Rational approach for patients
So what’s a rational approach for patients with stage I non-seminoma? For the low risk patient, surveillance if done well is appropriate, if the patient is compliant, if the physician is willing to do it. If there is a physician who is capable and experienced in performing a retroperitoneal lymph node dissection, that’s a reasonable alternative for these patients. For high risk patients, it is generally preferable to do something rather than watch the patient, although surveillance is an alternative for these patients. Either retroperitoneal lymph node dissection or chemotherapy with two cycles of BEP is an appropriate strategy for such patients.
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Now if a patient who undergoes a retroperitoneal lymph node dissection is found to have disease in the lymph nodes, there are two approaches for these patients. One is observation, and as you can imagine, about 50% of these patients will relapse, or alternatively adjuvant chemotherapy is appropriate. Two cycles of BEP chemotherapy here will cure the vast majority of patients. These alternatives were based on a randomized study published over 10 years ago in the New England Journal, in which patients were randomized to either observation after finding pathological stage II disease, or adjuvant chemotherapy. The death rate comparable from testicular cancer, no statistical difference between these two subgroups.
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Now for patients with advanced cancer, advanced testicular cancer, chemotherapy is the standard of care. This just happens to be our series of 150 patients who were treated with chemotherapy. This slide is important to illustrate what one sees with chemotherapy, that is, about an 80% cure rate overall, across risk groups and that the majority of patients who fail will do so within the first couple of years. Although about 10-20% of patients who fail will do so beyond two years.
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There is now a consensus with regard to risk stratification of patients with advanced disease for seminomas and non-seminomas. This is in the hand-out, but let me just go through this briefly in the slides. For seminomas, patients are considered to have good prognosis if they have pure seminoma, no elevation of alpha-fetoprotein and the seminoma is arising from any site, either testicular or extra-gonadal, and there is no evidence of non-pulmonary visceral metastases. These patients will be cured almost 90% of the time with chemotherapy. Poor prognosis seminomas are those with non-pulmonary visceral metastases. These patients will be cured about 70% of the time.