Urology in the twenty-first century: noninvasive targeted treatments for urologic malignancies

Notwithstanding the major advances that have been made in the treatment of bladder cancer, prostate cancer, and kidney cancer, much remains to be done if we are to translate the gains that have been made in "disease-free survival" into actual survival in terms of quantity as well as quality of life. Indeed, we are still at an embryonic stage in understanding how cancers originate, whether defense mechanisms exist that can recognize these cancers and recognize them when they first develop, when cancers metastasize during their development, whether we have methods that are sufficiently accurate to distinguish between organ-confined and regional extension or spread of disease, and the means by which we can identify cancers that are likely to remain organ-confined and distinguish them from those that are predestined to metastasize. If we are to be successful in the assessment and treatment of various urologic cancers, these questions must be answered. Many new methods of assessment and treatment are being explored that in themselves may provide some answers. The present discussion focuses on these issues, on how they may lead to further understanding of the unique biology of many of these tumors, and what we may expect in terms of increased longevity and improved quality of life as we attempt to cure patients of their disease.

Current concepts in assessment and treatment of bladder cancer

Transitional cell carcinoma of the bladder is comprised of a variety of cancer diatheses that manifest a spectrum of distinct biologic potentials. The challenge is to control superficial disease recurrence and progression and to identify invasive carcinoma at an earlier stage, when it may be more amenable to cure.

The natural history of bladder cancer. Implications for therapy

Transitional cell carcinoma of the bladder is comprised of a variety of cancer diatheses that manifest a spectrum of distinct biologic potentials. Although these diseases have traditionally been classified as "superficial" and "muscle invasive" on the basis of their histologic appearance (depth of penetration of the "bladder wall" and corresponding prognosis) the pathways presumably followed by the various forms of these cancers imply an even greater complexity. These disparate pathways may reflect different events in carcinogenesis, which may determine subsequent development and risk for either recurrence or progression. In addition, biologic activity and malignant potential for each type of cancer may be associated with distinctive molecular and genetic alterations. These considerations may provide an opportunity to expand traditional staging systems in creating molecular profiles that may more precisely characterize the biologic potential of these tumor diatheses. Although there are far more questions than answers concerning how these alterations may effect the natural history of bladder cancer, molecular-based identification of bladder cancer patients at greatest risk for progression may ultimately improve clinical management.