NCCN Guidelines for Testicular Cancer

[Fed]

The NCCN Clinical Practice Guidelines for the treatment of Testicular Cancer have been updated, and there are several major changes noted:

• All three management strategies for stage I-A and I-B seminoma (surveillance, adjuvant radiation and adjuvant chemotherapy) are rated "category 1", meaning that there is a uniform consensus among experts on their recommendation as approved treatment.
• Post-chemotherapy surgical resection of residual masses (> 3 cm) for seminoma patients is now considered an option, though not by uniform consensus.
• Poor risk, stage III-C non-seminoma patients have the option of going straight into 4xVIP (etoposide, ifosfamide, cisplatin) as primary chemotherapeutic treatment instead of 4xBEP in cases where tolerance for bleomycin might be a problem.

Note: The "discussion" write-up at the end of the guidelines has not been updated yet. The manuscript is currently in the works.

[Mike]

It is good to finally see a stronger recommendation for carboplatin therapy for stage I seminoma. Dr. Oliver just presented his data on carboplatin at ASCO too.
http://www.renalandurologynews.com/S...rticle/116119/

[Paul54]

It is good to see single-agent carboplatin moving up the ladder of confidence and efficacy. I note, however, that the Follow-up protocol (scans, etc.) for carboplatin is still the same frequency as for Surveillance instead of the more relaxed frequency for XRT. Perhaps that will be changed as this draft moves along to final version. Otherwise, the assumption is that the board does not entirely agree that carbo reduces recurrence probability to the same low level as XRT.

Per the article Mike linked, and which I've seen elsewhere, if the findings that carbo significantly reduces the probability of developing a secondary (TC-2) is validated by another study, that alone would be a very compelling reason to jump on the bandwagon.

[Aegletes]

It's good to see this updated set of guidelines, although I'd be interested in seeing more said about bilateral cases (notably where the most extensive XRT field was used for TC1) as the justification that I've been given for my aggressive surveillance (certainly more aggressive than for classic stage IA seminoma) is precisely the fact that I'm bilateral and had prior full-field XRT. I suppose the guidelines are just that - guidelines - but it would be interesting to see a discussion in them of cases that don't quite fit the established categories.

[Fed]

Per the article Mike linked, and which I've seen elsewhere, if the findings that carbo significantly reduces the probability of developing a secondary (TC-2) is validated by another study, that alone would be a very compelling reason to jump on the bandwagon.

I have read that article, and, as it stands, I don't buy it. I believe the evidence is circumstancial, and like you said, further studies are warranted if they really want solid proof that carbo prevents a contralateral presentation.

[Fed]

The write-up at the end of the NCCN guidelines has been updated to reflect the most recent recommendations for treatment.

[Scott]

I see that the new NCCN.com site for patients is available, though a patient version of the testicular cancer guidelines is not yet. The guidelines for physicians are still available to all, though registration with the NCCN.org website is now required first.

[Fed]

The NCCN Clinical Practice Guidelines for the treatment of testicular cancer have been updated to v.1.2010. Among the most notable changes are the following:

• The term "salvage therapy" has been renamed "second-line therapy".
• High-dose chemotherapy has been added as a validated treatment option.
• Follow-up abdominal/pelvic CT scans for surveillance 6+ years post-treatment should only be done as "clinically indicated". Also, there is clarification noting that patients who have undergone an RPLND need not be followed by CT scan as long as they have a baseline read after surgery. Patients who have gone through chemotherapy alone should still have CT scans as indicated in the schedule.

[Scott]

The term "salvage therapy" has been renamed "second-line therapy"

Good, I've always preferred that term!

[Chris'Mom]

I just caught the post regarding cat scans and no longer needing every year if chemo and RPLND were done.....Chris just had his fifth cat scan....so now we should be set, correct? Even if teratoma was present, I presume...this is wonderful news knowing cat scan exposure would not be needed unless there were some problem...I would appreciate any feedback regarding my assumptions here....what good news to tell Chris..thanks for the information Mary Ellen

[dadmo]

Jason is 6 years from diagnosis on April 30th. He has his last cat scan this week. From now on it will be blood work and x-rays to keep a watch on those stupid lung spots.

[dmann999]

Hello Fed, I just read your summary on CT scans for RPLND patients. That would not apply in Joe's case would it? Given that his tertoma tranformed to adenocarcinoma and it is only identifiable by CTs and not bloodwork? He goes tomorrow for his 1 year and is hoping to get moved to every 4 months from 2 months. Hope all is well. Dawn

[NixMom]

Unable to see the document... wish I could, because I need some hard evidence to present to Nick's doc in case she wants to delay cycle 3 (already 2 was delayed by a week). I have been unable to find a thing and I can't very well say, "oh, I saw it on a forum," to a doctor---they don't usually take kindly to that.

[Scott]

Unable to see the document...

The guidelines are available at no charge after you register with the website: http://www.nccn.org/

[NixMom]

Thanks, snagged it.

[Fed]

The NCCN Clinical Practice Guidelines for the treatment of testicular cancer have been updated to v.1.2011. These are available free of charge after registration with the site. Unlike other versions, there are numerous updates mostly clarifying several terms. Aside from these clarifications, here are some of the most significant changes:

• For a diagnosis, an ultrasound is now required (the older versions used to say "recommended").
• A patient that presents with rapidly increasing levels of beta-HCG, symptoms of metastasis, and a testicular mass can skip the I/O and begin chemotherapy immediately (this is presumably to stymie the spread of choriocarcinoma).
• While all three management strategies are equally accepted, surveillance is now considered the preferred treatment for stage I-A and I-B seminoma. XRT is the preferred treatment if the pathology report states the primary tumor is pT3 or greater than 4 cm or for stage I-S disease.
• The upper limit for dosing radiation in seminoma has been reduced. For adjuvant XRT and stage I-S disease, the maximum dose was lowered from 30 Gy to 25 Gy and for stage II-A or II-B from 40 Gy to 35 Gy.
• 1xBEP has been added as an alternative (without full consensus) to 2xBEP for adjuvant chemotherapy for stage I-B nonseminoma.
• The surveillance intervals for stage I-A and I-B nonseminoma have been spread out. The same applies to surveillance post-RPLND or complete response to chemotherapy.
• The Guidelines now recommend that patients with recurrent nonseminoma be treated at centers of expertise. On a similar vein, they also recommend that patients having a post-chemotherapy RPLND should have their surgeries performed at high volume centers.

[Karen]

Fed,
Thanks for posting the update and summary of changes!

[K&R]

I also noticed that the follow-up for Stage I Seminoma has changed the x-ray frequency from alternative visits to "as clinically indicated".

Kevin

[Fed]

The NCCN Guidelines have been updated to version 2.2011. The only change is a re-write of the discussion section to reflect the changes made in version 1.2011. The link to the Guidelines is a few posts above.

[K&R]

The latest version of the NCCN Guidelines 1.2012 has been posted.

Major revision throughout - everyone should take a look. The biggest changes are a significant reduction in the recommended number and frequency of CT scans for for follow-up of Seminoma, especially following Carboplatin. Here are a couple of highlights

Seminoma
- Surveillance only: CT every 6 months for years 1-2, every 6-12 mo for year 3, then annually for years 4-5 (used to continue for 10 years). Chest x-rays as clinically indicated.
- Follow-up following Carbo: CT annually for years 1-3 (used to continue for 10 years). Chest x-rays as clinically indicated.
- Follow up following RT: Ab/Pelvic CT annually for 3 yrs (for only para-aortic RT) (used to be pelvic CT only). Chest x-rays as clinically indicated.

RT - big new section on how to plan radiation fields and dosages.

Non-seminoma - it looks mainly like clarification of some wording.

Kevin

[S P]

Thanks for posting the update. Downloaded.

[JPM]

Fantastic! Thanks!

Edit: Just spoke to my oncologist -- we are moving to the new followup schedule immediately, which means that I now only have 2-3 CT scans left (knock on wood) instead of 17 under the previous guidelines. Yay!

JPM

[Paul54]

I am very curious to see what Dana Farber will recommend for surveillance imaging for seminoma when I get my checkup in a few weeks. We've been told that seminoma presents a significant number of relapses out to ten years. The NCCN 2011 guidelines called for A/P CT's annually for years 5-10. Chest X-rays are done as clinically indicated, by what isn't clear but I assume an A/P relapse. The 2012 guidelines changed that and end all imaging at 5 years.

Since seminoma rarely raises markers, how are we supposed to know if a relapse is occuring after 5 years? The study used to rationalize reduced imaging referenced in the other thread on adjuvant treatment http://www.tc-cancer.com/forum/showthread.php?t=16792 covers relapse after adjuvant radiation and carbo but I couldn't find anything specific to surveillance alone. The timeframe of the study is relatively short. There are many other studies out there using longer periods that show how the cumulative chances of relapse do continue increasing beyond 5 years, although the rate change over time does flatten out. The chances of a relapse do not drop to zero (nor does it for non-seminoma).

Let's say the relapse risk for stage I seminoma declines to only 1% per year after 5 years. That means I could be the 1 in 100 that relapses without any indication for years until the tumor was infringing on organs, i.e., suffering pain or physiological effects. I am not volunteering to be the 1.

I didn't volunteer to be the 1 in 250 males that developed TC in my lifetime, nor the 1 in 5000 that developed it after the age of 54.

I will admit that annual CT imaging at and beyond my age has advantages for picking up many other cancers that we face later in life. I think it's worth the small risk of CT radiation causing secondary cancers, particularly since good imaging centers are fine-tuning the amount of radiation down to the minimal levels needed to get the job done.

If I were younger, I might have a different perspective on eliminating CT's as soon as possible. Thoughts?
Paul

[Aegean]

My Oncologist knew these were coming back at the end of year 1 and was trying to get me over to them 2 years ago. We ended up finding some middle ground after many pleasant discussions on the subject. However, this past summer he did state that although frequency may change, he would be seeing me regularly till year 10... maybe he just enjoys the banter?

Paul, although I do share some of your thoughts and anxieties, I think that the guidelines can be negotiated with your caregiver to fit your personal situation. Personally I would be happy to get off the CT schedule, not because I fear radiation exposure but because of the PITA that it is. As far as recurrence after year 5, annual CXR with bloods should be ok.

I know I am supposed to have Mod superpowers, but memory is not part of it and I am not sure if I recall more than perhaps one person that had a recurrence here after 5years on this site, if that.

[Paul54]

I had my 6-month survey yesterday at Dana-Farber, which was a chest x-ray, markers and exam by a nurse practitioner. I alternate my oncologist and an NP. My onc is out on maternity leave. The NP was new and as usual got the look like "You're too old for this". Yes, I know. But she's nice plus she's a long-haul touring bicyclist who used to cover much of the territory I ride now. She road the Pan Mass Challenge a couple of times.

Anyway back to the topic, she checked the long-term orders file and told me that mine include annual A/P CT scans through year 7. She wasn't sure about the chest. I'll have to wait until my next visit in August

I don't have the x-ray and marker results yet, but I don't have any reason to suspect anything bad.
P-

[Nut of Mordor]

but memory is not part of it and I am not sure if I recall more than perhaps one person that had a recurrence here after 5years on this site, if that.

I'm here since less than a year but I already have seen a dude relapsing after 8 years, and another one asking for testosterone issues recently said he relapsed at 5 years and half. On a facebook group I have seen a guy with a reoccurance after 7 years. All of them were seminoma.
But the winner must be the dude who relapsed with chorio after 16 years, must be a 0,001% thing.

[steveb_uk]

With me having my I/O just a few weeks ago I'm brand new to this, but I too am already worried about the period between 5 and 10 years. My thoughts at this early stage in my experiences is that hopefully by then MRI and CT will be proved effective as each other and I'll then pay for a yearly MRI scan between years 5 and 10 myself (the regime here ends CT scans at 5years)

[CW406]

I have been managing my own surveillance schedule and thus consult the guidelines for timing. This is the first time I have looked to the 2012 version and I realize that the "clarification" of wording on the nonseminoma follow-up guidelines (slide TEST-12) are rather weird.

The three choices for patient types are:
1) Surveillance only (italics theirs)
2) Complete response to chemo and RPLND (bold mine)
3) RPLND only

Well, what does someone who had chemo (adjuvant) only like myself do? I'm planning to use the "surveillance" schedule, but the presence of the italicized "only" makes it really seem like they're trying to make it clear that this is not for patients who have had any additional treatment. In the treatment chart it clearly shows chemo only as an option, yet for follow-up it acts as if chemo and RPLND are always paired.

Am I missing something and/or an idiot?

[Davepet]

Did you have a non-seminoma & got 1 or 2X BEP? If so, I believe you can safely follow table 2. Even though it says chemo *and* RPLND I think they meant to say Chemo with or without RPLND. It is the only thing that makes sense to me, but I could be wrong.

Dave

[CW406]

Did you have a non-seminoma & got 1 or 2X BEP? If so, I believe you can safely follow table 2. Even though it says chemo *and* RPLND I think they meant to say Chemo with or without RPLND. It is the only thing that makes sense to me, but I could be wrong.

Dave

Yes, 1B nonseminoma, BEPx2. That is what I would like to assume as well but it is rather oddly worded. Especially strange given that this was a "clarification" - which excludes an entire patient population.

[JPM]

Newest version of the NCCN Guidelines (version 1.2013) is now available. Looks to be a fairly minor revision.

http://www.nccn.org/professionals/ph...testicular.pdf

John