Desarrollos afines: Intermodalismo y globalización.

Cora N Sternberg

Objectives • To understand the risk factors associated with urothelial cancers and the recommendations about cessation of smoking at any stage of disease

• To be able to distinguish between non-muscle invasive (NMIBC) and muscle invasive bladder cancer (MIBC) disease and to know the implications for progression, recurrence, spread, prognosis and treatment

• To be able to appreciate the role of urine cytology, and to know how to use diagnostic imaging and cystoscopy in the staging and follow-up of patients

• To know the role of intravesical therapy in the management of NMIBC, as well as the role of salvage instillation and surgery in recurrent, progressive non-muscle invasive and early-stage invasive cancers

• To understand the advantages and disadvantages and indications for radical cystectomy and lymph node dissection and definitive chemo-radiotherapy or trimodality treatment for MIBC

• To be able to distinguish the clinical prognostic groups and eligibility for standard chemotherapy with cisplatin

• To know about alternative treatment options for cisplatin-ineligible patients

• To understand that there are scarce treatment options for platinum-failing patients and that ongoing research is promising for antiangiogenic treatment, targeted therapies and immunotherapy

Awareness • Awareness that the most common presenting symptom is painless haematuria

• Awareness that 80% of diagnosed cases of MIBC present as primary invasive bladder cancer and only 15% of patients have a history of mainly high-risk NMIBC

• Awareness that the pathological diagnosis according to the WHO classification is mostly made from a biopsy obtained during transurethral resection of the bladder tumour (TURBT) and that 90% are transitional cell carcinomas (TCC); new molecular classifications in addition to histological subgroups have been described

• Appreciation that, at TURBT, complete resection of all tumour tissue is aimed at whenever possible

• Recognition that carcinoma in situ (CIS) has been shown to be an adverse prognostic factor; bladder biopsies should be taken from suspicious areas

• Awareness that MIBC requires further imaging with computed tomography (CT) or magnetic resonance imaging (MRI)

• Awareness that cystectomy or chemo-radiotherapy following maximal TURBT are curative treatment options for MIBC

• Recognition that perioperative chemotherapy is a standard of care for cisplatin-eligible patients; the body of evidence is stronger for neoadjuvant than for adjuvant chemotherapy but both options are recommended. More patients are able to receive neoadjuvant, ie, preoperative than adjuvant chemotherapy

• Awareness that, for systemic treatment of MIBC, eligibility for cisplatin has been defined and separates patients for standard chemotherapy or alternative treatment options with mostly carboplatin-based chemotherapy

• Awareness that there are several standard combination chemotherapy options with cisplatin that have different safety profiles

• Awareness of other less common pathologies than TCC that may be found and that have different treatment options

Knowledge • Knowledge that smoking is the major risk factor for bladder cancer and that smoking cessation improves outcomes

• Knowledge of the mandatory diagnostic procedures, the required full-body imaging for staging and the definitive treatment options for NMIBC and MIBC

• Knowledge of correct allocation of adjuvant instillation therapies with chemotherapy and Bacillus Calmette- Guérin (BCG) for different stages of NMIBC

• Knowledge of the options of early cystectomy or rechallenge instillation therapy in high-risk or recurrent, progressive NMIBC

• Knowledge of the results and the amount of benefit shown in the most important studies and meta-analyses about perioperative (neoadjuvant and adjuvant) chemotherapy for MIBC

• Knowledge that perioperative chemotherapy is a standard of care that should be discussed at the multidisciplinary tumour board before radical treatment and offered to patients eligible for cisplatin-based chemotherapy

• Familiarity with the most common urinary diversions and reconstruction by ileal conduit or bladder replacement, depending on tumour characteristics and patient choice

• Knowledge that age is no limiting factor for surgery although postoperative morbidity increases with age Continued

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References

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13. Galsky MD, Chen GJ, Oh WK,et al. Comparative effectiveness of cisplatin-based and carboplatin-based chemotherapy for treatment of advanced urothelial carcinoma.Ann Oncol2012;23:406–10. 14. Griffiths G, Hall R, Sylvester R,et al. International phase III trial

assessing neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy for muscle-invasive bladder cancer: long-term results of the BA06 30894 trial.J Clin Oncol2011;29:2171–7.

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gemcitabine and fractionated cisplatin in an outpatient setting using a 21-day schedule in patients with advanced and metastatic bladder cancer.Br J Cancer2004;91:844–9.

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Continued

• Knowledge of the clinical prognostic factors and prognostic groups for patients with metastatic disease at the start of platinum-based chemotherapy and at progression during or after platinum-based chemotherapy

• Knowledge that the standard of care is cisplatin-based combination chemotherapy

• Knowledge of the criteria for cisplatin ineligibility that were established by an international consensus and are widely used in daily practice and for clinical trials

• Knowledge of the alternative, carboplatin combination chemotherapy, in cisplatin-ineligible patients and the monotherapy options for those with more adverse prognostic factors

• Knowledge of the options for second-line chemotherapy

• Knowledge about the emerging literature on checkpoint inhibitors and their activity in bladder cancer

• Knowledge about the emerging data that urothelial cancer has a high number of mutations and that, in the future, it will be divided into different subclasses

Skills • Ability to council patients concerning risk factors for bladder cancer progression and recurrence

• Ability to perform the work-up and diagnostic procedures in case of haematuria

• Ability to discuss interdisciplinary the treatment options for NMIBC, instillation therapy and early cystectomy

• Ability to adequately stage patients with MIBC

• Ability to discuss definitive treatment options for MIBC, cystectomy, urinary diversions and trimodality treatment with bladder preservation

• Ability to explain patients the optimal treatment strategies according to the criteria for cisplatin eligibility and clinical prognostic factors

• Ability to discuss perioperative chemotherapy, chemotherapy for advanced and metastatic disease and second-line therapies as well as chemotherapy side effects and council patients and their families

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4.5.4.c Penile cancer