outpatient surgical procedure removes the diseased testicle along with the spermatic cord that contains the blood and lymphatic supply of the testicle. Depending on the final pathology report and staging studies, further management options may include surgical removal of abdominal lymph nodes, chemotherapy or radiation therapy.

Guidelines for Minimizing Risk for Urological (and other) Cancers

• Maintain a healthy weight
• Make healthy eating choices
• Stay physically active
• Limit sedentary behavior
• Limit alcohol
• Avoid tobacco
• Avail yourself of the benefits of screening

References

• New Jersey Urology
• Understanding Prostate Exam and PSA Screening
• Active Surveillance of Prostate Cancer: “To do nothing, that’s something”
• Robotic-Assisted Surgical Removal of the Prostate: What You Need to Know
• Radiation Therapy for Prostate Cancer: What You Need to Know
• Focal Ablative Therapy for Prostate Cancer: What You Need to Know
• Androgen Deprivation Therapy (ADT): What You Need to Know
• Treatment Options For Castrate-Resistant Prostate Cancer
• Bladder Cancer
• Kidney Cancer (“Renal Cell Carcinoma”) Part I
• Big Ball Series: How To Examine Your Testes (And What You Need to Know About Testicular Cancer)