Strategies for the management of recurrent and advanced urologic cancers. Quality of life
The goal of any treatment strategy for cancer is to improve not only patient survival but also quality of that survival. Quality of life (QL) involves individual perceptions (physical, mental, social) which are particularly germane to management of recurrent and advanced urologic cancers. Cancer therapy ideally equally documents a patient's QL as well as tumor response and survival. The QL is best achieved by optimal therapy, defined as appropriate treatment of those patients who need it and avoiding unnecessary or overtreatment of those patients who are not expected to obtain significant benefit. Specific goals of management of urologic neoplasms should strive to eradicate all existing and/or palliate symptomatic disease with the least possible morbidity while attempting to preserve function. Some examples of positive advances in this regard include reduction of therapeutic burden in good-risk patients with germ cell neoplasms; preservation of bladder and sexual function in childhood, adolescent and adult pelvic sarcomas with initial chemoradiotherapy programs and conservative surgery; improved responses of metastatic bladder cancer with combination chemotherapy; pelvic nerve-sparing techniques to preserve sexual potency and continent external or internal urinary diversions should total cystectomy become necessary; prevent or delay cystectomy with intravesical therapy in high-risk patients with polychronotopic superficial bladder tumors and ureteropyeloscopic management (rather than nephroureterectomy) of selected upper tract urothelial tumors. On the negative side, no appreciable value can yet be ascribed to nephrectomy, adjunct radiation or chemotherapy, hormonal or immunotherapy for advanced locoregional or metastatic renal cell carcinoma, aggressive radiation or chemotherapy for nodal metastases from bladder or prostate cancer or hormonal and/or chemotherapy of the asymptomatic patient with metastatic prostatic cancer. Future treatment strategies will improve tumor responses that now prove refractory but they should not be applied at the expense of QL as assessed by the patient. Valid methods for objective measurements of QL need to be devised and incorporated into multimodality curative and palliative clinical trials.