Personalizing, not patronizing: the case for patient autonomy by unbiased presentation of management options in stage I testicular cancer

J. Oldenburg, J. Aparicio, J. Beyer, G. Cohn-Cedermark, M. Cullen, T. Gilligan, U. De Giorgi, M. De Santis, R. de Wit, S.D. Fosså, J.R. Germà-Lluch, S. Gillessen, H.S. Haugnes, F. Honecker, A. Horwich, A. Lorch, D. Ondruš, G. Rosti, A.J. Stephenson, T. Tandstad

Testicular cancer (TC) is the most common neoplasm in males aged 15 to 40 years. The majority of patients have no evidence of metastases at diagnosis and thus have clinical stage I (CSI) disease.(1, 2) Management of CSI TC is controversial and options include surveillance and active treatment. Different forms of adjuvant therapy exist, including either one or two cycles of carboplatin chemotherapy or radiotherapy for seminoma and either one or two cycles of cisplatin-based chemotherapy or retroperitoneal lymph node dissection (RPLND) for non-seminoma. Long-term disease-specific survival is about 99% with any of these approaches, including surveillance. While surveillance allows most patients to avoid additional treatment, adjuvant therapy markedly lowers the relapse rate. Weighing the net benefits of surveillance against those of adjuvant treatment depends upon prioritizing competing aims such as avoiding unnecessary treatment, avoiding more burdensome treatment with salvage chemotherapy and minimizing the anxiety, stress and life-disruption associated with relapse. Unbiased information about the advantages and disadvantages of surveillance and adjuvant treatment is a prerequisite for informed consent by the patient. In a clinical scenario like CSI TC where different disease-management options produce indistinguishable long-term survival rates, patient values, priorities and preferences should be taken into account. In this review, we provide an overview about risk factors for relapse, potential benefits and harms of adjuvant chemotherapy and active surveillance and a rationale for involving patients in individualized decision making about their treatment rather than adopting a uniform recommendation for all.