A panel convened by ASCO conducted a systematic review of medical research literature in partnership with Cancer Care Ontario to develop the recommendations. The guideline will be published today in the Journal of Clinical Oncology (JCO).
GCTs are rare, with fewer than 9,000 new cases a year in the United States. They are also among the most curable cancers, with over 90 percent of men cured. Serum tumor markers have been routinely used for decades to help manage the care of men with GCTs, yet because such tumors are uncommon, many physicians may not be familiar with how to use them best.
“Testicular cancer is curable in most cases, but proper management is key because the stakes are high, both for survival and quality of life,” said Timothy D. Gilligan, MD, co-chair of ASCO’s Germ Cell Tumor Markers Committee and Director of the Late Effects Clinic at the Taussig Cancer Institute at the Cleveland Clinic. “These guidelines emphasize that germ cell tumor markers can prove enormously useful for staging and monitoring disease when used appropriately. Our hope is that this guideline will eliminate confusion and help doctors use serum markers appropriately, and help prevent unnecessary testing.”
GCTs most commonly start in sperm-producing cells in the testicles. There are two different types of germ cell tumors in men: seminoma and non-seminoma. Generally, seminomas are relatively slow-growing, while non-seminomas tend to grow and spread more quickly, and they are treated differently. A germ cell tumor can also develop in other parts of the body, such as the retroperitoneum (the back of the abdomen near the spine), the mediastinum (the central portion of the chest between the lungs), the lower spine, and very rarely, the pineal gland in the brain.
The panel recommends checking GCT marker levels prior to removing the testicle in men who are thought to have a testicular cancer. It notes, however, that while high levels of any one of three GCT-associated tumor markers – alpha-fetoprotein (AFP), human beta-chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) – may indicate a GCT, this by itself is not sufficient for diagnosis. Additionally, the guidelines state that changes in tumor marker levels can indicate response to treatment in patients who had high levels at diagnosis.
Specifically, the guideline recommends the following:
- AFP, hCG and LDH should not be used to screen for germ cell tumors, to decide whether orchiectomy (surgery to remove one or both testicles) is needed, or to make treatment decisions for patients with cancer of unknown origin.
- To determine the stage and prognosis of a testis cancer and to help confirm the diagnosis, AFP, hCG, and LDH should be measured before orchiectomy when a man is suspected of having testicular cancer.
- In men found to have a testicular nonseminoma, AFP, hCG, and LDH should be measured again after orchiectomy and before other treatment begins for testicular cancer, and before chemotherapy for patients with non-seminomas that began outside of the testicles.
- In men found to have a nonseminoma, AFP and hCG should be measured before retroperitoneal lymph node removal, before each cycle of chemotherapy begins, after all chemotherapy is finished, and periodically after treatment ends to watch for a recurrence.
- For patients with testicular pure seminoma, hCG and LDH should be measured again after orchiectomy if they were elevated before.
- Tumor markers should not be used to make or change treatment decisions for seminoma, or to watch for a recurrence of stage I seminoma.
- In men with stage II or III seminoma, hCG and AFP should also be measured when treatment finishes and periodically thereafter to monitor for relapse.
“It’s important to collect a blood sample so we can know what the marker levels were prior to removing the testicle,” Dr. Gilligan said. “They provide a baseline and these levels have implications for interpreting tumor pathology and future test results. We also need to watch if marker levels have changed after surgery, and they ultimately help in determining prognosis, stage and the type of GCT.”
One of the most important uses of tumor marker levels in non-seminomas is to determine which chemotherapy regimen to use and the duration of chemotherapy. Specifically, the level of AFP, hCG and LDH immediately prior to starting chemotherapy helps determine the amount and duration of chemotherapy as well as the prognosis. In addition, tumor markers are valuable for monitoring patient response to chemotherapy.
The panel did not find evidence that tumor markers are important as part of post-treatment monitoring for early-stage seminomas. The panel said that for men with non-seminoma and advanced seminoma, it’s important to continue with follow-up testing of tumor marker levels after treatment ends, particularly because increases in the tumor marker levels could mean that the cancer has recurred. The guideline includes detailed recommendations on appropriate testing frequency for each disease.
The clinical practice guideline and other clinical tools and resources are available at www.asco.org/guidelines/germcelltm. ASCO also has developed a corresponding patient guide available on ASCO’s patient website, www.cancer.net/whattoknow.
For a copy of the guideline, please contact Aaron Tallent at firstname.lastname@example.org.
The American Society of Clinical Oncology (ASCO) is the world’s leading professional organization representing physicians who care for people with cancer. With more than 28,000 members, ASCO is committed to improving cancer care through scientific meetings, educational programs and peer-reviewed journals. For ASCO information and resources, visit www.asco.org/presscenter. Patient-oriented cancer information is available at www.cancer.net
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