Follow-up for GU Malignancies

1. Follow-up for GU Malignancies David Kim Radiation Oncologist BCCA - Southern Interior

2. Follow-up of GU Malignancies Objectives • rationale, aim, and details of general follow-up • general BCCA guidelines and position • follow-up of specific GU sites • low risk seminoma • other sites (bladder, kidney, other testicular tumors, urethra, penis, renal pelvis and ureter) • prostate

3. Follow-up of GU Malignancies Objectives • rationale, aim, and details of general follow-up • general BCCA guidelines and position • follow-up of specific GU sites • low risk seminoma • other sites (bladder, kidney, other testicular tumors, urethra, penis, renal pelvis and ureter) • prostate

4. Follow-up of GU Malignancies Definition • “an action that serves to increase the effectiveness of a previous one”

5. Follow-up of GU Malignancies Rationale for follow-up: • early detection of recurrent or metachronous disease leads to more effective salvage • provide reassurance for patients • allows for improved ancillary patient support • improves data collection for research

6. Follow-up of GU Malignancies Aims of follow-up: • manage individual patient (where early detection and intervention would improve patient outcome) • permit a review of current cancer management policy

7. Follow-up of GU Malignancies Type and frequency of follow-up is determined by: • type and extent of disease ~ likelihood of recurrence (location, frequency and “curability”) • likelihood and severity of treatment complications • utility of investigative tools (early detection of abnormalities that results in improved outcomes) • viable/appropriate method of intervention • individual patient needs

8. Follow-up of GU Malignancies Location of follow-up: • follow-up is often managed at a cancer center • follow-up may be managed by a family doctor or a local specialist if: • investigative tools and interpretation of results are available • long distances complicate follow-up visits

9. Follow-up of GU Malignancies Objectives • rationale, aim, and details of general follow-up • general BCCA guidelines and position • follow-up of specific GU sites • low risk seminoma • other sites (bladder, kidney, other testicular tumors, urethra, penis, renal pelvis and ureter) • prostate

10. Follow-up of GU Malignancies Objectives • rationale, aim, and details of general follow-up • general BCCA guidelines and position • follow-up of specific GU sites • low risk seminoma • other sites (bladder, kidney, other testicular tumors, urethra, penis, renal pelvis and ureter) • prostate

11. Follow-up of GU Malignancies General guidelines from the BCCA GU tumor group website: • Following the completion of treatment, all patients need to be monitored for potential recurrence of cancer and complications of therapy. This is needed both for management of the individual patient (where early detection would improve outcome), and to permit periodic review and improvement of current treatment policy. • Often it is felt appropriate to share follow up with the family doctor (and/or the urologist), in which case it is important for the patient to be clear who is responsible for certain aspects of the disease, e.g., symptom control by the family doctor, with advice from the BC Cancer Agency at the doctor's request. • Notification is requested in the event of any of the following: • recurrence at the primary site (particularly in patients with clinically localized disease treated with surgery and/or radiotherapy) • metastasis at regional or distant sites • complications of therapy especially if acute requiring hospitalization, or chronic and symptomatic • death with primary cause and whether cancer or treatment contributed • The event, date, and evidence where appropriate should be sent to the Agency chart where it will come to the attention of the oncologist, and will be available for periodic review by the tumour group. This information is requested annually for patients no longer followed at the BCCA.

12. Follow-up of GU Malignancies General follow-up guidelines from the GU tumor group: • cancer recurrence and treatment complication monitoring • management of the individual patient • review and improve current treatment policy. • responsibility for various aspects of follow-up • notification is requested for: • recurrence, metastasis, treatment complications, death • information is requested annually

13. Follow-up of GU Malignancies Objectives • rationale, aim, and details of general follow-up • general BCCA guidelines and position • follow-up of specific GU sites • low risk seminoma • other sites (bladder, kidney, other testicular tumors, urethra, penis, renal pelvis and ureter) • prostate

14. Follow-up of GU Malignancies - Testis germ cell tumors non-germ cell tumors non seminoma seminoma N0 (surveillance) N0 (post-radiation) N1-2 N3, or post-relapse

15. Follow-up of GU Malignancies - Testis germ cell tumors non-germ cell tumors non seminoma seminoma N0 (surveillance) N0 (post-radiation) N1-2 N3, or post-relapse

16. Follow-up of GU Malignancies - Kidney • regular follow up for post-surgical patients • follow-up is through the urologist and/or the family doctor • asymptomatic recurrence usually incurable, but a solitary metastasis may be treated definitively.

17. Follow-up of GU Malignancies - Bladder • Superficial Bladder Cancer • subsequent resections, institution of intravesical chemotherapy or consideration of radical cystectomy may be indicated

18. Follow-up of GU Malignancies - Bladder • Muscle-Invasive Disease • follow up for local recurrence following radical irradiation is essential since salvage cystectomy may have curative potential • all post-cystectomy patients, unless on clinical trials, should be followed by the family physician and urologist

19. Follow-up of GU Malignancies - Prostate • The main goal of follow-up is the early detection of recurrence in those situations where the early institution of salvage therapy can cure or prolong life. Local recurrence after radical prostatectomy may be an example. In contrast, most patients who have received primary radical radiation therapy may only be managed with palliative intent in the event of recurrence, and the value of routine follow-up is questionable.

20. Follow-up of GU Malignancies - Prostate Watchful waiting • distinguish progressive from indolent cancer • PSA velocity • focus on symptoms • urinary incontinence, obstructive symptoms • erectile dysfunction • bone pain • imaging only if clinically warranted • institution of definitive therapy • other medical care should be maintained

21. Follow-up of GU Malignancies - Prostate • Surgery • regular PSA testing • early PSA nadir • treatment complications • salvage RT • salvage hormone therapy Post definitive therapy • Radiation Therapy • regular PSA testing • late PSA nadir • treatment complications • salvage hormone therapy

22. Follow-up of GU Malignancies - Prostate Metastatic disease • PSA testing at the physician’s discretion • focus on symptoms • imaging for specific symptoms where treatment is anticipated • more frequent follow-up if systemic therapy is refused? • management of hormone refractory disease

23. Follow-up of GU Malignancies Objectives • rationale, aim, and details of general follow-up • general BCCA guidelines and position • follow-up of specific GU sites • low risk seminoma • other sites (bladder, kidney, other testicular tumors, urethra, penis, renal pelvis and ureter) • prostate