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New AUA guideline offers ‘relevant blueprint’ for testicular cancer diagnosis, treatment
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The American Urological Association has released a new guideline on the diagnosis and treatment of early-stage testicular cancer.
“More than 250,000 men in the United States are testicular cancer survivors,” Andrew Stephenson, MD, chair of the guideline development panel and urologist at Rush University, said in a press release. “This new guideline is fully aligned to the latest science and provides physicians with a relevant blueprint to diagnosing, staging and treating this disease so as to maintain its high cure rate.”
The guideline recommends conducting a scrotal ultrasound and obtaining serum tumor markers as part of initial diagnosis and radical, inguinal orchiectomy for all men with testicular cancer. However, testis-sparing surgery is not recommended for men with a normal contralateral testis. For men with stage II disease, the guideline recommends retroperitoneal lymph node dissection, chemotherapy and/or active surveillance after orchiectomy.
HemOnc Today spoke with Stephenson about the importance of these guidelines for the treatment of patients with early-stage testicular cancer.
Question: How common is testicular cancer in the United States and what are the outcomes?
Answer : Testicular cancer is the most common cancer among men. About 8,000 patients between ages 15 and 40 years are diagnosed with testicular cancer each year, and 100 men in the U.S. die of the disease annually. In many cases, treatment is successful in curing men of this cancer, even in the setting of metastatic disease. The vast majority of cases are confined to the testis without evidence of spread to lymph nodes or other parts of the body. Observation has been embraced as the management strategy for these patients because, depending on the type of their cancer, less than half of these men will show evidence of recurrence after the testis is removed. Survival rates are excellent — in part because we have effective treatment.
Q: What is the importance of these guidelines?
A: This is a relatively rare cancer, and appropriate management has important impact on outcome. Many men with clinical stage I disease will be cured simply by removal of the testis. They should not be subjected to any further treatments, such as chemotherapy or radiation, which carry long-term health consequences.
Q: What are the key recommendations for guidelines and treatment?
A: Many organizations abroad have made recommendations for the management of testis cancer. This is the first time the AUA has developed recommendations, in conjunction with ASCO and the American Society for Radiation Oncology.
We tend to embrace surveillance for stage I disease, whereas in Europe, chemotherapy may be recommended in many cases. We also see an important role for surgery in the management of early-stage testis cancer, and surgery has been de-emphasized in Europe. The guidelines endeavor to provide information for physicians to make a useful, timely and accurate diagnosis, institute appropriate staging modalities and limit the exposure to unnecessary testing, and determine appropriate management to achieve the best outcomes while limiting the toxicity of therapy.
Q: Is there anything else that you would like to mention?
A: The guideline provides guidance for clinicians from the time of diagnosis until the end of care for these patients. In terms of the diagnostic workup, the appropriate staging modalities, initial interventions, appropriate secondary interventions and long-term follow-up are all covered. – by Jennifer Southall
For more information:
Andrew Stephenson, MD, can be reached at Rush University, 600 S. Paulina St., Chicago, IL 60612.
Disclosure: Stephenson reports no relevant financial disclosures.
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Ryan Berglund, MD
The new AUA guideline emphasizes that most cases of testis cancer are detected at an early stage and that survival with standard therapy is high; therefore, treatment-related toxicity should be limited when possible. Inguinal orchiectomy remains the standard of care for initial diagnosis, and men should be offered testicular prosthesis and sperm banking as part of shared decision-making.
The role of testis-sparing surgery (TSS) is outlined, and it may be offered to men with equivocal findings on ultrasound, functional solitary testis or bilateral masses. For those who undergo TSS, adjuvant radiation to the testis should be offered to optimize cancer control. Men on surveillance must comply with the follow-up regimen outlined in the guidelines. Beyond 5 years, there is a less than 1% risk for relapse, and men discontinuing surveillance at that time should be notified of this. Men who undergo radiation therapy and chemotherapy need to be made aware of risks of treatment — including cardiovascular risk and secondary malignancy — and should establish regular care with a primary care physician.
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