1. Christopher Saigal MD MPH Associate Professor UCLA Dept of Urology
Testis Cancer
Christopher Saigal MD MPH
Associate Professor
UCLA Dept of Urology

2. Differential
Burden of illness
Screening
Diagnosis
Treatment
Patient centered outcomes

3. Differential Differential of a scrotal mass:
History: Time course, associated pain, constitutional symptoms, exacerbating factors, etc
Past medical history: undescended testis, maternal DES exposure, h/o contralateral tumor

4. Evaluation of Scrotal Mass
Physical exam:
Vitals
Pain, redness, heat, reducibility, orientation of testis
Prehn’s sign
Transillumination
Cremasteric reflex
UA, urine culture
Ultrasound

5. Differential: Hydrocele

6. Differential: Epididymo-orchitis
Epididymitis is most common
Usually an ascending infection thru vas deferens
Age predicts causative organism
>35 yrs: coliform bacteria
12-35 yrs: chlamydia, gonorrhea
<12: coliform, ?viruses

7. Differential: Spermatocele/ Epididymal cyst

8. Differential: Varicocele

9. Differential: Testicular Torsion

10. Differential: Hernia Reducible or incarcerated
Usually does not transilluminate
Swells with valsalva

11. Differential: benign testicular lesions
Very rare. Ultrasound may be suggestive
epidermoid cysts
fibromas
fibroadenomas
adenomatoid tumors
lipomas

12. Differential: testis tumor
Physical exam
?gynecomastia (found in 5%)
adenopathy
abdominal mass

13. Burden of Illness
Incidence rose from 3.5 to 6.5/100,000 over 30 years
About 6,000 cases/yr
Survival is > 90%
For all males, lifetime probability of dying of testes cancer is 0.02%
SEER

15. Testicular Cancer: Is Screening Accurate
Can screen via:
Testicular self exam: Low specificity: about 8% of men with a “lump” found to have a tumor Buetow J, Med Screen. 1996
Testicular ultrasound: Highly sensitive and specific

16. Does Screening Improve Outcomes?
US Preventative Services Task Force 4/2004 Review
No evidence of decreased mortality
5 yr survival is >90% without screening
Risk of false positives with TSE
Cannot recommend screening

17. Diagnosis

18. Diagnosis

19. Diagnosis
Ultrasound is highly specific (hypoechoic lesion), but diagnosis is made at radical orchiectomy
Microlithiasis- not a risk factor
Biopsy contraindicated

20. Histologic types Germ cell tumors:
Seminoma versus Non seminomatous germ cell tumors (NSGCT)
Non-germ cell tumors (rare, <5%)
Leydig cell tumors (precocious puberty)
Sertoli cell tumors
Mixed sex chord-stromal tumors

21. NSGCT Choriocarcinoma (elevated b-Hcg) Embryonal cell
Teratoma (mature and immature)
Yolk sac
(elevated AFP)

22. Seminoma Rarely make hcg
Generally favorable prognosis when seen in older men

23. Tumor markers AFP levels are elevated 50%-70% NSGCT
hCG levels are elevated in 40%-60%.
AFP has a half-life of 5-7 days
hCG has a half-life of 36 hours.
Important to follow response after orchiectomy
LDH is non-specific measure of tumor burden

24. Treatment
Staging CT scan miss microscopic disease in 1 in 3 to 1 in 5 men
% embryonal cell, LV invasion, T stage can be predictive or RP disease
Dilemma: overtreat or undertreat?

25. Treatment Seminoma Stage IA and B:
radiation therapy vs surveillance (? Chemo)
NSGCT
Stage IA
retroperitoneal lymph node dissection vs surveillance
Stage IB
retroperitoneal lymph node dissection vs surveillance vs chemotherapy
Higher stages-chemo, f/b surgery as needed

26. Endocrine issues Higher proportion of oligospermic men
Sperm banking recommended before adjuvant therapy
Treatment can damage testis, decrease T levels
Leydig cell tumors, some that produce B-hcg can cause gynecomastia

27. Retroperitoneal Lymph Node Dissection

28. chemotherapy Usually 2 cycles of BEP Well tolerated ? Late effects
Effects on fertility

29. Surveillance NCCN guidelines CT q 2-3 months for first year or two
Then q4, q6
Labs, CXR q month for year one, then q 2 months, etc
Issues are compliance, anxiety

30. Quality of Surveillance for Stage I Testis Cancer in the Community
Stage I Testis Cancer Compliance With Surveillance Follow Up Guidelines for Seminoma
FOLLOW UP YEAR N*
COMPLIANCE†
Abdominal Imaging
Chest Imaging
Labs / Tumor Markers
100%
≥50% 0% 1
397
39.5%
14.9%
22.4%
56.7%
17.4%
25.9%
41.8%
10.3%
27.5% 2
227
15.9%
17.2%
39.6%
40.1%
20.3%
30.4%
11.9%
34.8% 3
110
3.6%
19.1%
45.5%
21.8%
30.9%
47.3%
25.5%
17.3%
39.1% 4 61
6.6%
31.1%
62.3%
42.6% NA
57.4%
27.9%
23.0%
49.2% 5 19
36.8%
63.2%
42.1%
57.9%
21.1% N*
COMPLIANCE†
Abdominal Imaging
Chest Imaging
Labs / Tumor Markers
100%
≥50% 0%
Surveillance For Seminoma 1
397
39.5%
14.9%
22.4%
56.7%
17.4%
25.9%
41.8%
10.3%
27.5% 2
227
15.9%
17.2%
39.6%
40.1%
20.3%
30.4%
11.9%
34.8% 3
110
3.6%
19.1%
45.5%
21.8%
30.9%
47.3%
25.5%
17.3%
39.1% 4 61
6.6%
31.1%
62.3%
42.6% NA
57.4%
27.9%
23.0%
49.2% 5 19
36.8%
63.2%
42.1%
57.9%
21.1%
Surveillance For NSGCT
23.7%
30.7%
12.3%
28.5%
21.4%
20.4%
5.3%
27.8%
3.1%
13.2%
18.2%
13.6%
29.1%
3.3%
8.2%
11.5%
16.4%
10.5%
31.6%
Post - RPLND 96
68.8%
22.9%
8.3%
60.4%
33.3%
57.3%
16.7%
14.6%
37.7%
14.8%
29.5%
26.2% 28
60.7%
39.3%
17.9%
28.6%
25.0%
14.3%
32.1% 14
50.0%
42.9% 7
71.4%
85.7%
Post - XRT
541
19.8%
30.1%
11.8%
28.8%
27.2%
15.3%
43.6%
16.5%
23.3%
309
19.7%
38.5%
41.7%
32.7%
36.2%
41.1%
31.7%
155
45.2%
54.8%
59.4%
40.6% 76
35.5%
64.5%
51.3%
48.7% 23
13.0%
87.0%
69.6%
60.9%
401, 96, and 541 patients received surveillance, RPLND and XRT, respectively.
Mean follow up was 23, 24 mo, and 23 months, respectively.
100% of surveillance patients had at least one follow up test in the first year, but 8-16% of patients had no follow tests of any kind in years 2-5.
Compliance with recommended follow up was generally poor.
Compliance with follow up was higher in RPLND patients.

31. Quality of Surveillance for Stage I Testis Cancer in the Community
The use of surveillance for testis cancer is widely accepted in the community.
Compliance rates with recommended follow up care are poor .
Compliance among RPLND patients appear to be superior, possibly due to greater selection for motivated patients.
Surveillance protocols developed at referral centers are not being followed in the community; further work is needed to understand the impact of this apparent quality of care problem on oncologic outcomes in men treated in the community with surveillance protocols.

32. Testicular Cancer outcomes
5 year survival for stage I is >95%
Focus is on reducing treatment side effects (e.g. retrograde ejaculation)
Concern over late effects of treatment

33. Patient Perspectives

34. California Cancer Registry study
Decision Regret Scale
Short Form - 12
Hospital Anxiety and Depression Scale
Locus of Control Scale
Tolerance of Ambiguity Scale
Questions about influencers, satisfaction
The survey also included 5 validated instruments:
The Decision Regret scale – which measures our primary outcome as a surrogate for decision quality.
The Short-Form 12 – which is a well established physical and mental HRQOL questionnaire.
The Hospital Anxiety and Depression Scale, which measures negative psychosocial effects of somatic disorders.
The Locus of Control Scale, which measures the relative importance of internal and external influences in patient preferences.
And the Tolerance of Ambiguity Scale, which measures individuals’ perceptions and attitudes toward uncertain situations

35. PHYSICIAN CONSULTATIONS
Urologist Oncologist RadOnc
Seminoma
Surveillance
XRT
NSGCT
Surveillance
Chemo
RPLND
We asked patients about the types of physicians that they saw and how many they saw.
Seminoma patients saw on average one Urologist and one RadOnc and were less likely to have seen an oncologist.
NSGCT surveillance pts were less likely to have seen an oncologist than those who underwent chemotherapy or RPLND.
RPLND patients saw an average of 2 Urologists and 1 oncologist.

36. DECISION INFLUENCE
Urologist Oncologist RadOnc
Seminoma
Surveillance
XRT
NSGCT
Surveillance
Chemo
RPLND
Family, friends, cost, time missed from work, internet mainly 2-3
Patients were then asked to rate on Likert scales of 1-5 the importance of other people’s opinions on influencing their decisions – 1 being not important and 5 being most important.
XRT patients weighed their Urologist’s and RadOnc’s opinions equally, and seminomas that chose surveillance were more influenced by their RadOncs.
RPLND patients weighed the opinion of their Urologists more highly than that of their oncologists, whereas surveillance NSGCT patients weighed the opinions of their oncologists more heavily.
The opinions of family, friends and other cancer patients, were mildly important to unimportant,
As were other factors as cost of treatment, time off for treatment, and information from the internet were also less important with scores of 4 or less, mostly in the 2-3 range.

37. COUNSELING ADEQUACY
Urologist Oncologist RadOnc
Seminoma
Surveillance
XRT
NSGCT
Surveillance
Chemo
RPLND
When asked if the men if they felt their physicians provided enough information to help them make a decision, patients were generally satisfied.
Surveillance patients were slightly more satisfied with their RadOncs and Oncologists than their Urologists
Whereas RPLND patients were slightly more satisfied with Urologists

38. PATIENT SATISFACTION
Urologist Oncologist RadOnc
Seminoma
Surveillance
XRT
NSGCT
Surveillance
Chemo
RPLND
When asked if they were satisfied with the care that they received , patients were generally satisfied.
NSGCT patients who underwent surveillance experienced slightly greater satisfaction with the care they receive than those who underwent adjuvant therapy.

39. DECISION REGRET SCALE
DRS Score
Seminoma
XRT
NSGCT Surveillance
Chemo
RPLND
Generally, men experienced little regret in their decisions – a score of 0 represents no regret, and 100 represents the highest level of regret.
Surveillance patients demonstrated the least regret within both the Seminoma and NSGCT groups
Suprisingly, patients who had recurrences and are now disease free have lower regret than those who underwent immediate treatment.
In the case of seminoma patients, this finding was statistically significant.

40. OTHER INSTRUMENTS Short Form - 12: Tolerance of Ambiguity Scale:
Physical component scores:
Similar between treatment groups
Higher than age matched population means
Mental component scores
Similar to age matched population means.
Tolerance of Ambiguity Scale:
Looking at the other instruments:
The SF-12 showed similarities between all treatment groups, but testis cancer patients scored higher than the norms for age matched men in the general population.
A previous study has also suggested that testis cancer patients have higher physical function scores than the general population, but may have lower mental health measures, which was not seen here.
Patient’s abilities to tolerate ambiguous situations did not appear to affect decision choice.

41. OTHER INSTRUMENTS Hospital Anxiety and Depression Score:
Similar between treatment groups
All groups scored in the borderline abnormal range
Locus of Control Scale:
Influence of chance < internal < powerful others.
Adjuvant therapy patients influenced more by powerful others.
RPLND patients have stronger internal LCS than other treatment groups.
While patient scores on the Hospital Anxiety and Depression Scale were similar between treatment groups, the means for all the scores were in the “borderline abnormal” range.
The Locus of Control Scale showed that chance affects their decisions less than their own self-determination or the influence of “powerful others,” which in this case, represents the physician.
Men that chose adjuvant therapy were more influenced by powerful others, and RPLND patients showed greater self- determination than those who underwent adjuvant therapy.

42. CONCLUSIONS Influence of the MD is important
RadOncs and Oncologists may doing better job of pt counseling
Pts generally tolerate surveillance and treatments well and do not regret their choice
In conclusion:
Influence of physicians appears to be the most important factor in testis cancer patients’ decision making – particularly in affecting patients’ choice of RPLND.
Radiation oncologists and oncologists may be doing a better job of counseling patients than Urologists.
In general, patients do not regret their decision choices, even among those that developed recurrences.

43. CONCLUSIONS
Despite borderline anxiety and depression scores, pts do not show mental QOL impairment compared with population – including recurrences
Surveillance pts do not experience more anxiety or depression
Consistent with previous studies, testis cancer survivorship may confer better perceived physical function QOL than the general population.
Despite borderline anxiety and depression scores, patients did not show mental QOL impairment compared with the population, even among those who developed recurrences.
Surveillance patients do not appear to experience more anxiety or depression than those who underwent active treatment.

44. CONCLUSIONS
Clinical outcome may not be the ultimate determinate of patient satisfaction
Prospective studies need to be done to evaluate true effect of surveillance vs treatments and the effects of clinical recurrence on pt satisfaction and QOL
All these trends suggest that clinical outcome may not be the ultimate determinate of Stage I testis cancer patient satisfaction
And prospective studies are needed to evaluate the true effect of surveillance, active treatment, and recurrences on patient satisfaction and QOL.

45. Surveillance and Treatment Expenditures of Stage I Testis Cancer
Stage I Testis Cancer Follow Up Expenditures N
Mean
Follow-Up
Total Expenditures
(5-Year)
NCCN Based Projection of
5-Year Follow-Up Test
Expenditures
5-Year
Follow-Up Test
Surveillance
279
30 mo
$100,015
Surveillance For Seminoma $17,512
$11,703
Surveillance for NSGCT $20,950
RPLND 72
$119,903
$7,164
$13,005
XRT
388
28 mo
$73,763
$5,280
$6,992

46. Surveillance and Treatment Expenditures of Stage I Testis Cancer
Long-term expenditures for stage I testis cancer are lowest after XRT.
Expenditures for surveillance were less than that for RPLND, but greater than that for XRT, even though no active treatment occurs.
Follow-up tests do not account for the bulk of expenditures - surveillance patients are incurring more expenses related to physician and hospital services, including treatment for recurrences.
Actual expenditures may vary from projected models due to high rates of non-compliance with follow up protocols.
Prospective studies on the clinical and economic impact s of surveillance noncompliance within the community need to be done.