SUO 2017: Analysis Defining Optimal Management of Clinical Stage 1 High-Risk Nonseminomatous Germ Cell Testicular Cancer

Washington, DC ( The standard of care for clinical stage non-seminomatous germ cell testicular cancer (NSGCT) is active surveillance, single dose chemotherapy (BEP x 1) or primary RPLND. While most favor active surveillance for all CS1 NSGCT, some centers favor a risk stratification approach. For patients with high-risk features, such as presence of lymphovascular invasion (LVI), they would favor BEP x 1 rather than AS. However, there are good arguments for and against both approaches. 

In this nice abstract, the group from Vanderbilt provides a decision analysis defining optimal management of patients with CS NSGCT with high-risk features. They ran the analysis accounting for a range of orchiectomy cure rates, utility values for each of the treatment arms, and range of orchiectomy cure rates if the utility rate = 1. Utility rate ranged from 0 (death from disease) to 1 (alive in good health).

The utility rates utilized are shown below:

The expected treatment values are below:

The sensitivity analysis for the efficacy of the orchiectomy is below:

Lastly, the sensitivity analysis for the efficacy of the orchiectomy is below, if utility = 1:

Interestingly, account for patient concerns for specific side effects are included, active treatment with either BEPx1 or RPLND is preferred over AS. The only time AS is superior to primary treatment in this high-risk cohort is if orchiectomy cure rates exceed 82%, which the authors state is unlikely in the setting of high-risk CS1 NSGCT.

While this certainly adds oil to the frying pan, this is a decision model nonetheless. At the end of the day, patient discussion and shared decision making is key. 

Presented by: Svetlana Avulova, MD

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC