Personalizing, not patronizing: the case for patient autonomy by unbiased presentation of management options in stage I testicular cancer.
Testicular cancer (TC) is the most common neoplasm in males aged 15-40 years. The majority of patients have no evidence of metastases at diagnosis and thus have clinical stage I (CSI) disease [Oldenburg J, Fossa SD, Nuver J et al. Testicular seminoma and non-seminoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013; 24(Suppl 6): vi125-vi132; de Wit R, Fizazi K. Controversies in the management of clinical stage I testis cancer. J Clin Oncol 2006; 24: 5482-5492.]. Management of CSI TC is controversial and options include surveillance and active treatment. Different forms of adjuvant therapy exist, including either one or two cycles of carboplatin chemotherapy or radiotherapy for seminoma and either one or two cycles of cisplatin-based chemotherapy or retroperitoneal lymph node dissection for non-seminoma. Long-term disease-specific survival is ∼99% with any of these approaches, including surveillance. While surveillance allows most patients to avoid additional treatment, adjuvant therapy markedly lowers the relapse rate. Weighing the net benefits of surveillance against those of adjuvant treatment depends on prioritizing competing aims such as avoiding unnecessary treatment, avoiding more burdensome treatment with salvage chemotherapy and minimizing the anxiety, stress and life disruption associated with relapse. Unbiased information about the advantages and disadvantages of surveillance and adjuvant treatment is a prerequisite for informed consent by the patient. In a clinical scenario like CSI TC, where different disease-management options produce indistinguishable long-term survival rates, patient values, priorities and preferences should be taken into account. In this review, we provide an overview about risk factors for relapse, potential benefits and harms of adjuvant chemotherapy and active surveillance and a rationale for involving patients in individualized decision making about their treatment rather than adopting a uniform recommendation for all.
Department of Oncology, Akershus University Hospital, Lørenskog; Department of Oncology, University of Oslo, Oslo, Norway. Electronic address: jan.oldenburg@medisin.uio.no.
J
J
Oldenburg
Department of Oncology, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
J
J
Aparicio
Department of Oncology, Universitätsspital Zürich, Zürich, Switzerland.
J
J
Beyer
Department of Oncology-Pathology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden.
G
G
Cohn-Cedermark
Department of Medical Oncology, Queen Elizabeth Hospital, University Hospital Birmingham Foundation Trust, Birmingham, UK.
M
M
Cullen
Department of Solid Tumor Oncology, Cleveland Clinic, Cleveland, USA.
T
T
Gilligan
Department of Medical Oncology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy.
U
U
De Giorgi
Kaiser Franz Josef Hospital and ACR-ITR and LBI-ACR Vienna-CTO, Vienna, Austria.
M
M
De Santis
Erasmus University Medical Center, Rotterdam, The Netherlands.
R
R
de Wit
Department of Oncology, Oslo University Hospital, University of Oslo, Oslo, Norway.
S D
SD
Fosså
Department of Oncology, Institut Català d'Oncologia, Gran Via de l'Hospitalet Hospitalet de Llobregat, Barcelona, Spain.
J R
JR
Germà-Lluch
Department of Medical Oncology, Kantonsspital, St Gallen, Switzerland.
S
S
Gillessen
Oncology Department, University Hospital of North Norway, Tromsø, Norway.
H S
HS
Haugnes
Tumor and Breast Center ZeTuP, St. Gallen, Switzerland.
F
F
Honecker
Department of Clinical Oncology, Royal Marsden Hospital and Institute of Cancer Research, Sutton, UK.
A
A
Horwich
Klinik für Urologie, konservative Uroonkologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany.
A
A
Lorch
Department of Oncology, Comenius University Faculty of Medicine, St Elisabeth Cancer Institute, Bratislava, Slovak Republic.
D
D
Ondruš
Medical Oncology, Ospedale Generale, Treviso, Italy.
G
G
Rosti
Department of Urology, Cleveland Clinic, Cleveland, USA.
A J
AJ
Stephenson
The Cancer Clinic, St Olavs University Hospital, Trondheim, Norway.
T
T
Tandstad
D000293:Adolescent; D000328:Adult; D000970:Antineoplastic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant; D002755:Choice Behavior; D003661:Decision Support Techniques; D018450:Disease Progression; D006801:Humans; D008297:Male; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D009373:Neoplasms, Germ Cell and Embryonal / Q000473:pathology / Q000628:therapy*; D009919:Orchiectomy / Q000009:adverse effects; D010358:Patient Participation; D018579:Patient Selection; D026684:Personal Autonomy; D011237:Predictive Value of Tests; D018714:Radiotherapy, Adjuvant; D012307:Risk Factors; D018239:Seminoma / Q000473:pathology / Q000628:therapy*; D013736:Testicular Neoplasms / Q000473:pathology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome; D057832:Watchful Waiting; D055815:Young Adult
D000970:Antineoplastic Agents
active surveillance; adjuvant chemotherapy; non-seminoma; risk factors; seminoma; testicular cancer stage I