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Platinum Priority – Testis Cancer
Editorial by XXX on pp. x–y of this issue

Conditional Risk of Relapse in Surveillance for Clinical Stage I Testicular Cancer

By: Madhur Nayana, Michael A.S. Jewetta, Ali Hosnib, Lynn Anson-Cartwrighta, Philippe L. Bedardc, Malcolm Moored, Aaron R. Hansenc, Peter Chungb, Padraig Wardeb, Joan Sweete, Martin O’Malleyf, Eshetu G. Atenafug and Robert J. Hamiltona

European Urology, Volume 71 Issue 1, January 2017, Pages 120-127

Published online: 01 January 2017

Keywords: Germ cell tumor, Testicular neoplasm, Treatment outcome

Abstract Full Text Full Text PDF (2,1 MB)

Abstract

Background

Patients on surveillance for clinical stage I (CSI) testicular cancer are counseled regarding their baseline risk of relapse. The conditional risk of relapse (cRR), which provides prognostic information on patients who have survived for a period of time without relapse, have not been determined for CSI testicular cancer.

Objective

To determine cRR in CSI testicular cancer.

Design, setting, and participants

We reviewed 1239 patients with CSI testicular cancer managed with surveillance at a tertiary academic centre between 1980 and 2014.

Outcome measurements and statistical analysis

cRR estimates were calculated using the Kaplan-Meier method. We stratified patients according to validated risk factors for relapse. We used linear regression to determine cRR trends over time.

Results and limitations

At orchiectomy, the risk of relapse within 5 yr was 42.4%, 17.3%, 20.3%, and 12.2% among patients with high-risk nonseminomatous germ cell tumor (NSGCT), low-risk NSGCT, seminoma with tumor size ≥3 cm, and seminoma with tumor size <3 cm, respectively. However, for patients without relapse within the first 2 yr of follow-up, the corresponding risk of relapse within the next 5 yr in the groups was 0.0%, 1.0% (95% confidence interval [CI] 0.3–1.7%), 5.6% (95% CI 3.1–8.2%), and 3.9% (95% CI 1.4–6.4%). Over time, cRR decreased (p ≤ 0.021) in all models. Limitations include changes to surveillance protocols over time and few late relapses.

Conclusions

After 2 yr, the risk of relapse on surveillance for CSI testicular cancer is very low. Consideration should be given to adapting surveillance protocols to individualized risk of relapse based on cRR as opposed to static protocols based on baseline factors. This strategy could reduce the intensity of follow-up for the majority of patients.

Patient summary

Our study is the first to provide data on the future risk of relapse during surveillance for clinical stage I testicular cancer, given a patient has been without relapse for a specified period of time.

Take Home Message

Surveillance protocols in clinical stage I testicular cancer should be based on individualized estimates of the conditional risk of relapse. This may reduce clinic visits, exposure to radiation, and the cost of follow-up for the majority of patients.

Keywords: Germ cell tumor, Testicular neoplasm, Treatment outcome.

Footnotes

a Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Canada

b Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada

c Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Department of Medicine, University of Toronto, Toronto, Ontario, Canada

d British Columbia Cancer Agency, Vancouver, Canada

e Department of Pathology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada

f Department of Medical Imaging, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada

g Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada

Corresponding author. Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. Tel. +1 416 9462909; Fax: +1 416 9466590.

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