22 © 2 0 0 6 B J U I N T E R N A T I O N A L | 9 9 , 2 2 – 2 7 | doi:10.1111/j.1464-410X.2006.06477.x Review Article MEDICAL MANAGEMENT OF PROSTATE CANCER STERNBERG et al. The medical management of prostate cancer: a multidisciplinary team approach Cora N. Sternberg 1 , Michael Krainer 2 , William K. Oh 3 , Sergio Bracarda 4 , Joaquim Bellmunt 5 , Haluk Ozen 6 , Alexandre Zlotta 7 , Tomasz M. Beer 8 , Stephane Oudard 9 , Michael Rauchenwald 10 , Iwona Skoneczna 11 , Markus M. Borner 12 and John M. Fitzpatrick 13 1 Department of Medical Oncology, San Camillo Forlanini Hospital, Rome, Italy, 2 Department of Medical Oncology, Medical University Vienna, Austria, 3 Dana-Farber Cancer Institute/Lank Center for Genitourinary Oncology, Boston, MA, USA, 4 Medical Oncology, Azienda Ospedaliera di Perugia, Perugia, Italy, 5 Medical Oncology Service, University Hospital del Mar, Barcelona, Spain, 6 Department of Urology, Hacettepe University, Ankara, Turkey, 7 Department of Urology, University Clinics of Brussels, Brussels, Belgium, 8 Oregon Health and Science University Cancer Institute, Portland, OR, USA, 9 Medical Oncology Department, European Georges Pompidou Hospital, Paris, France, 10 Department of Urology and Andrology, Ludwig Boltzmann Institute for Urological Oncology, Danube Hospital, Vienna, Austria, 11 M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Klinika Nowotworów Ukladu Moczowego, Warszawa, Poland, 12 Department of Medical Oncology, Inselspital, Bern, Switzerland and 13 Mater Misericordiae Hospital and University College Dublin, Ireland Accepted for publication 30 June 2006 assessing the treatment of prostate cancer within the context of a multidisciplinary team. It encompasses a broad range of topical issues, including the definition of hormone resistance, opportunities for introducing chemotherapy at earlier stages of the disease, and how urologists, medical oncologists, and radiation therapists can work together to identify these opportunities. IMPROVING COLLABORATION BETWEEN UROLOGISTS, MEDICAL ONCOLOGISTS, AND RADIATION THERAPISTS Education and further training will be required to optimize the relationship between specialists such as urologists, medical oncologists, and radiation therapists. This should include early interaction at the training level (urology and oncology fellowships). In general, urologists are further along in the process of obtaining the relevant subspeciality training, as exemplified by the recognition of urological oncologists in some countries. In medical oncology departments, the availability of expert experience in the treatment of urological cancers is currently often based on individual interest and needs to be provided in a structured way in the future. It will be important to ensure that urologists and radiation therapists do not feel that they are ‘losing’ their patients by collaborating with oncologists; instead, they should be encouraged to see it as gaining access to physicians who are experienced in administering systemic therapy and can thereby improve the overall treatment results with their complementary skills. Some of the barriers to successful collaboration between urologists, oncologists, and radiation therapists are: • Absence of interaction between urologists and medical oncologists in the past. • Chemotherapy for prostate, testicular, and bladder cancer is given by urologists in some departments. • Lack of feedback from oncologists to urologists in some cases. • Late referral of patients with prostate cancer to oncologists after the use of most therapeutic options. • Lack of a wide variety of potential treatments for advanced urological cancer in the past. • Difference of opinion between urologists and oncologists as to what constitutes a beneficial survival advantage from a drug. CURRENT TREATMENT OF PATIENTS WITH INCREASING PSA LEVELS AFTER LOCAL THERAPY An increasing PSA level in this situation is defined as PSA progression after a nadir following definitive local treatment. Varying thresholds have been used as the exact value for the PSA nadir, with 0.2 or 0.4 ng/mL both being accepted in the context of prostatectomy. Risk factors for metastases and prostate cancer-related death subsequent to an increasing PSA level after surgery or radiation therapy include a high preoperative PSA level, a high Gleason score, positive margins, seminal vesicle involvement, extracapsular extension, a short PSA doubling time of < 10 months and a disease-free interval of < 3 years between local treatment KEYWORDS multidisciplinary, chemotherapy, prostate cancer INTRODUCTION For many years the benefit of chemotherapy in patients with prostate cancer was thought to be limited to palliation of late-stage disease, and thus medical oncologists only became involved in patient care towards the end of the disease process, if at all. However, two recent landmark phase-III trials with docetaxel-based therapy (TAX 327 and Southwest Oncology Group, SWOG, 9916) have shown a survival benefit with chemotherapy for patients with metastatic androgen-independent prostate cancer (AIPC), prompting a change in patterns of care [1,2]. The consequent change in treatment has increased the need for closer collaboration between urologists, medical oncologists, and radiation therapists to benefit patient management. With clinical trials for new drugs and new indications (neoadjuvant therapy, adjuvant therapy, increasing PSA levels after local treatment, and hormone- sensitive cancer) planned or underway, it is crucial that solid foundations are laid for a dynamic relationship between the physicians responsible for the care of patients with prostate cancer, as this relationship is likely to become even more important over time. The aim of this review is to facilitate the medical management of patients with AIPC by