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Michael P. Porter and Paul H. Lange

Renal tumors are a common cause of cancer, and renal cell carcinoma accounts for the vast majority of the renal tumors in the United States. The past two decades have produced numerous advances in the treatment of localized and metastatic renal cell carcinoma. Nephron-sparing surgery, laparoscopic nephrectomy, and energy-ablative techniques are now in the armamentarium of the urologist. The role of adrenalectomy and lymphadenectomy are better understood today than in decades past, and recent advances in the understanding of immunotherapy, cytoreductive nephrectomy, and metastatic disease have also improved treatment for this disease. As is often the case as technology and knowledge evolve, controversies regarding the surgical treatment of renal cancer exist. This article outlines some of these controversies and reviews the evidence surrounding each.

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William J. Ellis and Paul H. Lange

Robotic-assisted laparoscopic radical prostatectomy is now one of the most common ways to treat prostate cancer. Although it is undoubtedly an outstanding procedure, in many contexts the advantages of the laparoscopic approach are overstated. The authors believe that open radical prostatectomy will continue to have an important role. For example, an extensive lymphadenectomy is more easily accomplished with the open technique and may be important in staging and possibly curing patients at high risk for prostate cancer. Also, tactile sensation is a valuable asset in assessing the extent of local tumor, and this cannot yet be replicated with a robotic approach. Furthermore, obese patients, those with a history of extensive prior surgical procedures, and men with extremely large prostates may experience advantages with the open technique. Finally, the open approach has a significant advantage in terms of hospital costs.

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Mark H. Kawachi, Robert R. Bahnson, Michael Barry, J. Erik Busby, Peter R. Carroll, H. Ballentine Carter, William J. Catalona, Michael S. Cookson, Jonathan I. Epstein, Ruth B. Etzioni, Veda N. Giri, George P. Hemstreet III, Richard J. Howe, Paul H. Lange, Hans Lilja, Kevin R. Loughlin, James Mohler, Judd Moul, Robert B. Nadler, Stephen G. Patterson, Joseph C. Presti, Antoinette M. Stroup, Robert Wake and John T. Wei

The NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer Early Detection (to view the most recent version of these guidelines, visit the NCCN Web site at www.NCCN.org) provide a set of sequential recommendations detailing a screening and subsequent workup strategy for maximizing the detection of prostate cancer in an early, organ-confined state and attempting to minimize unnecessary procedures. These guidelines were developed for men who have elected to participate in prostate cancer screening; they are not meant to address the controversy regarding population screening. Overview Prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer death in American men. More than 192,000 men will be diagnosed with prostate cancer in 2009, and an estimated 27,360 men will die of this disease.1 During the same period, nearly 20 million men in the United States will be confronted with important decisions regarding early detection for prostate cancer. Men in the United States have an approximately 1 in 6 chance of eventually being diagnosed with this malignancy and about 1 in 30 chance of eventually dying of it.2 African-American men and men with a first-degree relative with prostate cancer (especially cancer found at a younger age) have a higher risk for developing prostate cancer.2–4 In a recent study of 26,111 men, the baseline prostate-specific antigen (PSA) value was found to be a stronger predictive factor than a positive family history or being of African-American heritage.5 Men who undergo regular PSA tests have a higher chance of undergoing a...
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Robert J. Motzer, Neeraj Agarwal, Clair Beard, Graeme B. Bolger, Barry Boston, Michael A. Carducci, Toni K. Choueiri, Robert A. Figlin, Mayer Fishman, Steven L. Hancock, Gary R. Hudes, Eric Jonasch, Anne Kessinger, Timothy M. Kuzel, Paul H. Lange, Ellis G. Levine, Kim A. Margolin, M. Dror Michaelson, Thomas Olencki, Roberto Pili, Bruce G. Redman, Cary N. Robertson, Lawrence H. Schwartz, Joel Sheinfeld and Jue Wang

Kidney Cancer Clinical Practice Guidelines in Oncology NCCN Categories of Evidence and Consensus Category 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there isuniform NCCN consensus. Category 2A: The recommendation is based on lower-level evidence and there is uniform NCCN consensus. Category 2B: The recommendation is based on lower-level evidence and there is nonuniform NCCN consensus (but no major disagreement). Category 3: The recommendation is based on any level of evidence but reflects major disagreement. All recommendations are category 2A unless otherwise noted. Clinical trials: The NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Overview In 2008, an estimated 54,390 Americans were diagnosed with kidney cancer and 13,010 died of the disease in the United States.1 Renal cell carcinoma (RCC) comprises approximately 2% of all malignancies, with a median age at diagnosis of 65 years. The rate of RCC has increased 2% per year for the past 65 years. The reason for this increase is unknown. Approximately 90% of renal tumors are RCC, and 85% of these are clear cell tumors.2 Other, less-common cell types include papillary, chromophobe, and Bellini (collecting) duct tumors. Collecting duct carcinoma comprises fewer than 1% of all cases. Medullary renal carcinoma is a variant of collecting duct renal carcinoma and was initially described as occurring in patients who are sickle cell–trait positive. Smoking and obesity are among the risk factors for RCC development. Several hereditary types...
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Robert J. Motzer, Neeraj Agarwal, Clair Beard, Graeme B. Bolger, Barry Boston, Michael A. Carducci, Toni K. Choueiri, Robert A. Figlin, Mayer Fishman, Steven L. Hancock, Gary R. Hudes, Eric Jonasch, Anne Kessinger, Timothy M. Kuzel, Paul H. Lange, Ellis G. Levine, Kim A. Margolin, M. Dror Michaelson, Thomas Olencki, Roberto Pili, Bruce G. Redman, Cary N. Robertson, Lawrence H. Schwartz, Joel Sheinfeld and Jue Wang

Testicular Cancer Clinical Practice Guidelines in Oncology NCCN Categories of Evidence and Consensus Category 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there is uniform NCCN consensus. Category 2A: The recommendation is based on lower-level evidence and there is uniform NCCN consensus. Category 2B: The recommendation is based on lower-level evidence and there is nonuniform NCCN consensus (but no major disagreement). Category 3: The recommendation is based on any level of evidence but reflects major disagreement. All recommendations are category 2A unless otherwise noted. Clinical trials: The NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Overview An estimated 8090 new cases of testicular cancer will be diagnosed in the United States in 2008.1 Germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes. These tumors also occur occasionally in extragonadal primary sites, but they are still managed the same as testicular GCTs. Although GCTs are relatively uncommon tumors that comprise only 2% of all human malignancies, they constitute the most common solid tumor in men between the ages of 15 and 34 years. In addition, the worldwide incidence of these tumors has more than doubled in the past 40 years. Several risk factors for GCT development have been identified, including prior history, positive family history, cryptorchidism, testicular dysgenesis, and Klinefelter's syndrome. GCTs are classified as seminoma or nonseminoma. Nonseminomatous tumors often include multiple cell types, including embryonal cell...
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Peter R. Carroll, J. Kellogg Parsons, Gerald Andriole, Robert R. Bahnson, Daniel A. Barocas, Erik P. Castle, William J. Catalona, Douglas M. Dahl, John W. Davis, Jonathan I. Epstein, Ruth B. Etzioni, Thomas Farrington, George P. Hemstreet III, Mark H. Kawachi, Paul H. Lange, Kevin R. Loughlin, William Lowrance, Paul Maroni, James Mohler, Todd M. Morgan, Robert B. Nadler, Michael Poch, Chuck Scales, Terrence M. Shaneyfelt, Marc C. Smaldone, Geoffrey Sonn, Preston Sprenke, Andrew J. Vickers, Robert Wake, Dorothy A. Shead and Deborah Freedman-Cass

Prostate cancer represents a spectrum of disease that ranges from nonaggressive, slow-growing disease that may not require treatment to aggressive, fast-growing disease that does. The NCCN Guidelines for Prostate Cancer Early Detection provide a set of sequential recommendations detailing a screening and evaluation strategy for maximizing the detection of prostate cancer that is potentially curable and that, if left undetected, represents a risk to the patient. The guidelines were developed for healthy men who have elected to participate in the early detection of prostate cancer, and they focus on minimizing unnecessary procedures and limiting the detection of indolent disease.

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Peter R. Carroll, J. Kellogg Parsons, Gerald Andriole, Robert R. Bahnson, Erik P. Castle, William J. Catalona, Douglas M. Dahl, John W. Davis, Jonathan I. Epstein, Ruth B. Etzioni, Thomas Farrington, George P. Hemstreet III, Mark H. Kawachi, Simon Kim, Paul H. Lange, Kevin R. Loughlin, William Lowrance, Paul Maroni, James Mohler, Todd M. Morgan, Kelvin A. Moses, Robert B. Nadler, Michael Poch, Chuck Scales, Terrence M. Shaneyfelt, Marc C. Smaldone, Geoffrey Sonn, Preston Sprenkle, Andrew J. Vickers, Robert Wake, Dorothy A. Shead and Deborah A. Freedman-Cass

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer Early Detection provide recommendations for prostate cancer screening in healthy men who have elected to participate in an early detection program. The NCCN Guidelines focus on minimizing unnecessary procedures and limiting the detection of indolent disease. These NCCN Guidelines Insights summarize the NCCN Prostate Cancer Early Detection Panel's most significant discussions for the 2016 guideline update, which included issues surrounding screening in high-risk populations (ie, African Americans, BRCA1/2 mutation carriers), approaches to refine patient selection for initial and repeat biopsies, and approaches to improve biopsy specificity.

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Peter R. Carroll, J. Kellogg Parsons, Gerald Andriole, Robert R. Bahnson, Daniel A. Barocas, William J. Catalona, Douglas M. Dahl, John W. Davis, Jonathan I. Epstein, Ruth B. Etzioni, Veda N. Giri, George P. Hemstreet III, Mark H. Kawachi, Paul H. Lange, Kevin R. Loughlin, William Lowrance, Paul Maroni, James Mohler, Todd M. Morgan, Robert B. Nadler, Michael Poch, Chuck Scales, Terrence M. Shanefelt, Andrew J. Vickers, Robert Wake, Dorothy A. Shead and Maria Ho

The NCCN Guidelines for Prostate Cancer Early Detection provide recommendations for men choosing to participate in an early detection program for prostate cancer. These NCCN Guidelines Insights highlight notable recent updates. Overall, the 2014 update represents a more streamlined and concise set of recommendations. The panel stratified the age ranges at which initiating testing for prostate cancer should be considered. Indications for biopsy include both a cutpoint and the use of multiple risk variables in combination. In addition to other biomarkers of specificity, the Prostate Health Index has been included to aid biopsy decisions in certain men, given recent FDA approvals.

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James E. Montie, Peter E. Clark, Mario A. Eisenberger, Rizk El-Galley, Richard E. Greenberg, Harry W. Herr, Gary R. Hudes, Deborah A. Kuban, Timothy M. Kuzel, Paul H. Lange, Subodh M. Lele, Jeffrey Michalski, Anthony Patterson, Kamal S. Pohar, Jerome P. Richie, Wade J. Sexton, William U. Shipley, Eric J. Small, Donald L. Trump, Phillip J. Walther and Timothy G. Wilson

Bladder Cancer Clinical Practice Guidelines in Oncology NCCN Categories of Evidence and Consensus Category 1: The recommendation is based on high-level evidence (e.g., randomized controlled trials) and there is uniform NCCN consensus. Category 2A: The recommendation is based on lower-level evidence and there is uniform NCCN consensus. Category 2B: The recommendation is based on lower-level evidence and there is nonuniform NCCN consensus (but no major disagreement). Category 3: The recommendation is based on any level of evidence but reflects major disagreement. All recommendations are category 2A unless otherwise noted. Clinical trials: The NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Overview An estimated 68,810 new cases of urinary bladder cancer will be diagnosed in the United States (51,230 men and 17,580 women) in 2008.1 Bladder cancer is the fourth most common cancer in men and is 3 times more common in men than in women in the United States. Furthermore, approximately 14,100 deaths (9950 men and 4150 women) from bladder cancer are anticipated.1 Bladder cancers are rarely diagnosed in individuals younger than 40 years. Because the median age at diagnosis is 65 years, medical comorbidities are a frequent consideration in patient management. The clinical spectrum of bladder cancer can be divided into 3 categories that differ in prognosis, management, and therapeutic aims. The first category consists of noninvasive tumors, for which treatment is directed at reducing recurrences and preventing progression to a more advanced stage. The...
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James Mohler, Robert R. Bahnson, Barry Boston, J. Erik Busby, Anthony D'Amico, James A. Eastham, Charles A. Enke, Daniel George, Eric Mark Horwitz, Robert P. Huben, Philip Kantoff, Mark Kawachi, Michael Kuettel, Paul H. Lange, Gary MacVicar, Elizabeth R. Plimack, Julio M. Pow-Sang, Mack Roach III, Eric Rohren, Bruce J. Roth, Dennis C. Shrieve, Matthew R. Smith, Sandy Srinivas, Przemyslaw Twardowski and Patrick C. Walsh

In the late 1980s and early 1990s, the number of newly diagnosed prostate cancers in the United States increased dramatically, surpassing lung cancer as the most common cancer in men.1 Experts generally believe that these changes resulted from prostate-specific antigen (PSA) screening that detected many early-stage prostate cancers. For example, the percentage of patients with low-risk disease has increased (45.3% in 1999–2001 vs. 29.8% in 1989–1992; P < .0001).2 The incidence of prostate cancer increased 2.0% annually from 1995 to 2001 and has since declined. In 2009, an estimated 192,280 new cases were diagnosed and prostate cancer was expected to account for 25% of new cancer cases in men.1 Fortunately, the age-adjusted death rates from prostate cancer have also declined (–4.1% annually from 1994 to 2001).1 Researchers expect prostate cancer to account for 27,360 deaths in 2009.1 This comparatively low death rate suggests that, unless prostate cancer is becoming biologically less aggressive, increased public awareness with earlier detection and treatment of prostate cancer has begun to affect mortality from this prevalent cancer. However, early detection and treatment of prostate cancers that do not threaten life expectancy cause unnecessary side effects that impair quality of life, increase health care expenses, and decrease the value of PSA and digital rectal examination (DRE) as early detection tests.3,4To properly identify and manage patients with prostate cancer or any other malignancy, physicians must have an in-depth understanding of the natural history and diagnostic, staging, and treatment options. To this end, every year the NCCN...