What do I do once I finish treatment?

Testicular Cancer Treatments: After Treatment

One of the most common questions we hear on TC-NET is "My treatment is done. Now what?" Well, while the active part of the treatment process is behind you, you still need to have a regular check-up regimen (called a surveillance protocol) to make sure that the cancer is really gone for good - and guys unfortunately have a well-earned reputation for not following all the way through with surveillance protocols. Remember, just like initial diagnosis, the earlier a recurrence is detected, the easier it will be to treat it successfully.

With that in mind, here are our generic surveillance recommendations. They should be thought of as suggested follow-up procedures for standard situations, and they should not be thought of as the ONLY possible surveillance protocol. Individual circumstances may force a change in the protocol - but at least you will have a basis to work from. In general these protocols are pretty conservative (read: frequent) - but this IS cancer we're talking about, so being conservative is not necessarily a bad thing to shoot for. Our thanks to Dr. Craig Nichols of Providence Cancer Center and Dr. Mary Gospodarowicz of Princess Margaret Hospital in Toronto for their assistance in providing the data and reviewing the content of this page.

Before we start, there are a couple of things you should know:

These recommendations are NOT the divine word handed down by the gods. You should not get into a fight with your doctor because their follow-up is not exactly like the ones listed here. However, it should be something close. For example, if you are in the first year of a surveillance protocol for Stage I nonseminoma and your doctor tells you to come back in 4 months, then something is clearly wrong and you should look for a second opinion.
CT scans are not to be taken lightly. They provide a reasonably large dose of radiation, and they should not be used if they are not needed. Our surveillance protocols do not call for abdominal CT scans post RPLND or post radiation. Studies have shown that the odds of a recurrence in the retroperitoneum are very small following these therapies, and these odds do not justify the use of a CT scan. However, these studies also assume that the RPLND was done correctly by a surgeon familiar with the operation. The nodes should have been removed as a package, not plucked out one by one. If this was not the case, then it probably makes sense to add CT scans to the post RPLND surveillance protocol.
Most nonseminoma recurrences occur within the first two years after treatment. Most seminoma recurrences happen within the first five years after treatment. However, in all TC cases, the cancer can occasionally come back much later. It may not be reasonable to follow a surveillance protocol for the next 40 years, but you should do your best to keep in contact with your doctor yearly, and you should always be sure that your current doctor knows that you had testicular cancer way back when. If your doctor says you are cured and done after 2 years, don't believe it.

When we talk about a CT scan, we are normally talking about an abdominal scan. Pelvic CT's are normally given as a part of the abdominal scan. They generally do not add much to the evaluation of testicular cancer patients, but occasionally they are useful for patients with odd areas of recurrence, especially those patients with a history of scrotal violation, prior pelvic surgery (i.e. hernia repair), undescended testicles, or prior pelvic recurrences. Additionally, there are certain individual situations where abdominal or chest CTs are used and are appropriate even if there isn't large volume teratoma (especially after chemo if the CT isn't quite normal).

When we talk about tumor markers, we are referring to alphafetoprotein (AFP), beta-hCG (b-hCG), and lactate dehydrogenase (LDH). AFP and b-hCG are proteins often produced by active TC. Less familiar may be the role of LDH. Total LDH level is a useful marker for advanced disease as it's not related to a specific site of spreading - the levels should return to normal when the patient has achieved a complete remission. But since there is nonspecific origin of this high LDH (i.e. something else could be causing it other than TC), elevated LDH level alone cannot be used to initiate therapy.

While not specifically mentioned in the surveillance protocols listed below, a physical examination by your oncologist should coincide with all of your testing. A physical exam is necessary because you cannot always rely on the blood tests and CT scans. The idea that the CT "sees" everything is simply not true. Dr Nichols describes the physical exam as follows:

"The primary goals of physical exam are to assess areas not well evaluated by CTs, to evaluate any new symptoms, to assess potential toxicities of treatment and to evaluate the remaining testis for second primary tumors. Accordingly, I recommend that, at a minimum, vital signs be taken (especially blood pressure), an exam of the neck be done to assess for lymph nodes (especially supraclavicular nodes), palpation of the male breasts be performed to rule out gynecomastia, examination of the orchiectomy and other surgical scars should be done and, especially, a thorough examination of the remaining testis should be performed. This also gives the opportunity to query the patient regarding symptoms like sexual function, back pain, shortness of breath, fatigue, social function and other issues that may impact on survivorship. The exam obviously would be expanded if new symptoms are reported."

Our recommendations are divided by type of testicular cancer, stage, and treatment given.

Clinical Stage I Nonseminoma - Treated with Surveillance only
Note: "Clinical" refers to the diagnosis being based on clinical data (pathology, markers, xrays)

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

Pathological Stage I Nonseminoma - Treated with RPLND only
Note: "Pathological" refers to the diagnosis being based on physical evidence (in TC usually via RPLND surgery)

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

Pathological Stage II Nonseminoma - Treated with RPLND only

(Please note that this protocol is appropriate if you had a good RPLND where all the lymph nodes in the template were removed as a single package. If your RPLND was not done in this manner, you might want to discuss a protocol that uses an occasional CT scan in addition to the tests listed here.)

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

Pathological Stage II Nonseminoma - Treated with RPLND and 2xBEP

(This is a difficult protocol to specify: On the one hand, 2 cycles of BEP chemo will not make up for a bad RPLND. If you feel that you fall into this category, you might want to discuss a more frequent protocol that uses an occasional CT scan in addition to the tests listed here. On the other hand, patients in this category treated at IU essentially never relapse, so this protocol may be overkill.)

Year 1: Tumor Markers and Chest X-ray done every 2 months
Year 2: Tumor Markers and Chest X-ray done every 4 months
Years 3-5: Tumor Markers and Chest X-ray done once or twice a year
After Year 5: Tumor Markers and Chest X-ray done once a year

Stage II or Stage III nonseminoma - Treated with Chemotherapy, cancer in remission:

For Good Risk cancer (seminoma; nonseminoma with AFP < 1000 ng/ml, hCG < 5000 mIu/ml, or LDH < 1.5 times the upper limit of normal; no liver, bone, or brain metastases; gonadal or retroperitoneal primary tumor)

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

For Poor Risk cancer (nonseminoma with AFP > 10,000 ng/ml, hCG > 50,000 mIu/ml, LDH > 10 times upper limit of normal; mediastinal primary site; bone. liver, or brain metastases; advanced lung metastases)

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

*** An abdominal CT should be done twice a year for those patients who had large volume teratoma.

Clinical Stage I Seminoma - Treated with Surveillance only

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: No Tumor Markers required
Chest X-ray done once a year
Physical exam and Abdominal CT scan done every 6 months
Years 8-10: No Tumor Markers required
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

Clinical Stage I Seminoma - Treated with Adjuvant Radiation

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 done every 4 months
Years 4-7: No Tumor Markers required
Chest X-ray done once a year
Physical exam done every 6 months
Years 8-10: No Tumor Markers required
Chest X-ray done once a year
Physical exam done once a year

Nichols protocol

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

Stage II Seminoma - treated with Radiation

Princess Margaret Hospital protocol

Years 1-3: Tumor Markers done every 4 months (for the first 2 years only)
Chest X-ray done every 4 months
Physical exam done every 4 months
Years 4-7: No Tumor Markers required
Chest X-ray done every 6 months
Physical exam done every 6 months
Years 8-10: No Tumor Markers required
Chest X-ray done once a year
Physical exam done once a year

Nichols protocol

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

Stage III or IIb Seminoma - treated with Chemotherapy

Nichols protocol

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

More questions? Ask away!

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This page was last updated on Mar 29, 2018