Non-risk-adapted Surveillance for Stage I Testicular Cancer: Critical Review and Summary

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.

Keywords: Active surveillance; Germ cell tumor; Testicular cancer.