Urology Cancer

Urology is the branch of medicine that deals with the diagnosis, prevention and treatment of the diseases of the urinary tract system and the organs and its associated structures. The organs that are included in this category are the kidneys, the ureters, urethra, urinary bladder, prostate and the testes. Testes are considered part of the male reproductive system but the problems associated with are dealt with by a urologist. Many types of cancers arise in these organs and can be life threatening if not diagnosed in primary stages. The occurrence of prostate cancer is highest and is the second most diagnosed cancer in males (about 15% of all cancers diagnosed in males). The other cancers that occur are:

• Renal cell carcinoma (cancer of the kidneys)
• Bladder and the urinary tract cancer
• Testicular cancer

Urology is the branch of medicine that deals with the diagnosis, prevention and treatment of the diseases of the urinary tract system and the organs and its associated structures. The organs that are included in this category are the kidneys, the ureters, urethra, urinary bladder, prostate and the testes. Testes are considered part of the male reproductive system but the problems associated with are dealt with by a urologist. Many types of cancers arise in these organs and can be life threatening if not diagnosed in primary stages. The occurrence of prostate cancer is highest and is the second most diagnosed cancer in males (about 15% of all cancers diagnosed in males). The other cancers that occur are:

• Renal cell carcinoma (cancer of the kidneys)
• Bladder and the urinary tract cancer
• Testicular cancer

Prostate and bladder cancer are the most common type of urological cancer in India in recent times. 

Prostate cancer occurs in a small walnut-shaped gland called prostate gland that is a part of the male reproductive system. The main function of this gland is to produce prostatic fluid that is rich in enzymes, proteins and minerals. This fluid helps to nourish and protect the sperms. Changes occur in the prostate gland as age advances and may be benign that is localized or malignant that which can spread. About 99% of the cases occur in men older than 50 years of age. Family history also increases the risk of developing prostate cancer. Some remain indolent and require treatment only to manage the symptoms while some may be malignant and highly aggressive and need medical attention. It is the most diagnosed form of cancer in men and is responsible for mortality in a large population. 

The early symptoms may not be noticeable and even if they occur, they overlap with BPH (Benign Prostatic Hyperplasia). These include.

• Frequent urination
• Increased urination at night
• Difficulty in initiating and maintaining a steady stream of urine
• Blood in the urine and
• Painful urination

Since the prostate gland surrounds the urethra, prostate cancer causes urinary dysfunction

The causes of prostate cancer are still unknown. About 99% of the cases occur in men older than 50 years of age. Family history also increases the risk of developing prostate cancer. The main risk factors for the development of this cancer are advanced age and genetic factors.

Factors that can increase your risk of prostate cancer include:

• Age: About 99% of the cases occur in men older than 50 years of age.
• Race: Prostate cancer affects ethnic groups differently. Matched for age, African-American males have a higher incidence and present at a more advanced stage with higher-grade, more aggressive tumors.
• Family history: Epidemiologic studies show that the risk of being diagnosed with prostate cancer increases 2.5-fold if one first-degree relative is affected and fivefold if two or more are affected. Current estimates are that 40% of early-onset and 5–10% of all prostate cancers are hereditary.
• Obesity: Obese men diagnosed with prostate cancer may be more likely to have advanced disease that's more difficult to treat.

Screening is done to detect prostate cancer. The prostate specific antigen (PSA) blood test and digital rectal examination (DRE) are two tests that are used to screen for prostate cancer. Both are used to detect cancer early. However, these tests are not perfect. Abnormal results with either test may be due to benign prostatic hyperplasia (BPH) or infection, rather than cancer.

The tumors that are localized can be treated by performing prostatectomy either solely or in combination with radiation therapy. Male androgen hormones particularly testosterone is implicated in causing the progress of prostate cancer. Thus androgen deprivation therapy (ADT) is one of the mechanisms to treat prostate cancer. The most common form of ADT involves chemical suppression of the pituitary gland with GnRH (Gonadotropin Releasing Hormone) agonists. The drugs that act via this mechanism include leuprolide, goserelin, triptorelin, histrelin, and nafarelin. The other form of therapy is to target the androgen receptor thus competing with the androgens in binding to these receptors.

The drugs that act via this mechanism are steroidal drugs like cyproterone and non-steroidal like enzalutamide, flutamide, bicalutamide and nilutamide. Androgen receptor signalling can support continued prostate cancer growth and the source of androgens include the adrenal glands and the prostate cancer themselves. Testosterone is also formed from androstenedione in the peripheral tissues and tumors. Two drugs that are used fall under this category are the antifungal agent ketoconazole and the novel drug abiraterone acetate. It is used with prednisone for the treatment of castration resistant prostate cancer (CRPC) who are chemotherapy naïve or in those who has previously received docetaxel. In both the settings, it prolongs survival.Freezing prostate tissue which involves the use of Cryosurgery or Cryoablation involves freezing tissue to kill cancer cells.

Cancers of the urinary tract including the bladder, renal pelvis, ureter and urethra occur frequently and represent the second most common class of genitourinary cancers. Occasionally, patients will present with flank pain in association with an upper tract renal pelvis or ureter cancer or due to hydronephrosis in association with a bladder tumor obstructing the orifice of the ureter within the bladder. Only in rare cases do patients present with significant cachexia and widespread metastatic disease. For most patients, painless hematuria (either gross or microscopic) represents the initial manifestation of an underlying urinary tract cancer. In females, hematuria due to malignancy can often be mistaken for a urinary tract infection or menstrual bleeding.

Bladder cancer signs and symptoms may include:

• Blood in urine (hematuria), which may cause urine to appear bright red or cola colored, though sometimes the urine appears normal and blood is detected on a lab test (microscopic)
• Frequent urination
• Painful urination
• Abdominal pain or flank pain

The Factors that may increase bladder cancer risk include:

• Smoking
• Increasing age
• Being male. Men are more likely to develop bladder cancer than women are.
• Exposure to certain chemicals
• Previous cancer treatment
• Chronic bladder inflammation
• Personal or family history of cancer

The methods adopted by doctors in diagnosing bladder cancer are:

• Urine analysis
• X-rays
• Examining internally to feel for lumps which may indicate cancerous growth.
• Cystoscopy which involves insertion of a tube with camera into the bladder to observe it internally
• Biopsy of the tissue
• CT scan of the bladder
• An intravenous pyelogram (IVP)

Doctor can rate bladder cancer with a staging system that goes from stages 0 to 4 to identify how far the cancer has spread. The stages are as follows:

• Stage 0 cancer hasn’t spread past the lining of the bladder.
• Stage 1 cancer has spread past the lining of the bladder, but it hasn’t reached the layer of muscle in the bladder.
• Stage 2 cancer has spread to the layer of muscle in the bladder.
• Stage 3 cancer has spread into the tissues that surround the bladder.
• Stage 4 cancer has spread past the bladder to the neighbouring areas of the body.

The treatment options are decided depending on the stage of the disease when it is diagnosed. The following is the treatment approach:

Early stage disease: For non-muscle invasive bladder cancer (NMIBC), the approach is to remove all the visible tumors by transurethral resection of bladder tumor (TURBT). To prevent the relapse of the tumor after the surgery, addition of chemotherapeutic agents like mitomycin C, epirubicin, or gemcitabine can be instilled directly into the bladder (intravesical therapy) within 24 hours of the surgery.

Muscle invasive disease: In patients with urothelial carcinoma of the bladder that invades into or through the muscularis propria but with no evidence of metastatic spread, more aggressive therapy are required to achieve cure. These include:

• Bladder sparing chemoradiation
• Bladder sparing partial cystectomy
• Cystectomy
• Neoadjuvant cisplatin-based chemotherapy
• Adjuvant cisplatin-based chemotherapy

Metastatic disease: in these patients having metastatic urothelial carcinoma, systemic chemotherapy is the most established standard of care irrespective of the primary tumor origin. The chemotherapeutic agents include combination of methotrexate, vinblastine, doxorubicin and cisplatin (MVAC).

Since doctors don’t know yet what causes bladder cancer, it may not be preventable in all cases. The following factors and behaviours can reduce the risk of getting bladder cancer:

• Avoid smoking
• Avoiding second-hand cigarette smoke
• Avoiding other carcinogenic chemicals
• Drinking plenty of water

The impact of bladder cancer treatment on other bodily processes varies according to the treatment received. Sexual function, particularly the production of sperm, can be affected by radical cystectomy. Damage to nerves in the pelvic area can sometimes affect erections. Bowel movements, such as the presence of diarrhea, may also be affected by radiation therapy to the area.