Surveillance Therapy - MRI vs. CT?

[indymike]

I am nearly 1 year cancer free, having chosen surveillance therapy.

I had an uneasy feeling regarding all the CT scans, and chance for inducing secondary cancers. My family doctor recently suggested I get a "heart calcium scan", which is basically a CT scan to show blockages. As I was researching the scan, I came upon the publication of a study from March 2011:

http://www.ucdmc.ucdavis.edu/publish/news/cancer/5190

It basically says that there was a statistically significant increase in secondary cancers related to the radiation from surveillance CT scans for patients of testicular cancer.

My oncologist does not want me to do an MRI, claiming we do not have a good baseline image, and that they are not as good at detecting small metasis in lymph nodes as CT.

I sent an e-mail to Dr. Einhorn questioning, and he promptly replied that he sees no difference between CT and MRI, except that MRI is more costly and time consuming. He did however recommend a lighter CT schedule for the next 4 years than I had been assuming.

My question is: what do you all think about the radiation exposure of surveillance CT vs. MRI?

[CancerSux]

Looking at that article (I can't access the e-pub from my University ), they cite that those undergoing active surveillance (the CT #'s seem slightly higher than the current recommended schedule) have a slight, but statistically significant, higher incidence of secondary malignancy (306 versus 233 without 'active surveillance').

Those on active surveillance did NOT receive the RPLND or the adjuvant chemo, which may play a role here too (although the secondary malignancy is not t.c., so the presumption is that the CT radiation is the causative factor), and there are 73 more patients developing a secondary cancer, which the authors compare to 50 patients in the overall study who expired from their primary disease.

I guess my question is this - of those developing secondary malignancy within the next 15 years (rates are only significant for men > 45 years of age), are they treatable/curable cancers? What stage were they found, as compared to the cohorts that were not on active surveillance?

There is a lot of gambling in all of this - gambling that the cancer is gone, that treatment A will be better than B. With which gambles are you comfortable?

[Slurpeeholic]

Looking at that article (I can't access the e-pub from my University ), they cite that those undergoing active surveillance (and the CT #'s seem higher than the current recommended schedule) . . .

What is the current recommended schedule? I thought it was every 3- 4 months for years 1-3 (9-12 scans), one every six months for years 4-7 (8 scans), and annually for years 8-10 (3 scans), which would total 20-23 scans over ten years, with 13-16 over the first five years.

[davidhanson90]

The Royal Marsden have been conduction a trial of mri over ct scans for stage 1a seminona cases. At one point they said I may be able to be in the trial but because of the less than 1% non-seminona in my pathology they weren't to enthusiastic.

I may try and push for that again when I go next month as ct scans do worry me. But as far as I'm aware MRI have just as accurate imaging but the problem lies with the fact that firstly patients have to remain still for longer during the scan. They are more expensive and thirdly alot of consultants just don't know how to read the scans and are used to ct.

[Aegean]

Seminoma Stage 1

Years 1-3 every 4mths
Years 4-6 every 6 months
Years 7-10 annually

SELF-EDIT DUE TO POOR MATH SKILLS: Total of 19 scans unless my math is off.

Many docs are now taking you to the next level earlier unless you had other risk factors (i.e. switching to every 6 mths once successfully completing yr 2) or elongating the time period between scans by a month or two (i.e. going to 8 month interval instead of 6 for years 4-6). Not too many going to MRI for reasons stated by Dr. E's email to OP above.

I would strongly recommend that at least the first two years, where recurrence is most statistically reported, you adhere to the 4 month schedule.

[CancerSux]

I guess their #'s aren't that far off in the article, citing 15+ in 5 years. I was estimating 12 or so from the schedule Zsolt mentioned (was off by one).

Sad thing is I am actually good at math ...

[Slurpeeholic]

Seminoma Stage 1

Years 1-3 every 4mths
Years 4-6 every 6 months
Years 7-10 annually

Total of 16 scans unless my math is off.

Many docs are now taking you to the next level earlier unless you had other risk factors (i.e. switching to every 6 mths once successfully completing yr 2) or elongating the time period between scans by a month or two (i.e. going to 8 month interval instead of 6 for years 4-6). Not too many going to MRI for reasons stated by Dr. E's email to OP above.

I would strongly recommend that at least the first two years, where recurrence is most statistically reported, you adhere to the 4 month schedule.

Years 1-3 every 4mths (9=3*3)
Years 4-6 every 6 months (6=2*3)
Years 7-10 annually (4=1*4)

Total of 19 using this regimen.

[ukboyuk]

In the UK (RM), CTs are every 6 months for 2 years then every year thereafter. I was quite happy with reduced CT regime compared to the US.

In Netherlands, my doc did not want CTs after 2 years. I thought it due to the cost but he kept talking about limiting the radiation dose. He wanted ultrasound which is not often heard about but still more accurate than you might think. In the event, I left The Netherlands before my U/S scan was due.

I am coming up for my end of 3 year (6th) CT scan. I don't mind getting CT shortly because I don't feel "out of the woods" yet but this could be a turning point for me. After this I might try to get MRIs. Sounds to me that the only reason we are not getting MRIs now (at least in latter years) is due to cost

After 5 years, I don't know if I will still be on surveillance but I will definitely not accept CTs after this point. The risk to reward ratio is not favourable, in my opinion, especially for Stage I seminoma.

As for increased risks from CTs, I have read that those having RT suffer from (roughly) 2x to 4x increased incidence of various cancers/cardiovascular consequences. I would expect it to be somewhat less for CTs.

I am not too surprised by the study you provided. CTs have long been known to increase cancers, no matter what your reason for having them is. They are used far too often. That study is a little scary though when they mention that 16 scans are creating 73 new cancers compared to 50 non-seminoma deaths. The comparable death stats for stage I seminoma would be even less, making the risk of CTs even more unacceptable.

[CancerSux]

On the math - by the normal schedule which Zsolt posted, 13 CTs would be had by 5 years. This was a 18 year study, and included a time when CTs were being done q2-3 months through year 1.

That study is a little scary though when they mention that 16 scans are creating 73 new cancers compared to 50 non-seminoma deaths. The comparable death stats for stage I seminoma would be even less, making the risk of CTs even more unacceptable.

Those 50 deaths are the mortality stats in that study for stage I nonseminoma; the study was done on nonseminoma.

The risk to benefit ratio is something people have to weight for themselves, with their docs, and decide. Chemo causes secondary cancers as well.

[Aegean]

Years 1-3 every 4mths (9=3*3)
Years 4-6 every 6 months (6=2*3)
Years 7-10 annually (4=1*4)

Total of 19 using this regimen.

Can you believe I am actually helping my gr3 and gr6 kids with their math

I did it on the fly, that's my excuse and I am sticking to it.

[ukboyuk]

On the math - by the normal schedule which Zsolt posted, 13 CTs would be had by 5 years. This was a 18 year study, and included a time when CTs were being done q2-3 months through year 1.



Those 50 deaths are the mortality stats in that study for stage I nonseminoma; the study was done on the nonseminoma only due to the rarity of true 100% seminoma.

The risk to benefit ratio is something people have to weight for themselves, with their docs, and decide. Chemo causes secondary cancers as well.

100% seminoma is rare? It doesn't seem uncommon to me but I'd like to hear more. Do you mean that it would have changed into mixed GCT?

Yes, chemo also can cause leukemia right? But does BEP/EP cause other cancers? I've never heard much in this regard except for the leukemia.


The more information the better. Hopefully there will be more studies like this to inform doctors and affect protocols. Because reality is that most doctors take their own view, within the parameters of protocols, and suggest it to the patient who usually accepts it.

[indymike]

Additional info

I am really pleased to see that this topic was interesting and spurred some discussion.

I am not sure if it is accepted etiquette to share something from Dr. E's e-mail, but I wanted to add that he said he "has no other concern for CT" besides the stated issues of time and convenience.

Also, he proposed that THEY would do a lower frequency CT surveillance given my disease parameters that I shared, than that which my oncologist is currently proposing, which is the NCCN guideline (I believe):

"We would test every 4 months year 1, every 6 months year 2 and annually years 3-5."

This adds up to a significantly fewer number of CTs, 8 total by my count! After I complete my 1-yr all clear scan in January, I plan to discuss this proposed schedule with my oncologist.

[ukboyuk]

If you include your original CT scan at diagnosis, I make that 9 total.

[DARDEVIL]

Hi all

There is no evidence that CT Scan Schedule for TC, may increase the risk of a second cancer, especially for adults compare to kids. This risk is only a theory very difficult to catch in real life.

But I m still concern as many victims here.

My oncologist, who is a TC specialist here in France told me to stick to the schedule at least the first year, due to the probability of recurrence in non seminoma tumor case.
Then options are :
MRI and chest x rays with at least one CT scan/y the following years
Ultra sound can also be an option with fit body persons + Chest x rays with at least one CT scan/y the following years.

But to conclude, my oncologist is not concerned about this risk especially with the new generation of ct scan. For example, the dose for me : chest abdo and pelvis scan is at 1000 - 1200 msv

I think I will try MRI (3 tesla) for the second year : Abdo and pelvis (time 20 min each !) + chest x rays

I know there is a radiologist on this forum, I would be glad to hear from him. Anyone knows him ?

All the best

[CancerSux]

100% seminoma is rare? It doesn't seem uncommon to me but I'd like to hear more. Do you mean that it would have changed into mixed GCT?

Correcting myself now: Seminoma itself accounts for ~40% of germ cell tumors, please accept my apology for mis-stating this before.

DarDevil - the start of this post was an article commenting on a 18 year study that reports a statistically significant increase in secondary tumors in a group of NSGCT patients (over 7000 of them) for those following active surveillance (meaning CTs) in patients over age 45. So there is scientific evidence of a CT schedule for TC increasing the incidence.