CUA 2017: Safety of Minimizing Intensity of Followup on Active Surveillance for Clinical Stage I Testicular Germ Cell Tumors

Toronto, Ontario ( Active surveillance of stage 1 testicular germ cell tumors remains a standard of care, but the AS regimen continues to be modified and improved with experience. The Princess Margaret Cancer Centre (PMCC) experience with active surveillance has a long history, and began recommending a non-risk adapted active surveillance protocol for all clinical stage I (CSI) testicular germ cell tumors (TGCT) in 1981.

While the initial protocol had much more frequent blood draws, clinic visits, imaging, and higher radiation doses compared to the current protocol, particularly after the 2-year time point, the consequences of that reduction have never before been analyzed.

In this study, the authors searched the extensive PMCC testicular cancer experience for patients with seminoma and non-seminoma TGCT on AS between 1981‒2014 (allowing a minimum of two years follow-up). During that time period, surveillance schedules were meaningfully changed four times for non-seminoma and three times for seminoma. Primary endpoints for this study included relapse rate, time to relapse, stage at relapse, and burden of relapse treatment during each schedule.

Overall, they identified 710 patients with seminoma and 552 patients with non-seminoma patients who underwent AS, with median follow-up of 6.76 and 5.21 years, respectively. During that time frame, the number of computed tomography (CT) scans decreased from 11 to five (non-seminoma patients) and from 20 to 10 (seminoma), while chest X-rays decreased from 27 to 0 (non-seminoma) and from 13 to 4 (seminoma). 

In terms of cancer outcomes, the relapse rate decreased over time, with no increase in stage or treatment burden at relapse. This was likely due to improved patient selection for AS patients, due to better staging studies. For seminoma, there appeared to be a decrease in N, M, and S stages at the time of relapse. For patients on the most recent protocols, of the patients with relapse, 100% of seminoma and 82.6% of non-seminoma patients were cured with monotherapy only. 

Overall, this study reaffirms that a more limited protocol based on better understanding of disease progression has not sacrificed oncologic care, but has reduced patient burden. Patients that did relapse on the new protocols were able to be salvaged safely. 

Presented By: Matthew Da Silva, BMSc, Faculty of Medicine, University of Toronto, Toronto, Ontario

Co-Authors: Michael A. Jewett, Padraig Warde, Eshetu Atenafu, Lynn Anson-Cartwright, Aaron Hansen, Peter Chung, Philippe Bedard, Joan Sweet, Martin O'Malley, Robert J. Hamilton
Institution: University of Toronto

Written By: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto   Twitter: @tchandra_uromd at the  72nd Canadian Urological Association Annual Meeting - June 24 - 27, 2017 - Toronto, Ontario, Canada