Though still a disease of young men, these data indicate that testicular cancer occurs in older age groups with over 10% occurring in men over the age of 45. As noted by McGlynn, et al, 2
testicular cancer remains predominantly a disease of white males. Despite including all cases of testicular cancer occurring in African American men in the participating SEER regions, they represented only 2.3% of the cases in this study.
The overwhelming majority of seminoma patients continue to be treated with radiation and orchiectomy despite increased use of chemotherapy in early stage NSGCT. Rather than being offered surveillance after surgery, patients with early stage seminoma have typically been offered radiation therapy after orchiectomy with excellent survival results and low toxicity rates. However, nearly 80% of early stage patients would not relapse with orchiectomy alone.6
Although adjuvant chemotherapy has been proposed by EGCCCG as an alternative to radiation in early stage seminoma6
and a single does of carboplatin has been shown to be as effective as radiation in the treatment of stage I seminoma7
, very few patients in our data set were treated with this approach. This may be due to the high success of radiation therapy in preventing relapse in early stage seminoma.
Patients with early stage NSGCT historically were offered orchiectomy followed by either RPLND although beginning in 1985, surveillance became more prevalent.8
While RPLND and surveillance the primary therapies, chemotherapy is being used early stage NSGCT disease. In this study one-third of patients with localized NSGCT received adjuvant chemotherapy and orchiectomy. The rate of adjuvant chemotherapy for early NSGCT reported in our study is higher than rates reported in Steele's POC study of patients diagnosed in 1985 through 1996 and may signal a trend in the increased use of chemotherapy in the treatment of early stage disease.9
Currently we do not have randomized clinical trials data that directly compares chemotherapy versus RPLND versus surveillance in early stage disease after orchiectomy, though each of these options is recognized as reasonable care by current National Comprehensive Cancer Network (NCCN) guidelines.10
NCCN guidelines allow for two cycles of BEP chemotherapy instead of RPLND for patients with stage IB.10
The European Germ Cell Cancer Consensus Group (EGCCCG) recommended 2 cycles of BEP to prevent relapse in high risk patients and 3 cycles for patients with advance disease and “good” prognosis.6
Another study reported that men with stage I NSGCT “at a moderate risk of relapse” men who received only one cycle of chemotherapy faired no worse than men who received two cycles.11
In low-volume stage II NSGCT patients one cycle of BEP plus two cycles of EP was as effective as three cycles of BEP. 12
However, a recent study of men diagnosed with stage I NSGCT reported that adjuvant chemotherapy was significantly more effective in preventing recurrences than an RPLND 13
Although not statistically significant, there was a suggestion that men treated in hospitals with a residency training program were more likely to receive chemotherapy than men treated in hospitals with our such training programs. The observation that chemotherapy use varies by geographic region suggests that physicians have differing opinions on the value of chemotherapy. In our study, men with NSGCT living in California and Atlanta were given chemotherapy relatively infrequently. Men living in the northern US, Detroit, Iowa Seattle (Puget Sound area) and Connecticut were more often given chemotherapy. Detroit, Iowa and Seattle had significantly higher use of chemotherapy than the San Francsico/Oakland area.
The vast majority (>90%) of chemotherapy agents utilized were standard BEP. Some patients received therapy with bleomycin omitted, a reasonable alternative in good risk individuals to avoid bleomycin toxicity. In patients with good-risk disease, 4 cycles of etoposide and cisplatin (EP) has been suggested as an option to 3 cycles of BEP when bleomycin is contraindicated.6
Two large trials have demonstrated the inferiority of carboplatin to cisplatin.14, 15
In our study, carboplatin was utilized in only 7 patients (3% of all chemotherapy patients). Several patients were treated with ifosfamide, an agent that is normally reserved for salvage therapy but currently being investigated as an alternative to bleomycin in high risk disease. Very small numbers of patients were treated with other agents such as doxorubicin, methotrexate and dactinomycin. These agents have been under investigation in poor-risk NSGCT.
Growth factor support with G-CSF was reported in less than 10% of patients receiving chemotherapy, in keeping with published literature and the most recent American Society of Clinical Oncology guidelines.16
Whereas growth factor use is considered reasonable to maintain dose intensity in patients with curable malignancies, the majority of germ cell patients can receive 3 to 4 cycles of BEP without a need for dose reduction.
Germ cell cancers continue to be a highly curable malignancy with 5-year survival of greater than 90% in men in this data set diagnosed with localized and regional disease. This is comparable to other studies and clinical trials.9, 14
A meta-analysis of NSGCT patients showed an improvement in survival for those diagnosed in the more recent years compared to the past.17
Testicular cancer is relatively rare and is usually diagnosed early therefore the number of cases, especially for the later stages, is limited. We have data from 1 year. However, it is collected from across the country and while treatments for cancer change over time, we do not believe that treatment in 1999 was dramatically different than the year preceding or following. The value of this study is that it is a population-based sample that provides a snapshot of therapies prescribed in communities across the US. With patient follow-up it provides the opportunity to examined subsequent survival of these patients following their treatment in the community.