title: Changes in adjuvant therapy utilization in stage I seminoma: are they enough to prevent overtreatment?
abstract: OBJECTIVE
  To determine if utilization of surveillance or adjuvant chemotherapy has increased compared with that of adjuvant radiotherapy (ART) in clinical stage I seminoma (CSIS) and to estimate the impact of this utilization trend on secondary malignancies.
  
  
  METHODS
  The National Cancer Data Base, a web-based data analysis tool was examined for first-course adjuvant therapy management in CSIS from 2000 to 2008. We assessed the utilization in academic vs community practice settings and changes in tumor stage. We also estimated the number of secondary malignancies based on the change in practice.
  
  
  RESULTS
  There were 52,672 patients of testicular cancer diagnosed. Of those, 28,974 (55.0%) patients had seminoma with 22,210 (84.2%) patients classified as CSIS. Overall, 14,005 (65.4%), 6430 (30.1%), and 951 (4.4%) patients received ART, surveillance, and adjuvant chemotherapy (AC), respectively. In 2000, most patients received ART (71.7%), followed by surveillance (26.5%), and AC (1.9%). In 2008, the majority of patients still received ART (47.7%) but surveillance (39.6%) and AC (12.6%) totaled a larger proportion. We calculated that this ART utilization rate would lead to an additional 372 solid tumor cases per year, 40 years later, whereas the current surveillance rate would lead to 34 cases of secondary malignancy annually in the United States.
  
  
  CONCLUSIONS
  ART was the leading adjuvant management strategy for CSIS, but its share drastically decreased with a concomitant increase in surveillance and AC, particularly after 2004. These trends were similar in both academic and community settings. The current level of ART, although decreasing, may nevertheless lead to additional cases of solid cancer comparable with testicular cancer deaths.
authors.affiliation: Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Kohut
authors.affiliation: Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Minnillo
authors.affiliation: Biostatistics, Case Western Reserve University, Cleveland, OH.
authors.forename: Georgios
authors.initials: G
authors.lastname: Kypriotakis
authors.affiliation: Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH.
authors.forename: Robert
authors.initials: R
authors.lastname: Abouassaly
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH; Urology Section, Surgical Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH. Electronic address: huizhu66@hotmail.com.
authors.forename: Hui
authors.initials: H
authors.lastname: Zhu
mesh_terms: D000328:Adult; D017024:Chemotherapy, Adjuvant / Q000706:statistics & numerical data; D015331:Cohort Studies; D003131:Combined Modality Therapy; D016208:Databases, Factual; D018572:Disease-Free Survival; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology*; D009367:Neoplasm Staging; D009919:Orchiectomy / Q000379:methods; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment; D018239:Seminoma / Q000401:mortality / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D012680:Sensitivity and Specificity; D015996:Survival Rate; D013736:Testicular Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*