Sunitinib, sorafenib and other systemic noncytotoxic kidney cancer therapies can and should be administered by urologists

Urology is not just a surgical discipline. More than surgeons from other surgical disciplines, urologists have a long tradition of managing patients with multimodality therapies, including systemic therapies. The most obvious example of this is the use of androgen deprivation therapy for prostate cancer. Other examples include the use of intravesical chemotherapy for bladder cancer, and tumour vaccines and cytokines for renal cancer. Urologists have been at the forefront of research into many systemic therapies for cancer, including androgen-deprivation therapies, anti-androgens, gene therapy for prostate cancer, and atrasentan, zoledronic acid, estramustine, and gamma interferon for kidney cancer. Urologists were involved in the development of systemic chemotherapy for metastatic testicular cancer. For the first 10 years after the introduction of multi-agent chemotherapy for testicular cancer, urologic oncologists administered these drugs in many centres. These physicians acquired clinical skills in the management of patients with metastatic disease and the toxicities associated with these drugs.

Why did this change? Primarily because of drug toxicity. Multi-agent, platinum-based cytotoxic chemotherapies can be lethal to patients. Methotrexate-vinblastine-adriamycin–cis-platinum chemotherapy, which was standard therapy for advanced prostate cancer for 20 years, induces fatal neutropenic sepsis in 2%–4% of patients. Physicians administering these regimens need to be highly focused on the morbidities associated with these drugs and the interventions required to manage them.

In this new era of noncytotoxic systemic therapies for cancer, of which the tyrosine-kinase inhibitors are excellent examples, these drugs do have associated toxicities, but their side effects are rarely life-threatening. These drugs do not induce neutropenia; they induce hypertension, hand-foot syndrome and other non-life-threatening toxicities. Much like many other agents used in urology, these drugs do require care and experience to administer.

Patients with metastatic cancer are not easy to manage. They experience complications from their malignancies that many urologists may find challenging to treat, for example, the management of malignant ascites, expanding liver metastases or recurrent malignant pleural effusions that cause dyspnea. Some urologists, however, will rise to the challenge and maintain the skills required, in conjunction with palliative care physicians.

The stakes are high. The future of cancer management lies in risk stratification with clinical, biochemical and genetic markers, and multimodality therapy for patients at risk. Chronic-disease management with long-term systemic therapy that uses targeted agents is likely to become common.

In that environment, surgeons may function in 1 of 2 ways. In one model, the medical oncologist acts as the primary caregiver, as is frequently the case for breast and colon cancer in North America. The urologist is relegated to the technical aspects of cancer resection. As many operations currently carried out are replaced by image-guided nonsurgical interventions, this limited role will decline further. The need for urologic oncologists will be limited, the numbers small, and the scope of practice narrow. A future scenario might unfold this way — a family doctor identifies a 4-cm mass during renal ultrasound and refers the patient to a medical oncologist for a management decision. The oncologist sends the patient to an interventional radiologist for biopsy and MRI-guided high-intensity focused ultrasound. The radiologist then sends the patient back to the medical oncologist for chronic adjuvant therapy. Plausible? Definitely. Desirable? You decide.

In the alternative model, urologists function as primary caregivers for patients with urologic cancer, helping the patient make the primary treatment decision, administering neoadjuvant and adjuvant therapy with noncytotoxic therapies, and following the patient through the chronic phase of the disease. Upon progression, relapse or failure of first-line therapy, the urologist would refer patients to a medical oncologist for consultation about further management. This is a much more robust and attractive model of urologic oncology, and in many environments will have benefits for the patient.

One shoe does not fit all, however. This model is appropriate for a subgroup of urologic oncologists with an interest in systemic therapy. It would not be appropriate for general urologists with limited interest and experience in managing patients with advanced cancer. Many factors will have an impact, including workload, resource base, and location (rural or urban) and type (academic or community) of practice. The interest and experience of the treating physician will be key. The availability and collaboration of medical oncologists with an interest in genitourinary cancer may obviate the benefit of initiatives in this area.

Urologists embarking on this path must obtain training in the use of agents for systemic therapy and structure their practice so that it can accommodate the increased needs of patients with advanced cancer. These urologists should seek a close working relationship with a medical oncologist and pursue a multidisciplinary model of care. However, the multidisciplinary model should not come at the expense of losing our hallowed status as primary care physicians for patients with urologic cancer, including renal cancer.