Testicular Cancer Treatments: Surveillance

Testicular cancer (specifically, testicular germ cell cancer) is one of the most curable cancers there is. The treatments available (RPLND, chemotherapy, and radiation) are so effective that most men can be cured even if their cancer is not discovered until after it has spread. That is very good news for all of us, and the fact that these treatments exist actually make it possible to offer a fourth treatment: surveillance.

In general, 70% of men diagnosed with Stage I Nonseminoma and 80% of men diagnosed with Stage I Seminoma are cured by the orchiectomy alone. In the past everyone with TC, regardless of stage, had to have some additional treatment above and beyond the orchiectomy. Since the cancer was so deadly, no one wanted to take any chances so they basically put everyone through the ringer. As time went by researchers began to understand how the disease spreads, and how to treat it. The state of the art has advanced so far that it is now possible to avoid this "extra" or "adjuvant" treatment because the doctors are sure that they can cure any recurrence that comes along as long as it is caught early enough.

If you choose surveillance and you stick to the surveillance protocol, then regardless of whether you have Stage I Seminoma or Nonseminoma, your odds of being cured are the same as someone who chose to have radiation or an RPLND. To make an analogy, imagine that all Stage I TC patients are in their cars driving to the same destination. The guys that choose RPLND or radiation are going to be in for a very rocky ride for a while, but once they've gotten over the initial unpleasantness, they will have smooth driving the rest of the way. The guys that choose surveillance are going to travel a much smoother road at the start, but they will have the occasional scare or near miss along the way. In some cases, they will even end up taking a detour to the chemo ward before finally making it to their destination. Nevertheless, no matter which road you choose, the odds are the same that you will reach your destination!

My point is that Stage I testicular cancer can be cured in different ways. Stage I Seminoma can be cured 99% of the time regardless of whether you choose radiation or surveillance. Stage I Nonseminoma can be cured 98% of the time regardless of whether you choose RPLND or surveillance. (It is possible to choose chemo for either Seminoma or Nonseminoma, but we do not recommend doing that for Stage I disease).

OK, so what's the catch?

Medically, there is no catch. The numbers do not lie, and what I said is completely true. Surveillance will get you to a cure just as well as radiation or RPLND. Realistically, however, there is a catch. Many guys just cannot stand the thought that there might be cancer in there while they are idly standing by waiting for it to grow large enough to be detected. They want to zap it or cut it out as soon as possible. Similarly, many guys are scared of chemotherapy, and they want to do whatever they can now to reduce the odds of needing chemo later on. Some people would rather have certainty now than live with uncertainty for the next 5 years. Finally, everything I've said is only true if and only if the cancer is caught early, so if you can't stick to the surveillance protocol you are lowering your odds of being cured.

So how do you decide whether to choose surveillance or some active treatment? I won't lie to you. This is typically a very difficult decision - I personally think of it as TC hell. You will be cured one way or the other, but different folks will give you different advice, and few will be able to identify with what you are going through.Your parents or spouse will find it hard to believe that you would even consider doing "nothing." Your urologist will urge you to have surgery, in part because he is a surgeon and that is what he knows best. Your radiation oncologist will want to zap you, again because that is what he does. Others like me or your medical oncologist may tell you to consider surveillance. This is one decision that could definitely benefit from a second or even a third opinion!

Here are some pros and cons. There are probably others related to your individual circumstances, and some of these may not apply at all. Since the treatments for seminoma and nonseminoma are different, I will address their pros and cons separately.

• You want to avoid the RPLND surgery
• Your tumor markers were elevated before the orchiectomy, but fell down to normal after the surgery.
• You can live with the idea that some cancer might still be in there, but chemotherapy will act as your safety net if it ever comes back.
• You believe that you could stick to the surveillance schedule without much problem. (In other words, you don't travel a lot and you will not try to put off seeing the doctor.)
• Your odds of recurrence are lower than normal (For example, your tumor had no embryonal carcinoma at all and there was no vascular invasion), and you do not want to put yourself through any further treatment without knowing that it is actually needed.
• Your odds of recurrence are higher than normal, but you want to avoid having both the RPLND and chemo, so you are willing to take your chances that the cancer is gone because you believe that you will end up needing chemo anyway.
• You are interested in having a baby NOW, and you want to try to do it the old fashioned way.
• You are interested in having a baby, and you do not trust your urologist to perform a nerve sparing RPLND.
• You get the feeling that your urologist is recommending the RPLND because he hasn't done one in a long while and would like some more experience. (I'm not kidding).
• Your insurance provider will not let you go outside of their network to have the RPLND done by an expert with experience in the nerve sparing RPLND.
• Your odds of being cured are the same as if you chose any other treatment, so why not minimize the immediate pain and take your chances later?
• Your job, finances or personal life would be more convenient if you waited until another time to be treated. In other words, you can handle getting treatment, but now is not a good time. (For example, if your wife just had a baby or you are nearing the end of school.)
• You do not want that scar on your belly.
• This is an unusual one, but when you were first diagnosed your AFP was so high that it is going to take more than two months to see if it is going to normalize. After waiting two months, you are essentially already on a surveillance protocol, why not just keep with it?

• You cannot live with the idea that there might be cancer growing inside of you while you sit idly by and do "nothing." In other words, to be sure, now.
• Your odds of recurrence are much higher than normal, and you'd like to do whatever you can to avoid chemotherapy (For example, the tumor was 100% embryonal carcinoma with vascular invasion)
• You ignored that lump for a long time, and in spite of what you have been told, you have a hard time believing that you caught it before it spread.
• Your tumor marker levels were never elevated, making it less likely that they would provide an "early" warning that the cancer had come back.
• You do not have easy access to a hospital with a CT scanner.
• Your job or personality make it difficult to ensure that you would stay on the strict surveillance schedule.
• You are interested in having a baby, you trust your urologist to perform a nerve sparing RPLND, and you want to do all you can to avoid chemotherapy.
• Your job or hobby (scuba diver, jet pilot, for example) would be adversely affected by the side effects of chemotherapy, and you want to do whatever you can to avoid or minimize it.
• Your job, finances or personal life would be more convenient if you got the whole thing out of way now. In other words, you can handle getting treatment now, but waiting and possibly getting it at some random time in the future may not work out. (For example, if your wife is going to have a baby in the near future, you might not want to have to worry about going through treatments at an inopportune time.)

• You want to avoid any unnecessary radiation. Some studies have shown that this type of radiation will increase your risk of getting another cancer by as much as 4%. You feel that you'd rather not get the treatment unless you know you actually need it.
• Your odds of recurrence are lower than normal (For example, the tumor was smaller than 4cm, you are more than 35 years old, and the tumor showed no evidence of vascular invasion), and you do not want to put yourself through any further treatment without knowing that it is actually necessary.
• You would rather think that you have been cured than know you have been radiated.
• You can live with the idea that some cancer might still be in there, but radiation, and maybe chemotherapy will act as your safety net if it ever comes back.
• You believe that you could stick to the surveillance schedule without much problem. (In other words, you don't travel a lot and you will not try to put off seeing the doctor.)
• You believe that you have already been cured, and you do not want to put yourself through any further treatment without evidence that it is actually needed.
• You are not comfortable with the expertise or quality of the radiation oncologist or radiation equipment available to you.
• You are interested in having a baby NOW, and you want to try to do it the old fashioned way.
• You are interested in conceiving a baby in the next year or two, and you do not want to worry about the effects of radiation on your sperm.
• Your odds of being cured are the same as if you chose any other treatment, so why not minimize the immediate pain and take your chances later?
• Your job, finances or personal life would be more convenient if you waited until another time to be treated. In other words, you can handle getting treatment, but now is not a good time. (For example, if your wife just had a baby or you are nearing the end of school.)
• This is an unusual one, but important. If this is your second time around with seminoma and you have had prior radiation, surveillance is pretty much your best option.

• You cannot live with the idea that there might be cancer growing inside of you while you sit idly by and do "nothing." In other words, to be sure, now.
• Your odds of recurrence are much higher than normal, (For example, the tumor was larger than 4cm, you are less than 35 years old, and the tumor showed evidence of vascular invasion) and you'd like to do whatever you can to avoid chemotherapy.
• You ignored that lump for a long time, and in spite of what you have been told, you have a hard time believing that you caught it before it spread.
• You do not have easy access to a hospital with a CT scanner.
• Your job or personality make it difficult to ensure that you would stay on the strict surveillance schedule.
• Your job, finances or personal life would be more convenient if you got the whole thing out of way now. In other words, you can handle getting treatment now, but waiting and possibly getting it at some random time in the future may not work out. (For example, if your wife is going to have a baby in the near future, you might not want to have to worry about going through treatments at an inopportune time.)
• Your job or hobby (scuba diver, jet pilot, for example) would be adversely affected by the side effects of chemotherapy, and you want to do whatever you can to avoid it.

It is possible that there may be some financial concerns that might sway you one way or the other. Clearly, it is cheaper in the very short run to go with surveillance. However, those CT scans all add up, and over the next 2-5 years surveillance may actually cost more than treatment (I'm really not sure about this). Similarly, if you are uninsured and you can get someone to pay for treatment now, then it might make sense to do it now since that option may disappear as time goes by. Alternatively, you might not have insurance now, but you might expect that you will be able to get coverage within a year. Obviously this is a difficult problem, and I'm not sure I have really helped much. I would tend to advise people to separate their finances from the decision if that is at all possible.

OK, you've done your reading, grilled your doctor, and surveillance is the path you've chosen--what else do you need to do?

"Why the fuss? Of course I'll go to the doctor--don't you know what I have on the line here?!" -- Yeah, of course I do, and that's why I'll say it again: Follow Up, Follow UP, FOLLOW UP!!!

The reason for all this repetition is simply this: guys are notorious for starting out on their surveillance regimens as faithful as can be. Then, as time goes on and the results keep coming back clean, some combination of apathy and stupidity sets in, and we simply don't get the lab work done, miss our Oncology/Urology appointments, and go about our bullet proof ways...that is, until you do finally go back, and now there's a spot on your chest X-ray, or that nagging cough starts bringing up blood, or you finally can't take anymore of that "stress induced" backache that just never seems to go away--get the picture?

The bottom line for TC surveillance is this: if you go this route, you simply MUST follow your doctor's testing regimen just as if you were doing any other form of TC treatment!

What is the correct testing regimen? Well, there is no one single "correct" surveillance protocol. However, if what your doctor tells you deviates from the ones listed here, please discuss the issue with them and ask them to call an expert to verify the correct regimen. In particular, if your doctor says that you do not need to check tumor markers, tell them that that is not true. In almost every case it makes sense to watch tumor markers.

Here are our preferred surveillance protocols...

Clinical Stage I Nonseminoma Surveillance Protocol

• Year 1: Tumor Markers and Chest X-ray done every month
  Abdominal CT scan done every 2 months
• Year 2: Tumor Markers and Chest X-ray done every 2 months
  Abdominal CT scan done every 4 months
• Years 3-5: Tumor Markers and Chest X-ray done every 6 months
  Abdominal CT scan done every 6 months
• After Year 5: Tumor Markers and Chest X-ray done once a year

Clinical Stage I Seminoma Surveillance Protocol

Princess Margaret Hospital Protocol

• Years 1-3: Tumor Markers done every 4 months (for the first 2 years only)
  Chest X-ray done every 8 months
  Physical exam and Abdominal CT scan done every 4 months
• Years 4-7: Tumor Markers optional
  Chest X-ray done once a year
  Physical exam and Abdominal CT scan done every 6 months
• Years 8-10: Tumor Markers optional
  Chest X-ray done once a year
  Physical exam and Abdominal CT scan done once a year

Nichols protocol

• Year 1: Tumor Markers and Chest X-ray done every 2 months
  Abdominal CT scan done every 3 months
• Year 2: Tumor Markers and Chest X-ray done every 2 months
  Abdominal CT scan done every 4 months
• Years 3-5: Tumor Markers and Chest X-ray done every 6 months
  Abdominal CT scan done every 6 months
• After Year 5: Tumor Markers and Chest X-ray done once a year

Remember, you are literally rolling the dice, playing the odds, whatever you want to call it, that you are TC clean, and your first line of defense are these testing regimens. If you do all the tests, this is not a risky choice.