Testicular cancer: germ cell tumours
Testicular cancer represents only 1% of all cancers, with germ cell tumours being by far the most common pathology. This disease is the most common form of cancer in men aged under 40 years, and is curable in a large majority of cases. However, it may be a significant burden to some men in the prime of their lives either due to the disease or to its treatment, or both. The primary treatment for testicular germ cell tumours is radical orchidectomy; this allows diagnosis and definitive histological subtyping. Further management depends on the histological subtype, extent of disease at diagnosis, and also the presence of elevated tumour markers, which is more likely in non-seminoma with loco-regional and/or distant metastases.
Focus of the review
The majority of men present with disease clinically confined to the testis (stage 1) and may be offered surveillance (observation with treatment at relapse), adjuvant chemotherapy, adjuvant radiotherapy (seminoma), or retroperitoneal lymph node dissection (non-seminoma). Despite the multiple available options for the management of stage 1 tumours, the optimal management is controversial. This overview focuses on the evidence for the various options and may help individual decision-making for patients and clinicians.
Comments on evidence
For a rare disease, several RCTs have been successfully completed to guide evidence-based decision making. However, one of the main options, surveillance, has been developed empirically over time.
Search and appraisal summary
The update literature search for this overview was carried out from the date of the last search, June 2010, to October 2014. A back search from 1966 was performed at this update to capture studies on non-seminomatous testicular germ-cell cancers, which were added at this update. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. After deduplication and removal of conference abstracts, 76 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 47 studies and the further review of 29 full publications. Of the 29 full articles evaluated, two systematic reviews and one RCT were added at this update. Data from long-term follow-up of an already reported study were also added.
The management philosophy for determining individual treatment strategy of germ cell tumours has changed from a general approach where cure was the main concern, to one where the potential toxicity of active treatment is now very much taken into account. The best example of this is in stage 1 disease, where cure is almost universal regardless of the initial management route. The toxicity of adjuvant treatment is increasingly becoming recognised to be of much importance in the clinical decision-making about individual treatment choice.
Substantive changes at this update
Adjuvant chemotherapy Evidence re-evaluated. Categorisation unchanged (trade-off between benefits and harms).
Adjuvant radiotherapy Follow-up to previously included RCT added. Evidence re-evaluated. Categorisation unchanged (trade-off between benefits and harms).
Adjuvant surgery New option. One systematic review added, which identified one RCT, the results of which were published subsequent to the search date of the review and we have reported results from the full publication. Categorised as 'trade-off between benefits and harms'.
INTRODUCTION: More than half of painless solid swellings of the body of the testis are malignant, with a peak incidence in men aged 30 to 34 years. Most testicular cancers are germ cell tumours and half of these are seminomas, which tend to affect older men and have a good prognosis. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of treatments following orchidectomy in men diagnosed with stage 1 germ cell tumours (confined to testis)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2014 (BMJ Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, 76 records were screened for inclusion. Appraisal of titles and abstracts led to the exclusion of 47 studies and the further review of 29 full publications. Of the 29 full articles evaluated, two systematic reviews and one RCT, were added at this update. Data from long-term follow-up of an already reported study were also added. We performed a GRADE evaluation for seven PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for seven interventions based on information about the effectiveness and safety of adjuvant chemotherapy (including different drugs and the number of cycles), adjuvant radiotherapy (including different regimens), adjuvant surgery, and surveillance/observation.
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