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• a reduction in the number of cycles of chemotherapy required for treatment of good-prognosis metastatic disease,

• a reduction in the radiation dose and field size for the treatment of early-stage seminoma, and

• the introduction of active surveillance (close, structured follow-up to detect and treat relapse) for Stage I non-seminomatous tumours.

In this issue of the Journal, Toner et al provide, for the first time, Australian population-based data on the management of testicular cancer.⁴ They retrospectively surveyed doctors who were involved in the management of more than 600 patients in Victoria with testicular cancer between 1988 and 1993. Their survey included information on the location of care, investigations performed, treatment and survival. The men were treated at a large number of hospitals, most of which treated fewer than two patients with testicular cancer each year. How did this dispersion of care and expertise affect management and outcomes?

Staging and surveillance were often inadequate. There was a low rate of completion of staging and follow-up investigations in the first year for patients with early-stage disease undergoing active surveillance, and no patients underwent primary retroperitoneal lymph node dissection. Furthermore, more than 10% of patients with Stage I seminoma were managed with surveillance (often poorly implemented), which at the time (and arguably even today) was not a proven treatment. There are no data about the delivery or adverse effects of treatment.

Despite some of the shortcomings in management, there was an excellent overall relative five-year survival of 95%, a figure that is similar to those obtained elsewhere in Australia,^5,6 and internationally.⁷ However, these findings offer only partial reassurance, since differences in outcomes between groups may be hard to establish with so few adverse events. This has been noted previously in similar studies. For example, no differences in outcome based on location of care were identified for Scandinavian men with testicular cancer when all patients were considered. However, when the patients with the earliest stage of disease (and hence the best prognosis) were excluded, differences became apparent, with better survival for patients cared for in centres that treated large numbers of patients.⁸ This is reinforced by better outcomes for patients managed in centres treating large numbers of patients in reports from the United States⁹ and the United Kingdom.¹⁰ The data also suggest better outcomes for men treated in centres recruiting the largest numbers of patients to randomised clinical trials.¹¹ Indeed, management of patients in small centres without the necessary expertise may limit access to some treatments.

The failure by Toner et al to demonstrate differences in outcome between the centres treating many patients and those treating few may also reflect imbalances in prognostic factors. For example, patients with the worst prognostic features seen at smaller centres are likely to be referred to larger centres, making outcomes appear to be better at the former and worse at the latter. Furthermore, in a disease with such effective salvage treatment, the main disadvantage of inadequate surveillance may be the need for more intensive therapy, with the associated problems of increased toxicity and cost, rather than worse overall survival. These aspects were not assessed in the Victorian study.

The apparent shortcomings in care must also be considered in the light of the study's limitations. The data are based on a questionnaire completed three to eight years after the patients were treated. Although the response rate was high (with information obtained for 95% of cases), there was no independent verification of the data provided by the respondents. The answers reflect both the quality of the practitioners' medical records and their knowledge of the purpose and expectations of the investigators. In addition, although many hospitals each treated a small number of patients, it is not clear how many individual doctors were involved — potentially more important in terms of clinical experience and expertise.

Outcomes for men with testicular cancer in Victoria are excellent. However, there is much variability in the care of these men, and this may affect the extent and toxicity of their treatment. Optimal management is demanding on patients, doctors and support staff. Men with testicular cancer should be treated in centres with multidisciplinary expertise, experience and access to all treatment options — there is too much at stake for it not to be done right.

Michael J Boyer
Head, Department of Medical Oncology

Martin R Stockler
Senior Lecturer in Cancer Medicine and Clinical Epidemiology
Sydney Cancer Centre, Royal Prince Alfred Hospital
and University of Sydney, Sydney, NSW

1. Levi JA, Thomson D, Sandeman T, et al. A prospective study of cisplatin-based combination chemotherapy in advanced germ cell malignancy: role of maintenance and long-term follow-up. J Clin Oncol 1988; 6: 1154-1160.
2. Levi JA, Raghavan D, Harvey V, et al. The importance of bleomycin in combination chemotherapy for good-prognosis germ cell carcinoma. Australasian Germ Cell Trial Group. J Clin Oncol 1993; 11: 1300-1305.
3. Boyer MJ, Cox K, Tattersall MH, et al. Active surveillance after orchiectomy for nonseminomatous testicular germ cell tumors: late relapse may occur. Urology 1997; 50: 588-592.
4. Toner GC, Neerhut GJ, Schwarz MA, et al. The management of testicular cancer in Victoria, 1988-1993. Med J Aust 2001; 174: 328-331.
5. Supramanian R, Smith D, Coates M, Armstrong B. Survival from cancer in New South Wales in 1980 to 1995. Sydney: NSW Cancer Council, 1999.
6. South Australian Cancer Registry. Epidemiology of cancer in South Australia. Adelaide: South Australian Cancer Registry, 2000.
7. Ries LAG, Kosary CL, Hankey BF, et al. SEER cancer statistics review, 1973-1996. Bethesda: National Cancer Institute, 1999.
8. Aass N, Klepp O, Cavallin-Stahl E, et al. Prognostic factors in unselected patients with nonseminomatous metastatic testicular cancer: a multicenter experience. J Clin Oncol 1991; 9: 818-826.
9. Feuer EJ, Frey CM, Brawley OW, et al. After a treatment breakthrough: a comparison of trial and population-based data for advanced testicular cancer. J Clin Oncol 1994; 12: 368-377.
10. Harding MJ, Paul J, Gillis CR, Kaye SB. Management of malignant teratoma: does referral to a specialist unit matter? Lancet 1993; 341: 999-1002.
11. Collette L, Sylvester RJ, Stenning SP, et al. Impact of the treating institution on survival of patients with "poor-prognosis" metastatic nonseminoma. European Organization for Research and Treatment of Cancer Genito-Urinary Tract Cancer Collaborative Group and the Medical Research Council Testicular Cancer Working Party. J Natl Cancer Inst 1999; 91: 839-846.

©MJA 2001
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