Schoenberg Mark P., Watts Kara L. (Eds.) Management of urologic cancer: focal therapy and tissue preservation

John Wiley & Sons, 2017. — 255 p. — ISBN: 9781118868096.Two forces have conspired to change the landscape of urologic oncology over the past 30 years. The first is the availability of levelone evidence from authoritative clinical trials [1,2]. Data from randomized experiments have called into question basic assumptions about the blanket application of surgical standards of care for major classes of genito‐urinary malignancy. The second is the accelerating pace of discovery in cancer biology. The study of cancer is no longer the exclusive province of the molecular biologist; it now encompasses disciplines as diverse as immuno‐oncology, metabolomics, and microbiome science. These new disciplines will doubtless impact the already impressive progress that has been made by integrating molecular data into clinical trial design [3]. The more we know, the more there is to know; and the correlation of observations made in these new fields of inquiry with the natural and treated histories of human disease offers tremendous opportunity for future research. Urologic oncologists find themselves, therefore, on the cusp of a change driven by scientific and technological advance, the public’s demand for greater transparency in outcomes reporting, and the disclosure of treatment‐related risks and harms coupled with society’s everpresent inclination to contain the cost of health care.
In recent years it could be argued that those of us practicing urologic oncology for a living have not fully shouldered a responsibility to ourselves and to our patients. Falling victim to what Tversky and Kahneman called “belief in the law of small numbers,” we readily succumbed to the lessons of apprentice‐like training, surgical anecdote, and perhaps, as perniciously, to a historical, “heroic” vision of surgical judgment that may have placed the surgeon in the center of the picture instead of the patient [4]. Hamlet’s famous mother would likely have chuckled to herself had she witnessed the protests following the recent publication of the U.S. Preventive Services Task Force recommendations regarding prostate‐specific antigen testing. This is by no means intended to disparage the motives of surgeons who, with the best of intentions, applied what was known to what they encountered in practice. No mea culpa is required. The fault, if any can be found, lies in human nature, which inclines to overestimate benefit, understate risk, and exaggerate the importance of personal experience. This appears to be so even when compelling data to the contrary are available. Witness the small number of patients with muscle‐invasive bladder cancer who are offered neoadjuvant chemotherapy before cystectomy [7]. Having acknowledged some degree of skepticism regarding our contemporary standards of care, we sought to better understand the state of what could arguably be called a new branch of urologic oncology: image‐guided, tissue‐preserving or focal therapy. This new area of inquiry has deep roots in urologic practice that demand brief mention. Students of medical history are familiar with Philipp Bozzini’s introduction of the “lichtleiter” instrument, a tool employing a series of mirrors and candle‐illumination that paved the way for modern urologic endoscopy at the beginning of the nineteenth century [8]. Transurethral resection of bladder tumors is a time‐honored mainstay of practice that is by definition tissue sparing. In the 1980s, Walsh’s modification of Millin’s radical prostatectomy (1945) was a tissuesparing innovation that was initially criticized for fear of incomplete cancer resection [9]. The debate regarding partial nephrectomy continues to this day against the backdrop of a much‐refined appreciation of the biology of renal cancer [10]. Ironically, the field has been moving conceptually in the direction of focal therapy for decades. The dilemma we face now is determining how to view the contemporary results from studies of this new approach to cancer. As a corollary, how might we improve our understanding of which patients could benefit from the therapies described in this book?
The authors of the individual chapters were charged with answering a single question: what information can you provide to better inform the reader regarding the impact of tumor ablation on cancer care? Scholars from diverse specialties have contributed to this volume and the answers to the question posed vary accordingly. We sought to be inclusive but make no claim regarding comprehensiveness.
This book represents a modest contribution to an ongoing conversation about innovation in urologic oncology; and if we have succeeded only a little in serving the reader, this book will raise many more questions than it could possibly answer.