Adjuvant Surveillance Effective in Early-Stage Seminoma

Mette Saksoe Mortensen, MD

Active surveillance following radical orchiectomy is an effective treatment strategy for men with stage I seminoma, according to a large database analysis presented during an ASCO press conference.

This study represents the largest published analysis to support surveillance as a preferred management option for patients with stage I seminoma, researchers indicated. ASCO spotlighted the study in advance of its annual meeting, scheduled for May 31 - June 4 in Chicago, Illinois, where the abstract will be presented.

Seminomas are a less aggressive form of testicular cancer that can generally be cured with radiation therapy or carboplatin following primary surgery. However, some of the long-term side effects of treatment include secondary gastrointestinal cancers and leukemia, warranting a shift toward surveillance. This need is further enhanced by the commonly young age at diagnosis.

“To our knowledge, this study is the largest to address this issue in patients with stage I seminoma, and with the longest follow-up," said Mette Saksoe Mortensen, MD, from the Copenhagen University Hospital in Denmark. “Now we have solid proof that surveillance is safe and appropriate for most patients with this particular cancer.”

In the database analysis, researchers identified 1822 patients with stage I seminoma who were managed with surveillance between 1984-2008. This data was merged with a national registry allowing the Danish researchers to follow patient outcomes until December 2012. For their analysis, researchers examined relapses and the probability of surviving cancer in the absence of other causes of death, labeled as cancer specific survival (CSS).

After a median of 15.4 years, relapses were observed in a total of 355  patients (19.5%), 257 patients relapsed within the first 2 years, 72 relapsed between years 2 and 5, and 26 relapsed after 5 years. Overall, the median time to relapse was 13.7 months and the 10-year CSS for patients treated with surveillance was 99.6%. Following relapse, patients with stage I seminoma can still be effectively cured using radiation or chemotherapy. As a result, only 10 patients died of cancer or treatment-related causes over the course of the study.

As part of the study, researchers also interrogated tissue samples for prognostic markers of relapse that could be used to help guide treatment decisions. Across these analyses, vascular invasion, tumor size >4 cm, and serum human chorionic gonadotropin >200 IU/L were all predictive factors for relapse.

"We also characterized key prognostic factors for relapse, which can help us identify 'high-risk' patients who may need adjuvant therapy instead of surveillance," Mortensen noted. "However, in general, seminoma stage I patients can safely be followed on a surveillance program."

The current strategy for surveillance calls for 5 years of follow-up, with frequent physical exams, blood tests, CT scans, and x-rays for the first 2 years followed by a less strenuous approach for the remaining 3 years. Concerns over the costs associated with this approach are a leading roadblock to the widespread adoption of surveillance for patients with stage I seminoma. As a result of these concerns, the National Comprehensive Cancer Network (NCCN) updated its 2012 guidelines to include fewer imaging and lab tests after orchiectomy. This adjustment prompted an investigation into the costs associated with each management strategy for patients with stage I seminoma.

In this analysis, presented at the 2013 Genitourinary Cancers Symposium, the differences in costs were significantly narrowed by the NCCN recommendations. However, when the expenses associated with salvage therapy following relapse were included, surveillance was more costly than other options. Unfortantely, the study had several limitations, the authors admitted, since it did not include long-term costs associated with follow up care or quality-adjusted data.

Placing these findings into perspective, Clifford A. Hudis, MD, said, "This important study is one of several recent reminders that sometimes 'less is more' in patient care. Opting for surveillance spares patients, most of whom are young men, from the harmful side effects of chemotherapy and radiation without diminishing their chances for a long and healthy life." Hudis is the ASCO President-Elect and chief of the Breast Cancer Medicine Service and attending physician at Memorial Sloan-Kettering Cancer Center in New York.

Mortensen MS, Gundgaard MG, Lauritsen J. A nationwide cohort study of surveillance for stage I seminoma. J Clin Oncol. 2013;(suppl; abstr 4502).

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