Surveillence Concerns

[Calliber50]

Good Evening,
I'm 2 years post 3xBEP and RPLND for Non-seminoma Stage II. Every three months I've gotten tumor markers and chest x-rays for a follow up. Which matches exactly what the TC-cancer website says.

http://www.tc-cancer.com/treatment/after-treatment.html

My concern is I've downloaded the latest copy of the NCCN guidelines for testicular cancer and I believe they've got Table 2 and Table 3 mixed up. I've attached a copy of page 18. I haven't had an abdominal CT in 2 years following the all clear abdominal scan. I hope I'm doing all I should!

Also what do they mean "as clinically indicated" when they refer to CTs? Does this mean if the tumor markers are up or if something shows up on the chest X-ray they want a CT?

*****As a warning I should mention if anyone is going through Surveillance, don't follow the image I attached. The guidelines state they aren't approved for distribution and may not be correct right now.*******

[Davepet]

The NCCN guidelines are pretty much what most docs follow & the document you attached seems like this years version (version 1.2012). It might be there were some changes this year not yet picked up on the tc-cancer site?

I believe "as indicated" means "if the doctor thinks it's needed" I could be wrong....

Dave

[Calliber50]

Well, I sent off a couple emails to NCCN. I will push to get a response in my freetime. Once I get answers I'll try and relay them to here so people won't be misinformed about what they should do in Surveillance. I'd hate to see someone missing a CT that they recommend should be done, and we don't want to expose people to anymore radiation than necessary.

[Aegean]

Most Docs will refer to the latest guidelines. Some centres of excellence will have slight variations to the guideline that they believe beneficial.

[Calliber50]

Well I got in touch with NCCN.

Thank you for your inquiry and interest in the NCCN Guidelines for Testicular Cancer.

1) The Guidelines are correct as written. CT scans apply only to patients treated with chemotherapy. For those with RPLND only - a baseline CT is recommended, as listed in Table 3 and then additional scans as indicated.

2) “As indicated” or “as clinically indicated” refers to the use of medical judgement based on probably any abdominal symptoms, H&P, and markers.

I hope this information is helpful for you.

Sincerely,
Kris



Kristina Gregory, RN, MSN, OCN
Vice President, Clinical Information Operations

Hope this helps anyone going through surveillance.

[BarclayBanister]

Calliber, I went to Dr. Einhorn at just about 8 mos. post chemo. He said that I really didnt need anymore ct scans but that he would do 1 per yr for the next 2 yrs just to be safe. And then no more. Im sure he played a large role in development of those guidelines

[Paul54]

For what it's worth, I happen to think there is a typo or mis-print on that page. In older versions of the guidelines, Table 2 was titled "Surveillance after complete response to chemotherapy and/or RPLND". Now it just says "and". Table 3 is new in the 2012 edition. It doesn't make sense to me why RPLND alone would warrant a less prescriptive CT plan than following both Chemo and RPLND. The NCCN's representative's explanation doesn't help. A small tumor which isn't producing markers could go undetected for a long time, in fact until the tumor was impacting other organs. Relapse rate following RPLND is still around 10%. I think the "As Indicated" in Table 3 is incorrect.

Hmmmmmm.

[Davepet]

I'm trying to download the latest complete guidelines (I have the 2010 version) to see if I can sort this out, but all I get is a black page, can anyone else get into the PDF?

Dave

[Geoff]

I can get into it. As Paul says, Table 2 is now for Chemo AND RPLND and includes a CT Scan every 6 months year 1, 6-12 months year 2, annually up through year 5, and As Indicated for Years 6+. The for RPLND only, it is Baseline CT in year 1, then as indicated from then on.

I agree with Paul that this doesn't seem to make sense. The RPLND alone would generally only be done for restaging purposes. Although an RPLND could be done for Stage IIA. If the RPLND came out clear or minimal spread, then it would be assumed that it won't show up again in the lymphnodes in that area. So the Chest X-ray would be used to find any spread as it would be assumed that spread would not occur in the lymphnodes. But you would think that since the RPLND post chemo essentially does the same thing, a CT scan wouldn't be all that helpful.

[Davepet]

I was able to get into it today. I think they just tried to keep it simple , perhaps a bit too much.

If you go through the treatment flowcharts, you will see that you end up on table two if you have chemo alone or chemo + post chemo RPLND. I guess the post chemo RPLND does not change things enough to warrant a lower surveillance schedule?