A comprehensive systematic review of testicular germ cell tumor surveillance

Abstract

Background

Testicular cancer is the most common malignancy in men aged 15–34, and its incidence has been increasing over the past half-century. Survival for stage I testis cancer approaches 100% regardless of management strategy which is often dictated by other factors such as perceived morbidity. Advances in treatment have attempted to decrease morbidity and surveillance is thought to achieve this goal.

Methods

An English language literature search of MEDLINE from 1966 to December 2005 and CINAHL from 1982 to December 2005 was conducted using a broad search strategy. Comparative and descriptive original articles on outcomes of seminoma or NSGCT surveillance would be deemed eligible and review articles containing no original data were omitted. One hundred and thirty-eight articles were selected for formal review, during which a database was compiled that documented the first author, publication year, tumor histologic type, study purpose or topic(s), methodology, sample size, median follow-up, and relevant results.

Results

Most evidence for the efficacy of surveillance is from descriptive series or non-experimental comparative studies. Relapse occurs in approximately 28% and 17% of surveillance patients in NSGCT and seminoma, respectively, and cause-specific survival is approximately 98% and 100%, respectively. Compliance with surveillance ranges from poor to adequate, however there is no evidence that compliance impacts clinical outcome. Cost analyses have yielded inconsistent results when comparing treatment modalities. There is scant literature on quality of life and psychosocial issues and results are inconsistent. Active surveillance appears to be appropriate and perhaps optimal first line management of clinical stage I seminoma and non-seminomatous germ cell tumors. Further quantitative and qualitative research is warranted to deepen understanding of these issues that may impact treatment decision-making.

Introduction

Testicular cancer is the most common malignancy in men aged 15–34 [1]. Although its overall incidence is low, it has been increasing significantly over the past half-century [2], [3], [4], [5], [6], [7] and an estimated 8250 new cases of testicular cancer will be diagnosed in the United States in the coming year [8]. Most testicular neoplasms are primary germ cell tumors (GCT), 61% being pure seminoma and the remainder non-seminomatous germ cell tumors (NSGCT) or mixed tumors [1]. Approximately 70–80% of seminomas [9] and one-third of NSGCT [10] present as clinical stage I (without evidence of metastases). Disease-specific survival for stage I testis cancer approaches 100% regardless of post-orchidectomy management strategy, which includes retroperitoneal lymph node dissection (RPLND), adjuvant radiotherapy, adjuvant chemotherapy, and initial active surveillance. It follows that management is often dictated by other factors such as perceived morbidity of alternatives and may be risk-adapted. Recent advances in treatment have attempted to decrease morbidity and surveillance is thought to achieve this goal.

Surveillance for stage I testis cancer involves varying regimens of serial clinical examinations, serologic studies and imaging studies in the absence of adjuvant treatment. Table 1, Table 2 illustrate the current standard surveillance protocols employed at our institution. Proponents of surveillance emphasize that potentially toxic treatments are avoided in the majority of patients with this approach. Orchidectomy alone followed by a surveillance regimen was first reported by Peckham in 1982 as a management option for stage I NSGCT [11]. A combination of concurrent factors served as the impetus for this management strategy. Improved accuracy of clinical staging with computerized tomography (CT) and tumor markers, a better understanding of prognostic features, and confidence that chemotherapy could offer a reliable salvage therapy for patients who progressed to metastatic disease provided patients and physicians with motivation to adopt surveillance and, at least initially, defer potentially avoidable treatment. In the late 1980s, surveillance strategies were implemented for stage I seminoma [12], [13], [14]. This has been more controversial as the alternative of adjuvant abdominal radiation has been perceived to have low toxicity and serum markers are considerably less reliable for surveillance of seminoma. This is a comprehensive systematic review of surveillance outcomes for stage I testicular cancer. To our knowledge, it is the first systematic review of surveillance for both seminoma and NSGCT and the first review that encompasses studies regarding cost, compliance, quality of life (QOL) and psychosocial aspects of surveillance.