Non-Seminoma: Stage I
Patients with stage I testicular cancer of non-seminoma type have a primary cancer that is limited to the testes and is curable in more than 95% of cases.
A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.
The following is a general overview of the treatment of stage I testicular non-seminoma. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.
Standard Approach: Retroperitoneal Lymph Node Dissection and Surveillance
Currently, surgical orchiectomy and retroperitoneal lymph node dissection is considered to be the standard approach to treatment of stage I non-seminoma in adults, but not in children. The major advantage of retroperitoneal node dissection is accuracy of staging. Following surgery, patients undergo surveillance, which consists of monthly checking of cancer markers and chest x-rays for the first year and slightly less frequent evaluations in the second year. Patients that experience a cancer recurrence are treated with chemotherapy.
In clinical studies, 15% of patients with a negative lymph node dissection (no evidence of spread) experienced cancer recurrence, usually in the lungs. Recurrences usually occur within 18 months of surgery and most patients are subsequently cured with combination chemotherapy. In patients with stage I cancer confirmed by retroperitoneal lymph node dissection, the presence of lymphatic or venous invasion in the primary cancer appears to predict for a greater chance of cancer relapse.
Alternative Approach: No Retroperitoneal Lymph Node Dissection, Surveillance, and Chemotherapy for Those Who Relapse
Since virtually all patients with stage I non-seminoma that relapse after orchiectomy can be cured with combination chemotherapy, some doctors believe it is not necessary to perform a retroperitoneal lymph node dissection. Patients who elect this approach are treated with orchiectomy, but do not undergo retroperitoneal lymph node dissection. Instead, they have frequent follow-up visits with their doctor (surveillance) including chest x-rays, evaluations of cancer markers and, during the first year, abdominal CT scan every 2 months. Since approximately 25% of patients initially diagnosed with stage I cancer who are treated with orchiectomy and careful observation will in fact have a stage II cancer with spread to the retroperitoneal lymph nodes, careful follow-up and prompt administration of chemotherapy for relapse is important.
In a large clinical study involving 105 patients with clinical stage I disease (no retroperitoneal lymph node dissection), not including patients with choriocarcinoma, the relapse rate following treatment with orchiectomy alone was 26%. All cancer recurrences occurred within 2 years of diagnosis and 24 of the 27 patients with recurrent cancer were cured with chemotherapy. Relapses have, however, been reported more than 5 years after the orchiectomy in patients who did not undergo a retroperitoneal lymph node dissection. The option of no lymph node dissection is considered only if a CT scan and cancer markers are negative.
Alternative Approach: No Lymph Node Dissection and Adjuvant Chemotherapy
Patients with clinical stage I non-seminoma may also elect to receive treatment with chemotherapy following orchiectomy and avoid a retroperitoneal lymph node dissection. Two courses of bleomycin, etoposide and Platinol® (BEP) have been given to patients with clinical stage I disease who were considered at high risk of relapse based on the presence of vascular invasion and aggressive histology. In these studies, 95-98% of patients were cured. These results may be better than results achieved in patients treated with orchiectomy followed by surveillance, with chemotherapy reserved only for patients who relapse.
The number of patients treated with adjuvant chemotherapy is too small to draw conclusions about the risk of chemotherapy-induced secondary malignancies, impact on fertility or risk of late relapse. It is unclear if the 3 approaches to treatment are equivalent or one is superior to another. It is clear, however, that the differences will be small and hard to detect without an extremely large clinical trial performing a direct comparison of the 3 approaches.
Factors Which Affect Decision Making
Physicians have been surveyed to determine which therapy they would select. Half chose surgery and half chose chemotherapy. However, 82% of medical oncologists chose chemotherapy and 83% of urologists chose surgery. Medical oncologists are experts in the delivery of chemotherapy and urologists perform surgery. This survey demonstrated that physicians often make decisions based on their experience and comfort level with the procedure they perform. Thus, the treatment offered for a stage I testicular cancer patient may depend on the type of physician the patient sees. The management of stage I testicular cancer is still evolving. This survey demonstrates the importance of having all treatment information presented in an objective fashion and for the need to seek the opinion of more than one physician, preferably in a different subspecialty.
Questions to Ask Your Physician:
- What are the advantages, disadvantages and side effects of a retroperitoneal lymph node dissection?
- What are the chances of my disease coming back without lymph node dissection or chemotherapy?
- How frequently do I need to have CT scans if I do not receive adjuvant chemotherapy treatment?
- What are the long-term side effects of adjuvant chemotherapy?
Strategies to Improve Outcomes
The progress that has been made in the treatment of testicular cancer has resulted from improved development of chemotherapy and radiation treatments in patients with more advanced stages of cancer and participation in clinical trials.
Clinical trials for patients with stage I non-seminoma testicular cancer are limited to determining the initial extent of treatment necessary for optimal results and what the factors are that favor one approach over another. It will be important to determine which treatment approach produces the fewest long-term side effects in patients with stage I non-seminoma.