Phillip Martin Pierorazio1, Peter Albers2, Peter C Black3, Torgrim Tandstad4, Axel Heidenreich5, Nicola Nicolai6, Craig Nichols7. 1. Brady Urological Institute, Johns Hopkins Medicine, Baltimore, MD, USA; Department of Urology, Johns Hopkins Medicine, Baltimore, MD, USA. Electronic address: philpierorazio@jhmi.edu. 2. Department of Urology, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany. 3. Department of Urologic Sciences, The University of British Columbia, Vancouver, BC, Canada. 4. St Olavs University Hospital, Trondheim, Norway. 5. Department of Urology and Uro-Oncology, Universitätsklinikum Köln, Köln, Germany. 6. Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy. 7. Section of Urology, Virginia Mason Medical Center, Seattle, WA, USA.
Abstract
CONTEXT: Cancer-specific survival for men with clinical stage I testicular cancer (CSITC) is uniformly excellent. Non-risk-adapted active surveillance (NRAS) is a management strategy for CSITC to minimize overtreatment and avoid possible long-term side effects of adjuvant therapy. OBJECTIVE: To review the evidence regarding oncologic outcomes for men with CSITC undergoing NRAS and discuss ongoing controversies in the management of CSITC. EVIDENCE ACQUISITION: MEDLINE/PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 1987 through January 1, 2017. EVIDENCE SYNTHESIS: A total of 68 studies were included in the critical review. The rationale for NRAS, oncologic outcomes, surveillance protocols, and comparative efficacy of risk-adjusted active surveillance (AS) were reported with strength of evidence and risk of bias evaluated. Cancer-specific survival approaches 100% for men with CSITC undergoing NRAS. Active treatment is limited to 20-30% of patients who will recur; these patients will require salvage chemotherapy and possible retroperitoneal lymph node dissection. Existing AS protocols include imaging and laboratory evaluations that are initially intensive but less frequent with increasing follow-up. CONCLUSIONS: NRAS is an attractive management option for men with CSITC, which maintains outstanding long-term cancer cure while sparing most patients treatment by avoiding prophylactic chemotherapy, radiation, or surgery. PATIENT SUMMARY: Men with clinically localized (stage I) testicular cancer have an excellent prognosis, regardless of management. Non-risk-adapted active surveillance is an attractive management option where only patients destined to relapse will receive any treatment following orchiectomy. However, individual patient preferences should be discussed in selecting a management strategy.
CONTEXT: Cancer-specific survival for men with clinical stage I testicular cancer (CSITC) is uniformly excellent. Non-risk-adapted active surveillance (NRAS) is a management strategy for CSITC to minimize overtreatment and avoid possible long-term side effects of adjuvant therapy. OBJECTIVE: To review the evidence regarding oncologic outcomes for men with CSITC undergoing NRAS and discuss ongoing controversies in the management of CSITC. EVIDENCE ACQUISITION: MEDLINE/PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 1987 through January 1, 2017. EVIDENCE SYNTHESIS: A total of 68 studies were included in the critical review. The rationale for NRAS, oncologic outcomes, surveillance protocols, and comparative efficacy of risk-adjusted active surveillance (AS) were reported with strength of evidence and risk of bias evaluated. Cancer-specific survival approaches 100% for men with CSITC undergoing NRAS. Active treatment is limited to 20-30% of patients who will recur; these patients will require salvage chemotherapy and possible retroperitoneal lymph node dissection. Existing AS protocols include imaging and laboratory evaluations that are initially intensive but less frequent with increasing follow-up. CONCLUSIONS: NRAS is an attractive management option for men with CSITC, which maintains outstanding long-term cancer cure while sparing most patients treatment by avoiding prophylactic chemotherapy, radiation, or surgery. PATIENT SUMMARY:Men with clinically localized (stage I) testicular cancer have an excellent prognosis, regardless of management. Non-risk-adapted active surveillance is an attractive management option where only patients destined to relapse will receive any treatment following orchiectomy. However, individual patient preferences should be discussed in selecting a management strategy.
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