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Observation most common adjuvant management for stage I testicular seminoma

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December 16, 2014

The use of observation after orchiectomy has significantly increased and is now the most common form of adjuvant management for patients with stage I testicular seminoma, according to study results.

Race, insurance status and site of treatment all influenced whether patients underwent observation, chemotherapy or radiation post-orchiectomy, results showed.

Observation after orchiectomy was more common in racial minorities and in the uninsured,” researcher Phillip J. Gray, MD, of the department of radiation oncology at Massachusetts General Hospital, told HemOnc Today. “We know from many other studies that these groups often lack access to high-quality medical care. This finding raises the concern that, while these patients are receiving management preferred by the National Comprehensive Cancer Network guidelines, they may not be receiving appropriate follow-up imaging and examinations necessary to detect disease recurrence.”

Gray and colleagues used the National Cancer Data Base to identify 34,067 patients who had been treated for their stage I testicular seminoma between 1998 and 2011. The cohort’s median age at diagnosis was 37 years, and 79.6% were non-Hispanic white.

A majority of the patients had stage IA disease (68.8%), whereas 27% had stage IB disease and 4.1% had stage IS disease.

In 1998, the most common form of adjuvant therapy for patients with stage IA or IB disease was radiation therapy (70.8%), followed by observation (23.7%) and chemotherapy (1.5%). However, by 2011, most patients underwent observation (54%). The rate for radiation therapy decreased to 28.8% that year, whereas the utilization of chemotherapy increased to 16%.

Further analyses of patients with stage IA or IB disease indicated observation was more common among those who were black (OR=1.31; 95% CI, 1.14-1.51), Hispanic (OR=1.39; 95% CI, 1.27-1.53) or another race (OR=1.33; 95% CI, 1.14-1.55) compared with those who were non-Hispanic white.

Observation also was more common among patients with Medicare (OR=1.55; 95% CI, 1.37-1.75) and those who did not have insurance (OR=1.33; 95% CI, 1.22-1.45).

However, patients treated in comprehensive community centers were less likely to undergo observation compared with patients treated in NCI-designated cancer centers (OR=0.80; 95% CI, 0.72-0.89).  Observation was more common in patients treated at centers with seminoma case volumes that were medium (OR=1.2; 95% CI, 1.12-1.27) or low (OR=1.55; 95% CI, 1.38-1.74) compared with centers with high case volumes.

When researchers evaluated trends for adjuvant management among patients with stage IS disease between 1998 and 2011, they found similar trends occurred in the increased use of observation (18.4% vs. 39.3%) and decreased use of radiation therapy (76.3% vs. 40.2%). However, in 2011, these patients were significantly more likely to undergo adjuvant radiation (40.2% vs. 28.8%) or chemotherapy (20.5% vs. 16%) compared with patients with stage IA or IB disease (P˂.001 for both).

“The change in practice patterns for patients with stage IS seminoma was similar to that for stage IA/B (including an increase in observation),” Gray said. “This is problematic as these patients were excluded from clinical trials of active surveillance (observation) or chemotherapy. Radiation therapy has long been the standard of care for these patients and that recommendation has only recently changed in the NCCN guidelines. We need additional data to define the best strategy in managing that subgroup.”

Disclosure: The study was funded by the American Cancer Society. The researchers report no relevant financial disclosures.

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PERSPECTIVE

Over the past 2 decades, there have been dramatic changes in the management of patients with stage I testicular seminoma (TS1). As Gray and colleagues note in their recent report in Cancer, post-orchiectomy active surveillance (AS) for TS1 has increased significantly within the past decade, with a corresponding rise in adjuvant chemotherapy and decline in radiotherapy. With recurrence rates of 3% to 4%, adjuvant radiotherapy had been the preferred treatment for the management of patients with TS1. More recently, several fundamental principles have challenged this approach. More than 80% of all patients with TS1 are cured with orchiectomy alone. In patients who relapse following orchiectomy, effective treatment modalities are available, with cure rates approaching 100%.

Notwithstanding improvements in technique — as well as reductions in dose and field — numerous studies have demonstrated late long-term sequelae associated with adjuvant radiotherapy, including increased risk for cardiovascular disease and secondary malignancies. Long-term survival and toxicity data associated with chemotherapy (single-agent carboplatin) are not yet available. Though formal comparisons between AS and chemotherapy or radiotherapy are lacking, growing observational and retrospective data support AS as an effective strategy for these patients. As such, for the majority of patients, AS rather than adjuvant treatment in compliant patients with TS1 is recommended.

Consistent with previous studies that highlighted the racial and ethnic disparities in the delivery of cancer treatment, the authors also note that sociodemographic factors affected the choice of treatment approach. Though minority patients were more likely to not receive adjuvant treatment, which is an appropriate strategy, there is concern that such findings may be attributed to suboptimal surveillance and monitoring. Reducing the influence of nonclinical factors in the management of patients with testicular cancer is critical to optimizing therapy and reducing health care disparities.

— Rana R. McKay, MD

Dana-Farber Cancer Institute, Harvard Medical School

— Quoc-Dien Trinh, MD

Brigham and Women’s Hospital, Harvard Medical School

— Philip W. Kantoff, MD

Dana-Farber Cancer Institute, Harvard Medical School

Disclosure: McKay, Trinh and Kantoff report no relevant financial disclosures.

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Shavers VL. J Natl Cancer Inst. 2002;94:334-357.

Tandstad T. J Clin Oncol. 2011;29:719-725.

Travis LB. J Natl Cancer Inst. 2010;102:1114-1130.



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