The Testicular Cancer Resource Center

Testicular Cancer Treatments: Surveillance


cartoonTesticular cancer (specifically, testicular germ cell cancer) is one of the most curable cancers there is. The treatments available (RPLND, chemotherapy, and radiation) are so effective that most men can be cured even if their cancer is not discovered until after it has spread. That is very good news for all of us, and the fact that these treatments exist actually make it possible to offer a fourth treatment: surveillance.

In general, 70% of men diagnosed with Stage I Nonseminoma and 80% of men diagnosed with Stage I Seminoma are cured by the orchiectomy alone. In the past everyone with TC, regardless of stage, had to have some additional treatment above and beyond the orchiectomy. Since the cancer was so deadly, no one wanted to take any chances so they basically put everyone through the ringer. As time went by researchers began to understand how the disease spreads, and how to treat it. The state of the art has advanced so far that it is now possible to avoid this "extra" or "adjuvant" treatment because the doctors are sure that they can cure any recurrence that comes along as long as it is caught early enough.

If you choose surveillance and you stick to the surveillance protocol, then regardless of whether you have Stage I Seminoma or Nonseminoma, your odds of being cured are the same as someone who chose to have radiation or an RPLND. To make an analogy, imagine that all Stage I TC patients are in their cars driving to the same destination. The guys that choose RPLND or radiation are going to be in for a very rocky ride for a while, but once they've gotten over the initial unpleasantness, they will have smooth driving the rest of the way. The guys that choose surveillance are going to travel a much smoother road at the start, but they will have the occasional scare or near miss along the way. In some cases, they will even end up taking a detour to the chemo ward before finally making it to their destination. Nevertheless, no matter which road you choose, the odds are the same that you will reach your destination!

My point is that Stage I testicular cancer can be cured in different ways. Stage I Seminoma can be cured 99% of the time regardless of whether you choose radiation or surveillance. Stage I Nonseminoma can be cured 98% of the time regardless of whether you choose RPLND or surveillance. (It is possible to choose chemo for either Seminoma or Nonseminoma, but we do not recommend doing that for Stage I disease).

OK, so what's the catch?

Medically, there is no catch. The numbers do not lie, and what I said is completely true. Surveillance will get you to a cure just as well as radiation or RPLND. Realistically, however, there is a catch. Many guys just cannot stand the thought that there might be cancer in there while they are idly standing by waiting for it to grow large enough to be detected. They want to zap it or cut it out as soon as possible. Similarly, many guys are scared of chemotherapy, and they want to do whatever they can now to reduce the odds of needing chemo later on. Some people would rather have certainty now than live with uncertainty for the next 5 years. Finally, everything I've said is only true if and only if the cancer is caught early, so if you can't stick to the surveillance protocol you are lowering your odds of being cured.

So how do you decide whether to choose surveillance or some active treatment? I won't lie to you. This is typically a very difficult decision - I personally think of it as TC hell. You will be cured one way or the other, but different folks will give you different advice, and few will be able to identify with what you are going through.Your parents or spouse will find it hard to believe that you would even consider doing "nothing." Your urologist will urge you to have surgery, in part because he is a surgeon and that is what he knows best. Your radiation oncologist will want to zap you, again because that is what he does. Others like me or your medical oncologist may tell you to consider surveillance. This is one decision that could definitely benefit from a second or even a third opinion!


How do you decide???

Here are some pros and cons. There are probably others related to your individual circumstances, and some of these may not apply at all. Since the treatments for seminoma and nonseminoma are different, I will address their pros and cons separately.

Nonseminoma

Why should you choose surveillance?

Why should you NOT choose surveillance?


Seminoma

Why should you choose surveillance?

Why should you NOT choose surveillance?


It is possible that there may be some financial concerns that might sway you one way or the other. Clearly, it is cheaper in the very short run to go with surveillance. However, those CT scans all add up, and over the next 2-5 years surveillance may actually cost more than treatment (I'm really not sure about this). Similarly, if you are uninsured and you can get someone to pay for treatment now, then it might make sense to do it now since that option may disappear as time goes by. Alternatively, you might not have insurance now, but you might expect that you will be able to get coverage within a year. Obviously this is a difficult problem, and I'm not sure I have really helped much. I would tend to advise people to separate their finances from the decision if that is at all possible.

OK, you've done your reading, grilled your doctor, and surveillance is the path you've chosen--what else do you need to do?

Follow Up, Follow UP, FOLLOW UP!!!

"Why the fuss? Of course I'll go to the doctor--don't you know what I have on the line here?!" -- Yeah, of course I do, and that's why I'll say it again: Follow Up, Follow UP, FOLLOW UP!!!

The reason for all this repetition is simply this: guys are notorious for starting out on their surveillance regimens as faithful as can be. Then, as time goes on and the results keep coming back clean, some combination of apathy and stupidity sets in, and we simply don't get the lab work done, miss our Oncology/Urology appointments, and go about our bullet proof ways...that is, until you do finally go back, and now there's a spot on your chest X-ray, or that nagging cough starts bringing up blood, or you finally can't take anymore of that "stress induced" backache that just never seems to go away--get the picture?


The bottom line for TC surveillance is this: if you go this route, you simply MUST follow your doctor's testing regimen just as if you were doing any other form of TC treatment!

What is the correct testing regimen? Well, there is no one single "correct" surveillance protocol. However, if what your doctor tells you deviates from the ones listed here, please discuss the issue with them and ask them to call an expert to verify the correct regimen. In particular, if your doctor says that you do not need to check tumor markers, tell them that that is not true. In almost every case it makes sense to watch tumor markers.

Here are our preferred surveillance protocols...

Clinical Stage I Nonseminoma Surveillance Protocol

Clinical Stage I Seminoma Surveillance Protocol

Princess Margaret Hospital Protocol

Nichols protocol

Remember, you are literally rolling the dice, playing the odds, whatever you want to call it, that you are TC clean, and your first line of defense are these testing regimens. If you do all the tests, this is not a risky choice.


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This page was last updated on Dec 05, 2012
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