A subgroup of patients with early-stage testicular cancer had significantly better survival with radiation therapy than with chemotherapy, a large retrospective analysis showed, supporting current clinical guideline recommendations.
Patients with stage IIa testicular seminoma had a 5-year overall survival of 99% when treated with radiation therapy and 93% with chemotherapy. Patients with stage IIb disease had similar 5-year survival with either treatment.
Nonetheless, use of radiation therapy for stage II seminoma declined over the study period, for all stage II subgroups, Scott Glaser, MD, of the University of Pittsburgh Cancer Center, reported at the European Society for Radiation Therapy and Oncology meeting in Turin, Italy.
"For patients with IIa testicular seminoma, this improvement in outcome with radiation over chemotherapy persisted after adjustments for all available factors that could introduce a bias," Glaser said in a statement. "For patients with stage IIb disease, similar rates of overall survival were seen regardless of treatment with multiagent chemotherapy or radiation therapy. This suggests that an individualized approach is necessary for such patients."
The findings were published online simultaneously in Clinical Oncology.
The results provide affirmation to the current National Comprehensive Cancer Network (NCCN) guidelines for treating stage II testicular cancer, said David Beyer, MD, president of the American Society for Radiation Oncology.
"It's not the kind of study that renders one kind of treatment obsolete," said Beyer, of Arizona Radiation Specialists in Scottsdale. "What it clearly does is say that, in a large number of patients who were selected for a variety of reasons that we don't know, those who got radiation tended to do better. This confirms what the NCCN recommendation is in the United States. It kind of reinforces what I already believe to be the better approach for these stage II patients.
"It isn't practice changing in that sense," Beyer told MedPage Today. "In the European population, where there is more use of chemotherapy upfront, it could wake people up and make people a little more inclined to question that treatment approach."
Testicular seminoma is uncommon, and prior studies have included small numbers of patients, resulting in a lack of randomized data to guide treatment, Glaser noted. Small differences in efficacy between radiation therapy and chemotherapy have been difficult to tease out.
More than 95% of testicular cancers are stage I-II at diagnosis, which has helped make the disease one of the most curable solid tumors. As a result recent investigations and focused more on reducing treatment-related toxicity. Orchiectomy followed by active surveillance has become the preferred approach for stage I disease.
As Beyer noted, the NCCN recommends radiotherapy for stage IIa testicular seminoma. In contrast, the European Association of Urology considers radiation therapy or chemotherapy acceptable.
"The trend away from radiation therapy [for stage II disease] may be due to a misperception that it is more toxic than three or four cycles of multiagent chemotherapy," said Glaser.
In an effort to identify survival differences favoring one treatment modality or the other, Glaser and colleagues analyzed data from the National Cancer Data Base, seeking patients with newly diagnosed stage II seminoma from 1998 to 2012. The 2,437 patients resulting from the query consisted of 960 patients with stage IIa disease, 812 with IIb disease, and 665 with IIc disease. The study population had a median follow-up of 65 months.
The data showed that 78.1% of patients with stage IIa disease were treated with radiation therapy, as compared with 54.4% of those with IIb disease and 4.2% of the IIc subgroup. For patients with IIa or IIb disease, preferential use of chemotherapy was associated with later year of diagnosis, treatment at an academic center, and pathologic confirmation of lymph node involvement.
"Utilization of radiotherapy decreased over time for both stage IIa (P=0.001) and IIb (P=0.016) patients, mirrored by an increase in the utilization of multiagent chemotherapy," Glaser and co-authors reported in the published article.
Comparing the 5-year survival for IIa disease treated with radiation therapy versus chemotherapy, investigators found the 6% absolute difference achieved statistical significance. The survival advantage with radiotherapy persisted in a propensity-adjusted multivariate analysis (HR 0.28, 95% CI 0.09-0.86, P=0.027).
Patients with IIb disease had a 5-year survival of 95.2% with radiation therapy and 92.4% with multiagent chemotherapy. The difference did not achieve statistical significance in a multivariable analysis.
Glaser and colleagues disclosed no relevant relationships with industry.
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