Open Access

ARTICLE

Compliance and outcome of patients with stage 1 non-seminomatous germ cell tumors (NSGCT) managed with surveillance programs in seven Canadian centres

D. Scott Ernst¹, Penny Brasher², Peter M. Venner³, Piotr Czaykowski⁴, Malcolm J. Moore⁵, Leonard Reyno⁶, Eric Winquist¹, Roanne Segal⁷, Desiree Hao⁸

1 London Regional Cancer Centre, London, Ontario, Canada
2 Dept of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
3 Cross Cancer Institute, Edmonton, Alberta, Canada
4 CancerCare Manitoba, Winnipeg, Manitoba, Canada
5 Princess Margaret Hospital, Toronto, Ontario, Canada
6 Genentech Inc, San Francisco, California, USA
7 Ottawa Regional Cancer Centre, Ottawa, Ontario, Canada
8 Tom Baker Cancer Centre, Calgary, Alberta, Canada
Address correspondence to Dr. D. Scott Ernst, London Regional Cancer Centre, 790 Commissioners Road East, London, Ontario N6A 4L6 Canada

Canadian Journal of Urology 2005, 12(2), 2575-2580.

Abstract

Objective: We evaluate the impact of surveillance programs on the outcome of men with clinical stage 1 NSGCT following orchidectomy.
Patients and methods: A retrospective review of 197 patients with a minimum of 2 years follow-up at seven cancer centres was conducted. Histological characteristics of the primary tumor were recorded for each patient. Surveillance protocols consisted of clinical assessments, chest X-rays, serum beta HCG (βHCG), alpha fetoprotein (αFP), and abdominopelvic CT. All clinic visits and test completions were tracked. In accordance with each centre's specific surveillance protocol, patient compliance was defined as missing no more than two assessments/year.
Results: Overall 5 year survival was 100%. With a median follow-up of 54 months (range: 11-164 months), the relapse rate at 5 years was 29%. The median time to relapse was 6 months (range: 2-135 months). Ninety percent of relapses occurred within 18 months and only two patients relapsed after 5 years. On univariate analysis, only the presence of lymphovascular invasion was predictive of relapse. The first indicator of relapse was: CT alone, 36%; elevated βHCG or αFP, 29%; CXR, 10%; or clinical exam, 7%. Either CT, tumor markers, or CXR detected 90% of all relapses. Although differences in the frequency of assessments between the centres existed, no significant differences occurred in rates of relapse or survival (p>0.07). The mean rate of compliance with clinic visit (which included CXR and tumor markers) was 78% (range: 68.4-94.2%). The mean rate of compliance with CT scanning, was 64.3% (range: 32.2-100%). In the centre with the protocol requiring the least frequent visits, the rates of compliance were observed to be highest.
Conclusions: Surveillance remains an effective means of managing stage 1 NSGCT despite variability in protocols and in patients compliance. An abnormal CT was the most frequent identifier of disease relapse, and in combination with tumor markers and CXR, 90% of relapses were detected within 2 years of orchiectomy. Modifications of surveillance protocols to less frequent assessments may be possible and should be subject to prospective evaluation.

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