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Non-risk-adapted Surveillance for Stage I Testicular Cancer: Critical Review and Summary

Phillip Martin Pierorazio, Peter Albers, Peter C Black, Torgrim Tandstad, Axel Heidenreich, Nicola Nicolai, Craig Nichols
European Urology 2018, 73 (6): 899-907
29338978

CONTEXT: Cancer-specific survival for men with clinical stage I testicular cancer (CSITC) is uniformly excellent. Non-risk-adapted active surveillance (NRAS) is a management strategy for CSITC to minimize overtreatment and avoid possible long-term side effects of adjuvant therapy.

OBJECTIVE: To review the evidence regarding oncologic outcomes for men with CSITC undergoing NRAS and discuss ongoing controversies in the management of CSITC.

EVIDENCE ACQUISITION: MEDLINE/PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 1987 through January 1, 2017.

EVIDENCE SYNTHESIS: A total of 68 studies were included in the critical review. The rationale for NRAS, oncologic outcomes, surveillance protocols, and comparative efficacy of risk-adjusted active surveillance (AS) were reported with strength of evidence and risk of bias evaluated. Cancer-specific survival approaches 100% for men with CSITC undergoing NRAS. Active treatment is limited to 20-30% of patients who will recur; these patients will require salvage chemotherapy and possible retroperitoneal lymph node dissection. Existing AS protocols include imaging and laboratory evaluations that are initially intensive but less frequent with increasing follow-up.

CONCLUSIONS: NRAS is an attractive management option for men with CSITC, which maintains outstanding long-term cancer cure while sparing most patients treatment by avoiding prophylactic chemotherapy, radiation, or surgery.

PATIENT SUMMARY: Men with clinically localized (stage I) testicular cancer have an excellent prognosis, regardless of management. Non-risk-adapted active surveillance is an attractive management option where only patients destined to relapse will receive any treatment following orchiectomy. However, individual patient preferences should be discussed in selecting a management strategy.

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