SAN FRANCISCO, CA USA (UroToday.com) - Testis cancer remains the most common cancer among men aged 15 to 35 years, and while the incidence is rising, most men will present stage I disease.
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Generally, treatment of stage I germ cell tumors (seminoma and non-seminoma) involves orchiectomy followed by either active surveillance or adjuvant therapy with chemotherapy or radiation. The use of surveillance for stage I disease has gained widespread acceptance.
For stage I seminoma, the risk of relapse is 5-15%, and no tumor characteristic accurately predicts recurrence. Adjuvant low-dose radiotherapy and single-dose carboplatin chemotherapy demonstrate equivalent efficacy in reducing relapse rates from 15% to 5%. However, unnecessarily exposing the vast majority of patients to potentially toxic therapy comes with risks. Despite improvements in modern radiotherapy, the standardized mortality ratios for all-cause mortality and mortality from second malignant neoplasm are still elevated. Of patients that do relapse, most will have stage IIA or IIB disease, and almost all will be salvageable with chemotherapy (in one large series, there was only one testis cancer mortality out of 1 477 patients). The risk of death during AS is equivalent to adjuvant therapy (< 0.1%) used for non-bulky relapses. We now have follow-up data of significant duration to safely recommend AS for patients with stage I seminoma.
The story for Stage I non-seminomatous germ cell tumors is similar. For patients with low-risk disease, the risk of recurrence following orchiectomy is again 10-15%, and AS remains the standard of care. For high-risk patients, there is a higher risk of recurrence (40-60%) following orchiectomy, and most will be treated with adjuvant therapy. However if AS is pursued, it must be performed with greater intensity and continued for a longer duration than that used for low-risk patients. The ideal surveillance protocol has not been rigorously defined. Implementation of AS has been slow to gain acceptance, largely driven by unfounded fears of salvage therapy failure and concerns regarding compliance. AS uses fewer resources, avoids exposure to unnecessary therapies, and is associated with better quality of life.
Highlights of a presentation by Clair J. Beard, MD at the 2014 Genitourinary Cancers Symposium - January 30 - February 1, 2014 - San Francisco Marriott Marquis - San Francisco, California USA
Dana-Farber Cancer Institute, Boston, MA USA
GU Cancers Symposium 2014, seminoma, non-seminoma, germ cell tumor (GCT), active surveillance (AS), orchiectomy