title: Surveillance and Radiation Therapy for Stage I Seminoma--Have We Learned From the Evidence?
abstract: OBJECTIVE
  To analyze, in the setting of stage I seminoma, the factors affecting adjuvant treatment decisions and resulting survival outcomes, using a national dataset.
  
  
  METHODS
  We identified 33,094 stage I seminoma patients after orchiectomy from 1998 to 2012 from the National Cancer Data Base. Factors affecting treatment selection (active surveillance [AS] vs adjuvant treatment [AT]) were identified using a parsimonious multivariate logistic regression model. Propensity scores for treatment decision were generated and incorporated into a multivariate Cox regression analysis of overall survival. This process was then repeated within the AT cohort for factors predictive for chemotherapy [CT] versus radiation therapy [RT].
  
  
  RESULTS
  Only 33% of patients received AS, and 65% received AT (89% RT and 11% CT). From 1998 to 2012 the proportion receiving AS increased from 23% to 60%, whereas RT utilization decreased from 73% to 21%, and CT utilization increased from 2% to 17%. Utilization of low-dose RT increased from 1.5% in 1999 to 34% in 2012. There was a small absolute overall survival advantage to AT over AS at 10 years (95.0% vs 93.4%, propensity adjusted hazard ratio 0.58, P<.0005).
  
  
  CONCLUSIONS
  There has been a significant increase in use of AS for stage I seminoma, influenced by both sociodemogrpahic and clinicopathologic factors. Between AT options, there has been significant increase in use of CT, mirrored by a decline in use of RT. Although overall survival remains high for all 3 treatment strategies, AT seems to be associated with a small absolute survival advantage over AS up to 10 years out from diagnosis.
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: Scott M
authors.initials: SM
authors.lastname: Glaser
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: John A
authors.initials: JA
authors.lastname: Vargo
authors.affiliation: Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Goundappa K
authors.initials: GK
authors.lastname: Balasubramani
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania. Electronic address: beriwals@upmc.edu.
authors.forename: Sushil
authors.initials: S
authors.lastname: Beriwal
mesh_terms: D000328:Adult; D000970:Antineoplastic Agents / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant / Q000401:mortality / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009919:Orchiectomy; D057216:Propensity Score; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant / Q000401:mortality / Q000706:statistics & numerical data; D012044:Regression Analysis; D012189:Retrospective Studies; D018239:Seminoma / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D012959:Socioeconomic Factors; D016019:Survival Analysis; D013736:Testicular Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D057832:Watchful Waiting / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D000970:Antineoplastic Agents